Use of VA and Non-VA Health Care after the Affordable Care Act

 描述（由申请人提供）： 项目背景/理由：2014年1月，《平价医疗法案》（ACA）将增加许多非老年退伍军人（<65岁）的医疗保险选择。ACA将允许各州将医疗补助覆盖范围扩大到所有收入低于联邦贫困线138%的非老年人。此外，收入在联邦贫困线138%至400%之间的个人将有资格获得保费补贴，通过新成立的保险交易所获得私人医疗保险。目前，有近90万非老年退伍军人，其唯一的健康保险来源是通过退伍军人健康管理局（VHA）。超过一半（52%）的退伍军人（约450，000人）的收入低于联邦贫困线的138%，可能有资格获得医疗补助扩展。另外38%（约328 000人）的收入在联邦贫困线的138%至400%之间，有资格通过保险交易所获得保险费补贴。因此，ACA将增加获得非VA护理的非老年退伍军人的很大一部分。了解ACA对退伍军人的覆盖面和使用VA和非VA护理的影响对于政策制定和规划至关重要。项目目标：本研究的主要目的是：1）确定ACA实施后退伍军人的总体和优先人口统计学和临床亚组对VA服务的利用率; 2）确定ACA对总体和优先人口统计学和临床亚组退伍军人非VA服务利用率的影响;和3）描述退伍军人的ACA保险登记的选择和经验与护理协调后，立即ACA实施VISN 12。项目方法：我们将使用混合方法，并最大限度地利用现有的数据源来实现我们的目标。我们将使用现有的VA管理数据来研究全国范围内的VA利用率（目标1），利用一个包含来自多个芝加哥提供者的医疗保健数据的独特数据库来了解居住在芝加哥的退伍军人的非VA使用情况（目标2），并收集调查和结构化访谈数据，以研究VISN 12中退伍军人的非VA利用率和对保险登记和护理协调的看法（覆盖4个州的农村和城市地区的不同人口：伊利诺伊州、威斯康星州、密歇根州和印第安纳州）（目标2和3）。与VISN 12的利益相关者合作，确定了退伍军人的关键高兴趣人口统计学亚组（农村/城市、需要VA共付费用、女性）和临床亚组（精神疾病、糖尿病合并症、脊髓损伤/疾病），以供特别关注。

 DESCRIPTION (provided by applicant): Project background/rationale: In January 2014, the Affordable Care Act (ACA) will increase health insurance options for many non-elderly Veterans (<65 years old). The ACA will allow states to expand Medicaid coverage to all non-elderly individuals with incomes less than 138% of the federal poverty level. Additionally, individuals with incomes from 138% to 400% of the federal poverty level will be eligible to receive premium subsidies for obtaining private health insurance through newly established insurance exchanges. Currently, there are nearly 900,000 non-elderly Veterans whose only source of health insurance coverage is through the Veterans Health Administration (VHA). Over half (52%) of these Veterans (approximately 450,000) have incomes below 138% of the federal poverty level and could be potentially eligible for the Medicaid expansion. An additional 38% (approximately 328,000) have incomes between 138% and 400% of the federal poverty level and could be eligible for premium subsidies for coverage through the insurance exchanges. Consequently, ACA will increase access to non-VA care for a substantial portion of non-elderly Veterans. Understanding the impact of the ACA on Veterans' coverage and use of VA and non-VA care will be crucial for policymaking and planning. Project objectives: The primary aims of this study are to 1) Determine utilization of VA services overall and among priority demographic and clinical subgroups of Veterans following implementation of the ACA; 2) Determine the impact of the ACA on utilization of non-VA services overall and among priority demographic and clinical subgroups of Veterans; and 3) Describe Veterans' ACA insurance enrollment choices and experiences with care coordination immediately following ACA implementation in VISN 12. Project methods: We will use a mixed methods approach and take maximum advantage of available data sources to accomplish our aims. We will use existing VA administrative data to study VA utilization nationwide (Aim 1), leverage a unique database containing healthcare data from multiple Chicago providers to learn about non-VA use among Veterans residing in Chicago (Aim 2), and collect survey and structured interview data to study non-VA utilization and perspectives on insurance enrollment and care coordination among Veterans in VISN 12 (covering diverse populations in rural and urban areas in 4 states: Illinois, Wisconsin, Michigan, and Indiana) (Aims 2 and 3). In collaboration with stakeholders from VISN 12, key high-interest demographic subgroups (rural/urban, VA copayment required, women) and clinical subgroups (mental illness, diabetes with co-existing comorbidities, spinal cord injury/disorder) of Veterans were identified for special focus.