Reducing Disparities for the Uninsured: Identifying Opportunities for Improved Coverage Through Emergency Medicaid Programs

摘要 2019冠状病毒病大流行和种族正义运动暴露了我们国家的结构性问题， 医疗保健系统。缺乏健康保险直接影响到医疗保健的获得和结果。没有保险 病人有灾难性的支出，更高的死亡率，更有限的获得出院后 这些资源对于恢复工作至关重要。这些负面影响在种族和族裔之间加剧， 少数民族。我们有一个前所未有的和及时的机会来研究我们国家的无保险者。在 截至2018年底，近14%的美国人口没有保险，这一数字随着 与COVID-19相关的失业率飙升。迫切需要缩小保险差距。 一个潜在的解决方案，医院推定资格（HPE），使医院能够申请紧急保险 没有保险的病人。HPE提供临时医疗补助保险（最长60天），但随后 患者参加医疗补助，以继续覆盖。鉴于COVID-19，几个州 拓宽HPE资格标准。目前对影响HPE收购的因素知之甚少， 以及HPE后的医疗补助登记及其与获得护理的关联。在我们的初步工作中， 患者、临床严重程度较高的患者和需要出院后服务的患者（包括 康复，长期护理）都更有可能被批准用于HPE。在大约1000个HPE中 2018年在我们机构获得批准的患者中，只有53%参加了医疗补助计划。我们假设 是可修改的患者和系统级障碍，阻碍了HPE之后的Medicaid登记。行政 和临床登记数据既没有获得HPE批准，也没有获得Medicaid登记，我们将分析新的 通过加州卫生保健服务部（DHCS）定制保险数据集， HPE计划并发现改进机会。 拟议工作将通过两个具体目标完成：（SA 1）在符合条件的HPE批准的 我们将确定与HPE后相关的社会人口统计学、临床和医院因素 医疗补助登记，以及（SA 2）了解患者对促成或 在获得HPE批准后阻止加入Medicaid。 可以利用住院时间获得可持续的保险覆盖，提高患者的健康水平。 长期的健康结果，并减少他们的灾难性卫生支出的风险。我们的研究评估了 慧与计划的最佳目标是改善健康结果和获得护理的机会，尤其是 脆弱的少数民族患者

ABSTRACT The COVID-19 pandemic and racial justice movements have laid bare the structural problems in our healthcare system. Lack of health insurance directly impacts health care access and outcomes. Uninsured patients have catastrophic expenditures, higher rates of mortality, and more limited access to post-discharge resources that are critical for returning to work. These negative impacts are exacerbated among racial and ethnic minorities. We have an unprecedented and timely opportunity to study the uninsured in our nation. At the end of 2018, nearly 14% of the US population were uninsured, a number that has further increased with spikes in unemployment related to COVID-19. There is an urgent need to reduce insurance disparities. A potential solution, Hospital Presumptive Eligibility (HPE), enables hospitals to apply for emergency insurance for uninsured patients. HPE provides temporary Medicaid coverage (up to 60 days), but subsequently enables patients to enroll in Medicaid in order to continue coverage. In light of COVID-19, several states are broadening their HPE eligibility criteria. Little is currently known about factors influencing HPE acquisition, as well as Medicaid enrollment post-HPE and its association with access to care. In our preliminary work, minority patients, those with greater clinical severity, and patients requiring post-discharge services (including rehabilitation, long-term care) were all more likely to be approved for HPE. Among approximately 1000 HPE approved patients in 2018 at our institution, only 53% of those enrolled in Medicaid. We hypothesize that there are modifiable patient- and system-level barriers inhibiting Medicaid enrollment after HPE. As administrative and clinical registry data capture neither HPE approval nor Medicaid enrollment, we will analyze novel customized insurance datasets through the California Department of Health Care Services (DHCS) to evaluate HPE programs and identify improvement opportunities. The proposed work will be accomplished through 2 specific aims: (SA1) Among eligible HPE-approved patients, we will determine the sociodemographic, clinical and hospital factors associated with post-HPE Medicaid enrollment, and (SA2) to understand patients' experiences of process factors that contributed to or impeded enrollment in Medicaid following HPE approval. The time of hospitalization can be leveraged to acquire sustainable insurance coverage that improves patients' long-term health outcomes and reduces their risk of catastrophic health expenditures. Our study evaluates how HPE programs can best be targeted toward improving health outcomes and access to care, particularly among vulnerable minority patients.