Analyzing geographic accessibility of community health centers for low-income adults in the United States
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Community health centers (CHCs) provide comprehensive primary care regardless of a patient’s ability to pay. Key policies in the last decade facilitated development of new CHC delivery sites, but the extent of change in geographic access to CHCs (CHC accessibility) is understudied. Furthermore, existing research on CHC accessibility relies on antiquated methods for measuring CHC accessibility despite the growing use of contemporary accessibility methods to study access to other types of health services. We conducted three studies that examined CHC accessibility using contemporary accessibility methods and publicly available data from the Health Resources and Services Administration, American Community Survey, Area Health Resources File, and the 500 Cities Project. The first study assessed CHC accessibility at the census tract level in 2008 and 2016, before and after implementation of policies that expanded CHCs, using the two-step floating catchment area method. It then investigated the association between indicators of CHC need and changes in CHC accessibility. The second study examined the association between CHC accessibility and primary care utilization. The third study investigated differential change in CHC accessibility for census tracts in a subset of Medicaid expansion states compared to census tracts in a subset of non-expansion states. We found that CHC accessibility substantially increased between 2008 and 2016, that spatial distribution of increases in CHC accessibility was not uniform, and that the two-step floating catchment area method could be successfully applied to reveal small area variation in CHC accessibility changes across states. We also found that CHC accessibility was positively related to primary care utilization, but moderated by extent of primary care provider supply and median household income in the surrounding area. Finally, we found that census tracts in Medicaid expansion and non-expansion states saw similar increases in CHC accessibility from 2008 to 2016. In the current health policy context, where gains in health coverage from the Affordable Care Act are in jeopardy of being scaled back, CHC accessibility is critically important. The findings of this work support the important role of CHC accessibility in primary care utilization and describe how CHC accessibility has changed in the last decade.