Medicaid Expansion, Coverage Loss, and Disparities in Kidney Health in the COVID-19 Era

项目摘要 肾衰竭的负担，一种威胁生命的疾病，困扰着近75万美国人，福尔斯下降 不成比例地对美国最弱势的社区。获得护理的机会不足， 缺乏医疗保险是造成种族/族裔和社会经济不平等的关键因素， 开始肾脏替代治疗后肾衰竭的发生率和结局。在我们目前的拨款中 （R 01 DK 113298），我们发现，在开始透析的非老年患者中， 平价医疗法案（ACA）减少了不保险，增加了开始长期血液透析的可能性 具有成熟或功能性动静脉通路，并降低了一年死亡率。与白色相比 黑人患者在扩展后死亡率绝对下降3倍。 虽然有越来越多的证据表明医疗补助扩大对获得医疗和健康的影响， 这些先前的研究审查了经济持续增长和不保险率下降的时期。 但在经济困难时期，扩大医疗补助覆盖范围的影响可能会被放大。期间 在COVID-19大流行的前六周，前所未有的4000万美国人提交了 失业救济金，预计覆盖率将大幅下降，特别是在非扩张州。 此外，COVID-19的死亡率在种族/少数民族人群和患有 慢性疾病，包括肾脏疾病。这一流行病还扰乱了护理工作， 对具有复杂医疗需求和社会风险因素的人群的影响。国家估计数 需要了解COVID-19和扩大医疗补助覆盖范围对获得护理和结果的影响 有效的公共卫生应对措施。此R 01更新应用程序将检查覆盖范围，获得 大流行期间和之后肾衰竭患者的护理、移植评估和死亡率 (Aim 1），以及医疗补助扩大对治疗和结果差异的保护作用。 肾衰竭（目标2）和发病率（目标3）。我们研究的理由是，COVID-19大流行 对肾病患者获得护理和健康结果构成根本威胁，但 扩大医疗补助覆盖范围可以减轻这些影响，减少种族/民族和社会经济差异， 从而为健康政策提供信息。我们通过地理定位ESKD患者的地址数据进行创新， 从而导出关于邻域缺点的粒度信息，在小范围内对发生率进行建模， 地理区域，并确定生活在高感染率地区的患者。此外，我们认为， 医疗补助扩大对移植和家庭透析差异的长期影响，这是两种替代方案， 2019年推进美国肾脏健康行政命令优先考虑血液透析。我们期望这 一项提案可以通过提供对扩大医疗补助的影响的及时和严格的估计来为政策提供信息 报道COVID-19大流行及其经济后果后肾脏健康的差异。

Project Summary The burden of kidney failure, a life-threatening condition that afflicts nearly 750,000 Americans, falls disproportionately on the most socially disadvantaged communities in the US. Inadequate access to care and lack of health insurance coverage are critical drivers of racial/ethnic and socioeconomic disparities in the incidence of kidney failure and outcomes after initiating kidney replacement therapy. In our current grant (R01DK113298), we found that, among nonelderly patients initiating dialysis, Medicaid expansions under the Affordable Care Act (ACA) reduced uninsurance, increased the likelihood of starting long-term hemodialysis with maturing or functional arteriovenous access, and lowered one-year mortality. Compared with white patients, Black patients experienced a 3-fold greater absolute decline in mortality following expansion. Although there is a growing evidence base of the impact of Medicaid expansion on access to care and health, these prior studies have examined a period of sustained economic growth and declining rates of uninsurance. But the effects of expanded Medicaid coverage may be magnified during times of economic distress. During the first six weeks of the COVID-19 pandemic, an unprecedented forty million Americans have filed unemployment benefits, with expectations of stark coverage losses, particularly in nonexpansion states. Moreover, death rates from COVID-19 are higher in racial/ethnic minority populations and among patients with chronic conditions, including kidney disease. The pandemic has also disrupted care, with potential adverse consequences for populations with complex medical needs and social risk factors. National estimates of the impact of COVID-19 and expanded Medicaid coverage on access to care and outcomes are needed to inform effective public health responses. This R01 renewal application will examine disparities in coverage, access to care, transplant evaluation, and mortality among patients with kidney failure during and after the pandemic (Aim 1), as well as the protective role of Medicaid expansion on disparities in treatment and outcomes of kidney failure (Aim 2), and incidence (Aim 3). The rationale for our study is that the COVID-19 pandemic presents fundamental threats to access to care and health outcomes for persons with kidney disease, but expanded Medicaid coverage may attenuate these effects, reduce racial/ethnic and socioeconomic disparities, and therefore inform health policy. We innovate by geolocating address data for incident ESKD patients, thereby deriving granular information on neighborhood disadvantage, modeling incidence within small geographic areas, and identifying patients living in areas with high infection rates. Further, we consider the long-term effects of Medicaid expansion on disparities in transplantation and home dialysis, two alternatives to hemodialysis prioritized by the 2019 Advancing American Kidney Health Executive Order. We expect that this proposal can inform policy by providing timely and rigorous estimates of the effects of expanded Medicaid coverage on disparities in kidney health following the COVID-19 pandemic and its economic aftermath.