National use of safety-net clinics for primary care among adults with non-medicaid insurance in the United States

Objective: To describe the prevalence, characteristics, and predictors of safety-net use for primary care among non-Medicaid insured adults (i.e., those with private insurance or Medicare). Methods: Cross-sectional analysis using the 2006-2010 National Ambulatory Medical Care Surveys, annual probability samples of outpatient visits in the U.S. We estimated national prevalence of safety-net visits using weighted percentages to account for the complex survey design. We conducted bivariate and multivariate logistic regression analyses to examine characteristics associated with safety-net clinic use. Results: More than one-third (35.0%) of all primary care safety-net clinic visits were among adults with non-Medicaid primary insurance, representing 6,642,000 annual visits nationally. The strongest predictors of safety-net use among non-Medicaid insured adults were: being from a highpoverty neighborhood (AOR 9.53, 95%CI 4.65-19.53), being dually eligible for Medicare and Medicaid (AOR 2.13, 95%CI 1.38-3.30), and being black (AOR 1.97, 95%CI 1.06-3.66) or Hispanic (AOR 2.28, 95%CI 1.32-3.93). Compared to non-safety-net users, non-Medicaid insured adults who used safety-net clinics had a higher prevalence of diabetes (23.5%vs. 15.0%, p<0.001), hypertension (49.4%vs. 36.0%, p<0.001), multimorbidity (≥2 chronic conditions; 53.5%vs. 40.9%, p<0.001) and polypharmacy (≥4 medications; 48.8% vs. 34.0%, p<0.001). Nearly one-third (28.9%) of Medicare beneficiaries in the safety-net were dual eligibles, compared to only 6.8% of Medicare beneficiaries in non-safety-net clinics (p<0.001). Conclusions: Safety net clinics are important primary care delivery sites for non-Medicaid insured minority and low-income populations with a high burden of chronic illness. The critical role of safety-net clinics in care delivery is likely to persist despite expanded insurance coverage under the Affordable Care Act.