The Medicaid expansion in the age of COVID-19: Effects on coverage, access, use, financial stress, and health.

摘要 新冠肺炎疫情对美国人的健康和福祉构成了前所未有的威胁， 尤其是低收入和少数族裔美国人以及健康状况不佳或在经济衰退中失去工作的人 经济低迷。拟议的项目将审查获得负担得起的医疗保险的保护效果 贫穷和低收入的美国人在他们的生活受到重大健康、经济和社会干扰的背景下。 获得负担得起的医疗保险的机会因州而异，因为只有35个州和哥伦比亚特区 已将医疗补助扩大到所有收入低于允许贫困人口138%的劳动适龄成年人 根据《平价医疗法案》。拟议的项目有三个具体目标： 目的1.评估扩大医疗补助对成人保险覆盖范围和 新冠肺炎大流行爆发后的儿童。 目的2.评估扩大医疗补助对获得和使用保健服务的保护作用， 卫生保健支出，以及新冠肺炎大流行爆发后的财务压力。 目的3.评估扩大医疗补助对包括身体健康在内的健康结果的保护作用 在新冠肺炎大流行开始后，成人和儿童的健康和心理健康。 我们亦会评估这些措施对弱势社群(包括穷人和低收入人士)的保障效果有何分别。 有收入的人、非裔美国人和西班牙裔人、健康状况不佳的人和失业者。 我们将采用两项相辅相成的全国性调查--国民健康访谈调查(NHIS)和 医疗支出小组调查(MEPS)-对跨越疾病开始的数据进行的阶段性分析 大流行。NHIS涵盖了许多结果，其中特别详细地衡量了经济压力、儿童 心理健康，以及一些健康行为。MEPS有更详细的成年人心理健康衡量标准， 医疗保健的使用和支出，其面板设计使我们能够使用更多的分析方法 对受试者特点进行综合管控。然而，欧洲议会议员的数据要到后来才能获得。 我们将使用回归分析将研究结果建模为个人特征的函数； 基线状态特征；时变的局部区域特征，包括大流行的严重性、深度 经济低迷，旨在减缓疫情蔓延的国家政策，以及坚持社会责任 距离；以及各州的医疗补助扩展状况与当地特点之间的互动。我们的 方法将使我们能够量化医疗补助扩大对研究结果的保护作用，并 评估这些影响发生的主要途径。拟议的项目将评估以下项目的价值 在新冠肺炎大流行期间，穷人和低收入者获得负担得起的医疗保险，但其 教训将适用于其他经济衰退和公共卫生危机、自然灾害和人为灾难， 以及在正常时期经历健康或经济挫折的人。

Abstract The COVID-19 pandemic has posed an unprecedented threat to the health and well-being of Americans, especially low-income and minority Americans and those in poor health or who lost jobs in the economic downturn. The proposed project will examine the protective effect of access to affordable health insurance for poor and low-income Americans in the setting of major health, economic, and social disruptions to their lives. Access to affordable health insurance differs across states because only 35 states and the District of Columbia have adopted the Medicaid expansion to all working-age adults with incomes below 138% of poverty permitted under the Affordable Care Act. The proposed project has three Specific Aims: Aim 1. To assess the protective effects of the Medicaid expansion on insurance coverage for adults and children following the onset of the COVID-19 pandemic. Aim 2. To assess the protective effects of the Medicaid expansion on access to and use of health care, health care expenditures, and financial stress following the onset of the COVID-19 pandemic. Aim 3. To assess the protective effects of the Medicaid expansion on health outcomes, including physical and mental health, for adults and children following the onset of the COVID-19 pandemic. We will also assess how the protective effects differ for disadvantaged persons including poor and low- income persons, African Americans and Hispanics, persons in poor health, and persons who lose their jobs. We will employ two complementary national surveys—the National Health Interview Survey (NHIS) and the Medical Expenditure Panel Survey (MEPS)—in a phased analysis of data straddling the onset of the pandemic. NHIS covers numerous outcomes, with especially detailed measures of financial stress, children's mental health, and some health behaviors. MEPS has more detailed measures of adults' mental health and health care use and expenditures, and its panel design enables us to use analytic methods that more comprehensively control for subjects' characteristics. However, MEPS data are not available until later. We will use regression analysis to model the study outcomes as functions of individual characteristics; baseline state characteristics; time-varying local area characteristics including pandemic severity, depth of the economic downturn, state policies intended to slow spread of the pandemic, and adherence to social distancing; and interactions between states' Medicaid expansion status and local area characteristics. Our approach will enable us to quantify the protective effects of the Medicaid expansion on the study outcomes and assess the main pathways through which these effects occur. The proposed project will assess the value of access to affordable health insurance for poor and low-income persons during the COVID-19 pandemic, but its lessons will be generalizable to other recessions and public health crises, natural and man-made disasters, and people who experience health or economic setbacks in normal times.