Presence of a Community Health Center and Uninsured Emergency Department Visit Rates in Rural Counties

Context: Community health centers (CHCs) provide essential access to a primary care medical home for the uninsured, especially in rural communities with no other primary care safety net. CHCs could potentially reduce uninsured emergency department (ED) visits in rural communities. Purpose: We compared uninsured ED visit rates between rural counties in Georgia that have a CHC clinic site and counties without a CHC presence. Methods: We analyzed data from 100% of ED visits occurring in 117 rural (non-metropolitan statistical area [MSA]) counties in Georgia from 2003 to 2005. The counties were classified as having a CHC presence if a federally funded (Section 330) CHC had a primary care delivery site in that county throughout the study period. The main outcome measure was uninsured ED visit rates among the uninsured (all-cause ED visits and visits for ambulatory care sensitive conditions). Poisson regression models were used to examine the relationship between ED rates and the presence of a CHC. To ensure that the effects were unique to the uninsured population, we ran similar analyses on insured ED visits. Findings: Counties without a CHC primary care clinic site had 33% higher rates of uninsured all-cause ED visits per 10,000 uninsured population compared with non-CHC counties (rate ratio [RR] 1.33, 95% confidence interval [CI] 1.11-1.59). Higher ED visit rates remained significant (RR 1.21, 95% CI 1.02-1.42) after adjustment for percentage of population below poverty level, percentage of black population, and number of hospitals. Uninsured ED visit rates were also higher for various categories of diagnoses, but remained statistically significant on multivariate analysis only for ambulatory care sensitive conditions (adjusted RR = 1.22, 95% CI 1.01-1.47). No such relationship was found for ED visit rates of insured patients (RR 1.06, 95% CI 0.92-1.22). Conclusions: The absence of a CHC is associated with a substantial excess in uninsured ED visits in rural counties, an excess not seen for ED visit rates among the insured.