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

摘要 新冠肺炎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。缺乏医疗保险直接影响到医疗保健的机会和结果。未投保 患者的支出是灾难性的，死亡率更高，出院后获得的机会更有限。 对重返工作岗位至关重要的资源。这些负面影响在种族和 少数民族。我们有一个前所未有的、及时的机会来研究我们国家的没有保险的人。在… 截至2018年底，近14%的美国人口没有保险，这一数字随着 与新冠肺炎相关的失业率飙升。目前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 对于未参保的患者。HPE提供临时的医疗补助覆盖范围(最多60天)，但随后将 患者登记参加医疗补助，以便继续承保。根据新冠肺炎，几个州正在 拓宽他们的HPE资格标准。目前对影响HPE收购的因素知之甚少，因为 以及HPE后的医疗补助登记及其与获得护理的联系。在我们的前期工作中，少数民族 需要出院后服务的病人、临床病情较严重的病人(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，只有53%的人参加了医疗补助。我们假设在那里 是可修改的患者和系统级别的障碍，限制了HPE后的医疗补助登记。作为管理人员 和临床注册数据既不包括HPE批准，也不包括医疗补助登记，我们将分析新的 通过加州卫生保健服务部(DHCS)评估定制的保险数据集 HPE计划，并确定改进机会。 拟议的工作将通过两个具体目标来完成：(SA1)在经HPE批准的合格人员中 患者，我们将确定与HPE后相关的社会人口学、临床和医院因素 医疗补助登记，以及(SA2)了解患者对导致或 在HPE批准后，阻碍了医疗补助的登记。 可以利用住院时间来获得可持续的保险覆盖范围，从而改善患者的 这将有助于改善长期健康结果，并降低其灾难性保健支出的风险。我们的研究评估了 卫生保健方案最有针对性地是改善健康结果和获得护理的机会，特别是在 脆弱的少数族裔患者。

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.