Access to Healthcare as a Driver of Place-Based Inequality in Mid-Life Mortality: Evidence from Movers in Medicaid

获得医疗保健是中年死亡率地区不平等的一个驱动因素：来自医疗补助推动者的证据

• 批准号: 10583235
• 负责人: Jacob Witt Samuel Wallace
• 金额: $ 49.94万
• 依托单位: YALE UNIVERSITY
• 依托单位国家: 美国
• 财政年份: 2023
• 资助国家: 美国
• 起止时间: 2023-09-15 至 2026-05-31
• 项目状态: 未结题
• 来源: https://reporter.nih.gov/project-details/10583235
• 关键词: Address; Adoption; Adult; American; Area; California; Caring; Characteristics; Climate; Clinical; Communities; Complex; Consensus; Country; County; Data Set; Destinations; Disparity; Economics; Effectiveness; Ethnic Origin; Evidence based treatment; Family; Gender; Geography; Goals; Grant; Health; Health Insurance; Health Services; Health Services Accessibility; Healthcare; Improve Access; Individual; Inequality; Inequity; Institution; Insurance Coverage; Interdisciplinary Health Team; Intervention; Life Expectancy; Literature; Living Costs; Longevity; Low Income Population; Low income; Medicaid; Medicare; Mental Health Services; Mental disorders; Methodology; National Institute of Mental Health; Neighborhoods; Outcome; Persons; Pharmaceutical Preparations; Policies; Population; Positioning Attribute; Public Health; Public Policy; Quasi-experiment; Race; Research; Research Design; Research Personnel; Role; Shapes; Social Gradients; Sorting; Source; Substance Use Disorder; Suicide; System; Time; United States; United States National Institutes of Health; Vermont; Woman; alcohol-related death; behavioral health; design; evidence base; geographic difference; health care availability; health care delivery; health care disparity; health care service; health care service utilization; health difference; health disparity; health disparity populations; health equity; health inequalities; improved; innovation; men; middle age; migration; mortality; novel; policy implication; population health; programs; sociodemographic group; sociodemographics

PROJECT SUMMARY It is well-documented that where you reside in America shapes when you die, and this has been shown to be particularly true among low-income Americans. These place-based inequalities in health have grown over time in the United States, driven by increased mid-life mortality due to drug- and alcohol-related deaths and suicides. While the drivers of this rise in mid-life mortality are complex and multifactorial, there is broad consensus that the adoption of evidence-based treatments for substance use disorder and mental illness has the potential to improve health and save lives. Despite their effectiveness, behavioral health services are generally thought to be underused, with very limited access to these services in some regions of the country. We study the drivers of place-based inequities in the Medicaid program, the primary source of insurance coverage and payer of behavioral health services for low-income populations. This application seeks to understand whether and to what extent place-based inequalities in mid-life mortality — and their gradients by gender and race/ethnicity — are driven by the causal effects of place on access to evidence-based behavioral healthcare treatment by studying the low-income population on Medicaid. Because families sort into areas based on a wide range of factors — e.g., economic opportunity, amenities, cost-of-living, etc. — if people predisposed to poor (or good) health outcomes tend to cluster in particular localities then observed health differences between areas may reflect this non-random sorting (or “selection”) rather than the causal effects of place. To address this challenge, we use a quasi-experimental movers research design that follows otherwise similar Medicaid enrollees residing in the same place that move to different destinations. Subsequent differences in their healthcare utilization and health can be attributed to place effects if movers are observed for a period of time before the move to adjust for baseline outcomes. Second, to better under social gradients we stratify by sociodemographic characteristics and recover the effects of places for distinct groups —comparing differences in the impacts of a place on different groups reveals whether it tends to narrow or widen inequalities. Finally, we examine whether place-based effects correlated with immutable characteristics of areas (e.g., climate) or features that are more readily amenable to policy intervention (e.g., the healthcare delivery system). We make an original contribution, by advancing the understanding of the relationship between “place” and health for low-income populations, with a focus on understanding the role of differential access to high-quality, behavioral healthcare services.

项目摘要 有充分的证据表明，你在美国居住的地方会影响你的死亡时间， 在低收入的美国人中尤其如此。这些基于地点的健康不平等随着时间的推移而加剧 在美国，由于与毒品和酒精有关的死亡和自杀造成的中年死亡率上升。 虽然中年死亡率上升的驱动因素是复杂和多因素的，但人们普遍认为， 对物质使用障碍和精神疾病采用循证治疗有可能 改善健康和拯救生命。尽管有效，行为健康服务通常被认为 这些服务没有得到充分利用，在该国的一些地区，获得这些服务的机会非常有限。我们研究了 医疗补助计划中基于地点的不平等，保险覆盖的主要来源和支付者， 为低收入人群提供行为健康服务。本申请旨在了解是否以及 中年死亡率基于地点的不平等程度-及其按性别和种族/族裔划分的梯度- 受地点对获得循证行为医疗保健治疗的因果影响的驱动， 低收入人群的医疗补助因为家庭根据各种因素划分区域- 例如，在一个实施例中，经济机会、便利设施、生活费用等--如果人们倾向于健康状况不佳（或良好） 结果往往集中在特定的地区，那么观察到的地区之间的健康差异可能反映了这一点 非随机排序（或“选择”），而不是位置的因果效应。为了应对这一挑战，我们使用 准实验推动者的研究设计，遵循居住在 同一个地方，不同的目的地。他们的医疗保健利用和健康的后续差异 可以归因于地点效应，如果在移动之前观察移动者一段时间以调整 基线结果。第二，为了更好地适应社会梯度，我们根据社会人口特征进行分层， 恢复地方对不同群体的影响-比较一个地方对不同群体的影响差异 群体揭示了它是倾向于缩小还是扩大不平等。最后，我们研究了基于地点的效应是否 与区域的不可变特性相关（例如，气候）或更容易适应的特征 政策干预（例如，医疗保健提供系统）。我们做出了原创性的贡献， 了解“地点”与低收入人群健康之间的关系，重点是 理解高质量、行为医疗保健服务的差异化获取的作用。