Changes in Utilization and Health Among Low-Income Adults After Medicaid Expansion or Expanded Private Insurance
Changes in Utilization and Health Among Low-Income Adults After Medicaid Expansion or Expanded Private Insurance
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DOI：
10.1001/jamainternmed.2016.4419
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发表时间：
2016-10-01
影响因子：
39
通讯作者：
Epstein, Arnold M.
中科院分区：
文献类型：
--
作者：
Sommers, Benjamin D.;Blendon, Robert J.;Epstein, Arnold M.
重要性 根据《平价医疗法案》(ACA)，30 多个州扩大了医疗补助范围，其中一些州选择扩大私人保险（“私人选择”）。此外，虽然 ACA 医疗补助扩大覆盖范围的增加有据可查，但对利用和健康的影响尚不清楚。 目的 评估采用 ACA 替代方法的 3 个州低收入成年人在获得护理、利用和自我报告健康方面的变化。 设计、设置和参与者 对 2013 年 11 月至 2015 年 12 月美国 19 至 64 岁公民的调查数据进行双重差分分析肯塔基州、阿肯色州和德克萨斯州收入低于联邦贫困线 138% 的年份 (n = 8676)。数据分析于 2016 年 1 月至 5 月期间进行。 暴露 肯塔基州医疗补助扩张以及阿肯色州使用医疗补助资金为低收入成年人购买私人保险（私人选择），而德克萨斯州则没有扩张。 主要结果和措施 自我报告获得初级保健、专科护理和药物的情况；护理负担能力；门诊、住院和急诊使用；接受葡萄糖和胆固醇检测、年度检查以及慢性病护理；结果 在本研究纳入的 3 个州中，阿肯色州 (n=2890)、肯塔基州 (n=2898) 和德克萨斯州 (n=2888)，性别、收入或婚姻状况没有差异。与阿肯色州和肯塔基州的受访者相比，德克萨斯州的受访者更年轻、城市化程度更高，拉丁裔比例不高。覆盖范围和服务范围发生显着变化2015 年比 2014 年更加明显。到 2015 年，与未扩张相比，扩张与未投保率下降 22.7 个百分点相关（P < .001）。扩张与初级保健的获得率显着增加（12.1 个百分点；P < .001）、因费用而跳过的药物减少（-11.6 个百分点；P < .001）、减少有关。自付费用（-29.5%；P = .02）、急诊就诊的可能性降低（-6.0 个百分点，P = .04）以及门诊就诊次数增加（每年 0.69 次就诊；P = .04）、糖尿病筛查（6.3 个百分点；P = .05）、糖尿病患者的血糖检测（10.7 个百分点；P = .03）以及慢性病的定期护理。 （12.0 个百分点；P = .008）在扩张后，护理质量评级均显着提高（-7.1 个百分点；“护理质量一般”；P = .03），报告健康状况良好的成年人比例也显着提高（4.8 个百分点；P = .04）。阿肯色州与肯塔基州的比较显示，前者的私人覆盖率有所提高（21.7 个百分点；P < .001）。后者的医疗补助（21.3 个百分点；P < .001），以及肯塔基州较高的糖尿病血糖检测率（11.6 个百分点；P = .04），但没有其他统计上的显着差异。 结论和相关性 在扩展的第二年，肯塔基州的医疗补助计划和阿肯色州的私人选择与门诊利用率、预防性护理和急诊科医疗质量的改善有关。除了获得的覆盖类型外，这两个州使用替代扩张方法的几乎所有其他结果都相似。
IMPORTANCE Under the Affordable Care Act (ACA), more than 30 states have expanded Medicaid, with some states choosing to expand private insurance instead (the "private option"). In addition, while coverage gains from the ACA's Medicaid expansion are well documented, impacts on utilization and health are unclear.OBJECTIVE To assess changes in access to care, utilization, and self-reported health among low-income adults in 3 states taking alternative approaches to the ACA.DESIGN, SETTING, AND PARTICIPANTS Differences-in-differences analysis of survey data from November 2013 through December 2015 of US citizens ages 19 to 64 years with incomes below 138% of the federal poverty level in Kentucky, Arkansas, and Texas (n = 8676). Data analysis was conducted between January and May 2016.EXPOSURES Medicaid expansion in Kentucky and use of Medicaid funds to purchase private insurance for low-income adults in Arkansas (private option), compared with no expansion in Texas.MAIN OUTCOMES AND MEASURES Self-reported access to primary care, specialty care, and medications; affordability of care; outpatient, inpatient, and emergency utilization; receiving glucose and cholesterol testing, annual check-up, and care for chronic conditions; quality of care, depression score, and overall health.RESULTS Among the 3 states included in the study, Arkansas (n=2890), Kentucky (n=2898, and Texas (n=2888), there were no differences in sex, income, or marital status. Respondents from Texas were younger, more urban, and disproportionately Latino compared with those in Arkansas and Kentucky. Significant changes in coverage and access were more apparent in 2015 than in 2014. By 2015, expansion was associated with a 22.7 percentage-point reduction in the uninsured rate compared with nonexpansion (P < .001). Expansion was associated with significantly increased access to primary care (12.1 percentage points; P < .001), fewer skipped medications due to cost (-11.6 percentage points; P < .001), reduced out-of-pocket spending (-29.5%; P = .02), reduced likelihood of emergency department visits (-6.0 percentage points, P = .04), and increased outpatient visits (0.69 visits per year; P = .04). Screening for diabetes (6.3 percentage points; P = .05), glucose testing among patients with diabetes (10.7 percentage points; P = .03), and regular care for chronic conditions (12.0 percentage points; P = .008) all increased significantly after expansion. Quality of care ratings improved significantly (-7.1 percentage points with "fair/poor quality of care"; P = .03), as did the share of adults reporting excellent health (4.8 percentage points; P = .04). Comparisons of Arkansas vs Kentucky showed increased private coverage in the former (21.7 percentage points; P < .001), increased Medicaid in the latter (21.3 percentage points; P < .001), and higher diabetic glucose testing rates in Kentucky (11.6 percentage points; P = .04), but no other statistically significant differences.CONCLUSIONS AND RELEVANCE In the second year of expansion, Kentucky's Medicaid program and Arkansas's private option were associated with significant increases in outpatient utilization, preventive care, and improved health care quality; reductions in emergency department use; and improved self-reported health. Aside from the type of coverage obtained, outcomes were similar for nearly all other outcomes between the 2 states using alternative approaches to expansion.