Post Affordable Care Act: Evaluation of Community Health Centers (PACE)

 描述（由申请人提供）：《平价医疗法案》（ACA）要求美国各州在2014年前将医疗补助覆盖范围大幅扩大到≤联邦贫困水平138%的个人。在2012年的一项法律的挑战中，最高法院裁定各州不需要实施ACA赞助的医疗补助计划;因此（到2014年12月31日），只有27个州和哥伦比亚特区扩大了医疗补助计划，而23个州没有。关于ACA赞助的医疗补助扩展对弱势群体获得医疗服务的机会和变化的影响知之甚少。然而，这方面的知识是必不可少的通知审议“非扩张”国家关于是否扩大其医疗补助计划，也将有助于“扩张”国家渴望了解其扩张的影响。最高法院决定为各州提供可选择的扩展，这一自然实验提供了一个独特的机会，可以评估医疗补助扩展在多大程度上改善了低收入患者和其他弱势群体获得医疗保健的机会。该拟议项目将是首批研究ACA医疗补助在大量安全网诊所患者中扩大后获得和接受医疗保健服务以及医疗补助支出变化的项目之一。我们将使用OCHIN基于实践的研究网络的电子健康记录数据（EHR），该网络为8个扩展州和8个非扩展州的442个社区卫生中心（CHC）的100多万患者提供服务。此外，使用来自8个扩展州的CHC数据，我们将研究获得新医疗补助覆盖范围（新投保）的患者与已经投保的患者（已经投保）和未投保的患者（未投保）之间的利用差异。最后，在我们之前工作的基础上，我们将把俄勒冈州213家OCHIN诊所的EHR数据与医疗补助行政索赔数据联系起来，以评估整体医疗保健利用率（包括在CHC之外接受的护理，如住院），并比较新投保个人与已投保个人的医疗补助支出。我们将研究保险覆盖范围，医疗保健利用和医疗补助支出，以解决以下具体目标：目标1：比较前后健康保险状态，初级保健，心理健康和牙科就诊，预防服务的接受，以及在扩大和没有扩大医疗补助的州OCHIN CHC之间付款人组合的变化;目标2：审查社区卫生中心服务的事前事后利用情况（包括接受预防服务）;以及目标3：衡量医疗补助计划扩大前后医疗服务总体利用率的变化以及新投保人与已投保人之间俄勒冈州医疗补助计划的成本。该项目的研究结果将与政策和实践极其相关，为进一步改善美国医疗保健系统提供信息，以确保弱势群体获得医疗保健。

 DESCRIPTION (provided by applicant): The Affordable Care Act (ACA) called for every state in the United States (US) to significantly expand Medicaid coverage to individuals at ≤138% of the federal poverty level by 2014. In a 2012 legal challenge, the Supreme Court ruled that states were not required to implement the ACA-sponsored Medicaid expansion; thus (by December 31, 2014), only 27 states and the District of Columbia expanded Medicaid, while 23 states did not. Little is known about the impact of ACA-sponsored Medicaid expansions on access to and changes in receipt of healthcare services among vulnerable populations. Yet this knowledge is essential to informing deliberations in `non-expansion' states regarding whether to expand their Medicaid programs, and will also be helpful to `expansion' states eager to learn about the impact of their expansions. The natural experiment created by the Supreme Court decision to make expansion optional for states provides a unique opportunity to assess the extent to which Medicaid expansions improve access to healthcare for low-income patients and other vulnerable populations. The proposed project will be one of the first to examine changes in access to and receipt of healthcare services and to Medicaid expenditures following ACA Medicaid expansions among a large population of safety net clinic patients. We will use electronic health record data (EHR) from the OCHIN practice-based research network, which serve >1 million patients in 442 community health centers (CHCs) in 8 expansion states and 8 non-expansion states. Moreover, using CHC data from the 8 expansion-states, we will examine differences in utilization among patients gaining new Medicaid coverage (newly insured), as compared to those already insured by Medicaid (already insured) and those who remain uninsured (uninsured). Finally, building on our prior work, we will link EHR data from the 213 OCHIN clinics in Oregon to Medicaid administrative claim data to assess overall healthcare utilization (including care received outside of CHCs, such as hospitalization) and to compare Medicaid expenditures among newly insured individuals versus those already insured. We will study insurance coverage, healthcare utilization, and Medicaid expenditures addressing the following specific aims: Aim 1: compare pre-post health insurance status, primary care, mental health, and dental visits, and receipt of preventive services, as well as changes in payer mix among OCHIN CHCs in states that did and did not expand Medicaid; Aim 2: Examine pre-post utilization of CHC services (including receipt of preventive services) by newly insured patients compared to already insured patients and uninsured patients; and, Aim 3: Measure pre-post Medicaid expansion changes in overall utilization of healthcare services and costs to the Oregon Medicaid program among newly insured compared to already insured. The findings from this project will be extremely relevant to policy and practice, informing further improvements in the US healthcare system to ensure access to healthcare for vulnerable populations.