Effects of Expanded Coverage on Access, Health Care and Health in the South

描述（由申请人提供）：本项目将及时和严格地分析《平价医疗法案》（ACA）的保险覆盖范围扩大对12个南方州（弗吉尼亚州、威斯康星州、肯塔基州、田纳西州、北卡罗来纳州、南卡罗来纳州、佛罗里达州、佐治亚州、夏威夷州、夏威夷州、加利福尼亚州、加利福尼亚州）大量低收入成年人的医疗保健使用和结果的影响。ACA的覆盖范围改革包括自1965年医疗保险和医疗补助以来最大的保险扩张。检查扩大对医疗保健的影响以及旨在从扩大的覆盖范围中受益的社会人口和临床群体的结果，对于推进关于保险覆盖范围与健康之间关系的科学知识以及为各州在未来几年扩大医疗补助计划的决策提供信息至关重要。美国没有哪个地区的无保险率比南方高，慢性病和癌症的患病率比南方高，《平价医疗法案》的实施范围预计将更加多样化。这项拟议的5年研究项目将利用这些地区特征和美国有史以来招募的最大的低收入、无保险和少数族裔成年人队列（总计近85,000人），即南方社区队列研究（SCCS）。我们将在ACA改革的第二年（2015年）及时进行额外调查，并在2016-2017年计划进行的一轮随访中增加问题，以支持对改革对健康的早期和后期影响的一致评估，并探索患者在扩大后时代获得保险和获得护理的经验，从而扩大现有的基线和2002-2014年的后续SCCS调查数据。通过建立数据链接，将这些数据与癌症登记、医疗保险和医疗补助索赔数据结合起来，并与州医院出院数据库建立新的数据链接，我们的目标是量化覆盖范围扩大对以下方面的影响：（目标1）获得护理、癌症筛查和使用预防性临床服务；（目标2）自我报告的健康结果、死亡率以及急诊和住院治疗的使用情况；（目的3）乳腺癌、肺癌和结直肠癌成年患者的癌症分期诊断和癌症护理质量。我们将考虑在保险改革之前可能没有保险的群体，以及之前有保险的成年人，他们获得医疗服务的机会可能会因其他人的保险扩大而受到损害。为了确定这些影响，我们将采用严格的准实验差中差设计，

DESCRIPTION (provided by applicant): This project will provide timely and rigorous analysis of the effect of the Affordable Care Act's (ACA) insurance coverage expansions on health care use and outcomes among a large cohort of low-income adults in 12 southern states (VA, WV, KY, TN, NC, SC, FL ,GA, AL, MS, LA, AR). The ACA's coverage reforms encompass the largest insurance expansion since Medicare and Medicaid in 1965. Examining the effects of expansions on health care and outcomes for socio-demographic and clinical groups intended to benefit from expanded coverage will be critical to advancing scientific knowledge about the relationship between insurance coverage and health and to informing state decisions to expand Medicaid over the next several years. In no region of the country are rates of uninsurance higher, the prevalence of chronic conditions and cancer greater, and the implementation of the ACA's coverage expansions expected to be more varied, than in the South. The proposed 5-year research project will draw on these regional characteristics and the largest cohort of low- income, uninsured, and minority adults ever recruited in the US (nearly 85,000 in total), the Southern Community Cohort Study (SCCS). We will augment existing baseline and follow-up SCCS survey data from 2002-2014 by fielding a timely additional survey in the second year of ACA reforms (2015) and by adding questions to a planned round of follow-up in 2016-2017 to support consistent assessment of early and later effects of the reforms on health and to explore patient experiences obtaining coverage and accessing care in the post-expansions era. By combining these data with cancer registry and Medicare and Medicaid claims data through established data linkages, as well as establishing novel data linkages with state hospital discharge databases, we aim to quantify the effects of coverage expansion on: (Aim 1) access to care, cancer screening and use of preventive clinical services; (Aim 2) self-reported health outcomes, mortality and use of emergent and inpatient care; and (Aim 3) cancer stage at diagnosis and quality of cancer care for adults with breast, lung, and colorectal cancer. We will groups likely to be uninsured before coverage reforms as well as adults with prior coverage whose access to care could plausibly be compromised by coverage expansions for others. To identify these effects, we will apply rigorous quasi-experimental difference-in-difference designs, exploiting both within- and between-state variation in coverage expansions. Our analytic approach will also incorporate regression and propensity score-based adjustment to balance observed characteristics between comparison groups. Finally, due to the longitudinal nature of our data and high observed mortality rates in the cohort, where appropriate we will use advanced methodological approaches to modeling death and health outcomes jointly. In short, our timely quasi-experimental analyses will help characterize the value of the ACA's coverage reforms, will inform policy debates over coverage expansions moving forward, and will advance understanding of the effects of insurance coverage on health care use and health outcomes.