Preconception Coverage Before and After the Affordable Care Act Medicaid Expansions
Preconception Coverage Before and After the Affordable Care Act Medicaid Expansions
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DOI：
10.1097/aog.0000000000002972
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发表时间：
2018-12-01
影响因子：
7.2
通讯作者：
Daw, Jamie R.
中科院分区：
文献类型：
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作者：
Clapp, Mark A.;James, Kaitlyn E.;Daw, Jamie R.
目的：评估 2014 年大规模实施的《平价医疗法案》医疗补助扩展条款对低收入女性孕前保险覆盖率的影响。方法：我们采用准实验、双重差分设计来比较医疗补助扩展前后生活在扩展状态的低收入妇女与非扩展状态的孕前保险覆盖范围的变化。家庭收入为联邦贫困线 138% 或以下的女性，以及 2009 年至 2015 年期间参与怀孕风险评估监测系统的女性，这些女性来自于 2014 年 1 月 1 日扩大或未扩大医疗补助计划的州。令人感兴趣的是州医疗补助计划的扩张。主要结局是受孕前 1 个月的保险状况。我们进行了额外的亚组和敏感性分析，以测试模型的假设和研究结果的稳健性。 结果：研究样本包括来自根据《平价医疗法案》扩大医疗补助的 8 个州的 30,495 名女性和来自 7 个未根据《平价医疗法案》扩大医疗补助的州的 26,561 名患者。非扩张州的孕前医疗补助覆盖率在保单前为 30.8%，保单后为 35.6%；在扩张州为保单前 43.2%，保单后为 56.8%。政策实施后，扩张州的医疗补助覆盖率显着增加（调整后的双重差分估计+8.6%，95% CI 1.1-16.0）。在非扩张州，保单前未保险率为 44.2%，保单后为 34.3%；在扩张州，保单前未保险率为 37.4%，保单后为 23.5%。保单后期间两组之间的未保险变化没有显着差异（调整后的双重差分估计值 -4.1，95% CI -11.1 至 2.9）。在非扩张州，非医疗补助保险覆盖率为保单前的 25.3% 和保单后的 30.5%；在扩张州，保单前的非医疗补助保险覆盖率为 19.4%，保单后的非医疗补助保险覆盖率为 19.7%。相对于非扩张州，政策实施后时期扩张州的非医疗补助覆盖率显着下降（调整后的双重差分估计为 -4.7，95% CI -8.3 至 -1.1）。结果对于替代模型规范和研究周期定义来说是稳健的。 结论：医疗补助范围的扩大与低收入女性怀孕前医疗补助登记人数的增加有关；然而，未投保率没有变化。需要额外多年的政策后数据才能充分评估政策变化的影响。
OBJECTIVE: To estimate the effects of the Affordable Care Act Medicaid expansion provision that was largely implemented in 2014 on preconception insurance coverage among low-income women.METHODS: We used a quasiexperimental, difference-in-difference design to compare changes in preconception insurance coverage among low-income women living in expansion compared with nonexpansion states before and after the Medicaid expansions. Women with family incomes 138% the federal poverty level or less who participated in the Pregnancy Risk Assessment Monitoring System from 2009 to 2015 from states that did or did not expand their Medicaid programs on January 1, 2014, were included. The exposure of interest was the state Medicaid expansion. The primary outcome was insurance status 1 month before conception. We conducted additional subgroup and sensitivity analyses to test the assumptions of the model and the robustness of the findings.RESULTS: The study sample included 30,495 women from eight states that expanded Medicaid under the Affordable Care Act and 26,561 patients from seven states in that did not. The rate of preconception Medicaid coverage was 30.8% prepolicy and 35.6% postpolicy in nonexpansion states and 43.2% prepolicy and 56.8% postpolicy in expansion states. There was a significantly greater increase in Medicaid coverage in expansion states after the policy implementation (adjusted difference-in-difference estimate +8.6% points, 95% CI 1.1-16.0). Rates of preconception uninsurance were 44.2% prepolicy and 34.3% postpolicy in nonexpansion states and 37.4% prepolicy and 23.5% postpolicy in expansion states. There was no significant difference in the changes in uninsurance between the two groups in the postpolicy period (adjusted difference-in-difference estimate -4.1, 95% CI -11.1 to 2.9). Non-Medicaid insurance coverage was 25.3% prepolicy and 30.5% postpolicy in nonexpansion states and 19.4% prepolicy and 19.7% postpolicy in expansion states. Relative to nonexpansion states, there was a significant decrease in non-Medicaid coverage in the expansion states in the postpolicy period (adjusted difference-in-difference estimate -4.7, 95% CI -8.3 to -1.1). The results were robust to alternate model specifications and study period definitions.CONCLUSION: Medicaid expansion was associated with increased enrollment in Medicaid before pregnancy among low-income women; however, there were no changes in the rates of uninsurance. Additional years of postpolicy data are needed to fully assess the effects of the policy change.