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

项目摘要 肾衰竭是一种危及生命的疾病，困扰着近75万美国人，它的负担减轻了 不成比例地集中在美国社会最不利的社区。没有足够的机会获得护理和 缺乏医疗保险是#年种族/族裔和社会经济差距的关键驱动因素。 肾功能衰竭的发生率和启动肾脏替代治疗后的结果。在我们目前的拨款中 (R01DK113298)，我们发现，在开始透析的非老年患者中，根据 《平价医疗法案》(ACA)减少了未投保，增加了开始长期血液透析的可能性 动静脉通路成熟或功能正常，一年死亡率较低。与白色相比 在患者中，黑人患者在扩大治疗后的死亡率绝对值下降了3倍。 尽管有越来越多的证据表明，扩大医疗补助对获得护理和健康的影响， 这些先前的研究考察了经济持续增长和失保率下降的时期。 但在经济困难时期，扩大医疗补助覆盖面的影响可能会放大。在.期间 新冠肺炎大流行的前六周，史无前例的4,000万美国人提交了 失业救济金，预计将出现明显的保险损失，特别是在不扩张的州。 此外，在少数族裔人群和患有新冠肺炎的患者中，新冠肺炎的死亡率更高。 慢性疾病，包括肾脏疾病。这种大流行还扰乱了医疗保健，可能会带来不利影响 对有复杂医疗需求和社会风险因素的人群造成的后果。国家估计的 需要了解新冠肺炎和扩大医疗补助覆盖范围对获得护理的机会和结果的影响 有效的公共卫生应对措施。此R01续订申请将检查覆盖范围、访问 大流行期间和之后肾功能衰竭患者的护理、移植评估和死亡率 (目标1)，以及扩大医疗补助对以下方面的治疗和结果差异的保护作用 肾功能衰竭(目标2)和发病率(目标3)。我们研究的理由是新冠肺炎大流行 对肾病患者获得护理和健康结果构成根本性威胁，但 扩大医疗补助覆盖范围可能会减弱这些影响，缩小种族/民族和社会经济差距， 并因此为卫生政策提供信息。我们通过对ESKD事件患者的地址数据进行地理定位进行创新， 从而获得关于邻里劣势的细粒度信息， 地理区域，并识别生活在高感染率地区的患者。此外，我们认为 扩大医疗补助对移植和家庭透析两种替代方案差异的长期影响 血液透析被2019年推进的美国肾脏健康行政命令列为优先事项。我们预计这一次 提案可以通过对扩大医疗补助的影响提供及时和严格的估计来为政策提供信息 报道新冠肺炎大流行及其经济后果后肾脏健康方面的差异。

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.