Changes in Racial and Ethnic Disparities in Access to Care and Health Among US Adults at Age 65 Years
Changes in Racial and Ethnic Disparities in Access to Care and Health Among US Adults at Age 65 Years
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DOI：
10.1001/jamainternmed.2021.3922
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发表时间：
2021-07-26
影响因子：
39
通讯作者：
Song, Zirui
中科院分区：
文献类型：
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作者：
Wallace, Jacob;Jiang, Karen;Song, Zirui
重要性 Medicare 为 65 岁的个人提供近乎全民的健康保险。人们对医疗保险资格如何影响获得护理和健康方面的种族和民族差异知之甚少。目的评估医疗保险与获得护理和健康方面的种族和民族差异之间的关系。设计、设置和参与者这项横断面研究使用回归不连续性来比较 65 岁（美国成年人有资格享受医疗保险的年龄）前后的种族和民族差异。 2008 年 1 月至 2018 年 12 月期间，行为风险因素监测系统中共有 2 434 320 名受访者，美国疾病控制与预防中心流行病学研究数据广泛在线数据（例如，2017 年纽约 63 岁个体的死亡率）共有 44 587 个州年龄观察数据。数据在 2 月至 5 月期间进行分析。 2021.暴露 65 岁享受医疗保险的资格。主要结果和措施 拥有健康保险的受访者比例，以及自我报告的健康和死亡率。为了检查访问情况，评估了受访者是否有常规的护理来源、是否遇到了与费用相关的护理障碍或是否接受了流感疫苗。 结果 在 2 434 320 名参与者中，192 346 名是黑人，104 294 名是西班牙裔，892 177 名是男性。 65 岁之后，黑人受访者（从 86.3% 增至 95.8% 或 9.5 个百分点；95% CI，7.6-11.4）和西班牙裔受访者（从 77.4% 增至 91.3% 或 13.9 个百分点；95% CI，12.0-15.8）的保险覆盖范围比白人受访者（从 92.0% 增至 92.0% 至 95% CI，12.0-15.8）增加更多。 98.5% 或 6.5 个百分点；95% CI，6.1-7.0）。与 65 岁之前白人和黑人之间的差距大小相比，这与 65 岁之前白人和黑人之间的差距大小相比减少了 53%（5.7% 至 2.7% 或 3.0 个百分点；95% CI，0.9-5.1；P = 0.003），与 65 岁之前白人和西班牙裔人之间的差距大小相比减少了 51%（14.6% 至 7.2% 或7.4 个百分点；95% CI，5.3-9.5；P < .001）。医疗保险资格与白人和西班牙裔个人在获得护理方面的差距缩小有关，获得常规护理来源的差距从 10.5% 降低到 7.5% (P = .05)，与成本相关的护理障碍从 11.4% 降低到 6.9% (P < .001)，流感疫苗接种率从 8.1% 降低到 3.3% (P = .01)。对于白人和黑人个体之间的差异，65 岁之前和之后获得常规护理来源的情况没有显着差异：1.2% 到 0.0% (P = .24)，与费用相关的护理障碍从 5.8% 到 4.3% (P = .22)，流感疫苗接种从 11.0% 到 10.3% (P = .60)。西班牙裔受访者自我报告健康状况不佳的比例下降了 3.8 个百分点，黑人受访者下降了 2.6 个百分点，白人受访者下降了 0.2 个百分点。 65 岁时与死亡率相关的差异没有变化。自 2014 年美国《平价医疗法案》生效后，医疗保险与缩小差距的关联在很大程度上持续存在。 结论和相关性 在这项使用断点回归设计的横断面研究中，65 岁的医疗保险资格与保险覆盖范围、获得护理机会和自我报告健康方面的种族和民族差异显着缩小相关。
IMPORTANCE Medicare provides nearly universal health insurance to individuals at age 65 years. How eligibility for Medicare affects racial and ethnic disparities in access to care and health is poorly understood.OBJECTIVE To assess the association of Medicare with racial and ethnic disparities in access to care and health.DESIGN, SETTING, AND PARTICIPANTS This cross-sectional study uses regression discontinuity to compare racial and ethnic disparities before and after age 65 years, the age at which US adults are eligible for Medicare. There are a total of 2 434 320 respondents in the Behavioral Risk Factor Surveillance System and 44 587 state-age-year observations in the US Centers for Disease Control and Prevention Wide-Ranging Online Data for Epidemiologic Research Data (eg, the mortality rate for individuals age 63 years in New York in 2017) from January 2008 to December 2018. The data were analyzed between February and May 2021.EXPOSURES Eligibility for Medicare at age 65 years.MAIN OUTCOMES AND MEASURES Proportions of respondents with health insurance, as well as self-reported health and mortality. To examine access, whether respondents had a usual source of care, encountered cost-related barriers to care, or received influenza vaccines was assessed.RESULTS Of 2 434 320 participants, 192 346 were Black individuals, 104 294 were Hispanic individuals, and 892 177 were men. Immediately after age 65 years, insurance coverage increased more for Black respondents (from 86.3% to 95.8% or 9.5 percentage points; 95% CI, 7.6-11.4) and Hispanic respondents (from 77.4% to 91.3% or 13.9 percentage points; 95% CI, 12.0-15.8) than White respondents (from 92.0% to 98.5% or 6.5 percentage points; 95% CI, 6.1-7.0). This was associated with a 53% reduction compared with the size of the disparity between White and Black individuals before age 65 years (5.7% to 2.7% or 3.0 percentage points; 95% CI, 0.9-5.1; P = .003) and a 51% reduction compared with the size of the disparity between White and Hispanic individuals before age 65 years (14.6% to 7.2% or 7.4 percentage points; 95% CI, 5.3-9.5; P < .001). Medicare eligibility was associated with narrowed disparities between White and Hispanic individuals in access to care, lowering disparities in access to a usual source of care from 10.5% to 7.5% (P = .05), cost-related barriers to care from 11.4% to 6.9% (P < .001), and influenza vaccination rates from 8.1% to 3.3% (P = .01). For disparities between White and Black individuals, access to a usual source of care before and after age 65 years was not significantly different: 1.2% to 0.0% (P = .24), cost-related barriers to care from 5.8% to 4.3% (P = .22), and influenza vaccinations from 11.0% to 10.3% (P = .60). The share of people in poor self-reported health decreased by 3.8 percentage points for Hispanic respondents, 2.6 percentage points for Black respondents, and 0.2 percentage points for White respondents. Mortality-related disparities at age 65 years were unchanged. Medicare's association with reduced disparities largely persisted after the US Affordable Care Act took effect in 2014.CONCLUSIONS AND RELEVANCE In this cross-sectional study that uses a regression discontinuity design, eligibility for Medicare at age 65 years was associated with marked reductions in racial and ethnic disparities in insurance coverage, access to care, and self-reported health.