Insurance Instability and Disparities in Chronic Disease Outcomes

描述（由申请人提供）：在慢性病护理的过程和结果中，种族和民族的健康差异是普遍存在的，有据可查的，并始终与健康保险覆盖范围有关。保险的不稳定性（保险覆盖范围的转换频率或没有覆盖范围的差距）可能会导致慢性病护理结果的差异。随着减少差距的明确目标，马萨诸塞州（MA）健康保险改革现已将全面的健康保险覆盖范围扩大到该州98%的居民，在种族/少数民族和穷人中的覆盖率有了不成比例的提高。为了研究MA保险改革是否通过增加保险稳定性来减少健康差距，我们的具体目标是：目标1：研究改革前后保险不稳定性的变化，总体上比较种族/民族特定的少数民族人口与白人。我们假设（a）保险不稳定性在改革后时期有所下降，（c）少数种族/民族的保险不稳定性下降更多。目标二：研究与接受保险改革前护理的患者相比，接受保险后护理改革的患者是否有更好的慢性病管理过程和更好的健康结局，以及这种模式是否因种族/民族而异。我们假设，从保险改革中受益最多的少数民族在慢性病管理的过程和结果方面的改善更大，从而减少了差异。目标3：评估与保险稳定性较差的患者相比，保险稳定性较好的患者是否具有更好的慢性病护理过程和改善的健康结局，以及种族/少数民族患者是否经历了不成比例的更大收益。我们假设，更大的保险稳定性将与改善慢性病管理的过程和结果，从而减少差距。我们将开展一项创新研究，评估MA医疗保险改革实施前后六种高度流行的慢性疾病的护理过程和结果。这些病症是糖尿病、高血压、高脂血症、充血性心力衰竭、哮喘和慢性阻塞性肺病。我们将利用波士顿医疗中心及其八个附属的联邦合格社区卫生中心（新英格兰最大的安全网机构，为非洲裔美国人和西班牙裔社区提供服务）和塔夫茨医疗中心（为波士顿唐人街的一个大型亚裔美国人社区提供服务）的110，000多名受试者的现有电子医疗记录。研究完成后，我们将提供经验数据，说明保险改革和保险不稳定性对多个人群健康差异的直接影响。

DESCRIPTION (provided by applicant): Racial and ethnic health disparities in the processes and outcomes of chronic disease care are pervasive, well documented, and consistently linked to health insurance coverage. Insurance instability (the frequency of switches in insurance coverage or gaps without coverage), may contribute to disparities in outcomes of chronic disease care. With the explicit goal of reducing disparities, Massachusetts (MA) Health Insurance Reform has now extended comprehensive health insurance coverage to 98% of the state's residents, with disproportionately greater gains in coverage among racial/ethnic minorities and the poor. To examine if MA insurance reform has lessened health disparities through increased insurance stability, our specific aims are: Aim 1: To examine changes in insurance instability pre- and post-reform, overall and comparing racial/ethnic specific minority populations to whites. We hypothesize that (a) Insurance instability decreased in the post-reform period and (c) Insurance instability decreased more for racial/ethnic minorities. Aim 2: To examine whether patients receiving care post-insurance reform had better processes of chronic disease management and improved health outcomes, compared with patients receiving care pre-insurance reform, and whether such patterns vary by race/ethnicity. We hypothesize that improvements in processes and outcomes of chronic disease management were greater among racial/ethnic minorities who benefited the most from insurance reform, resulting in reduced disparities. Aim 3: To assess whether patients with more favorable insurance stability had better processes of chronic disease care and improved health outcomes compared to patients with less favorable insurance stability, and whether racial/ethnic minority patients experienced disproportionately greater gains. We hypothesize that greater insurance stability will be associated with improved processes and outcomes of chronic disease management, resulting in reduced disparities. We will conduct an innovative study to assess the processes and outcomes of care for six highly prevalent, chronic conditions before and after the implementation of MA Health Insurance Reform. These conditions are diabetes, hypertension, hyperlipidemia, congestive heart failure, asthma, and chronic obstructive pulmonary disease. We will utilize existing electronic medical records on over 110,000 subjects from Boston Medical Center and eight of its affiliated federally qualified Community Health Centers, the largest safety net institution in New England that serves African American and Hispanic communities, and Tufts Medical Center, which serves a large Asian American community in Boston's Chinatown. When the study is completed, we will provide empiric data on the direct impact of insurance reform and insurance instability on health disparities in multiple populations.