Effects of Expanded Coverage on Access, Health Care and Health in the South

描述（由申请人提供）：该项目将提供及时和严格的分析负担得起的医疗法案（ACA）对医疗保健使用和结果的保险覆盖范围扩大的影响，在12个南方州（VA，WV，KY，TN，NC，SC，FL，GA，AL，MS，LA，AR）的一大批低收入成年人。ACA的覆盖范围改革包括自1965年医疗保险和医疗补助以来最大的保险扩张。研究扩大对医疗保健的影响以及旨在从扩大覆盖范围中受益的社会人口和临床群体的结果，对于推进有关保险范围与健康之间关系的科学知识以及告知国家决定在未来几年扩大医疗补助至关重要。在该国没有任何地区的不保险率更高，慢性病和癌症的流行率更高，ACA的覆盖范围扩大的实施预计将比南方更多样化。拟议的5年研究项目将利用这些地区特点和美国有史以来招募的最大的低收入、无保险和少数族裔成年人队列（总计近85,000人），即南方社区队列研究（SCCS）。我们将在ACA改革的第二年（2015年）及时进行额外调查，并在2016年计划的一轮后续调查中增加问题，以增加2002-2014年SCCS现有基线和后续调查数据-2017年，以支持对改革对健康的早期和后期影响的一致评估，并探索患者在获得医疗保险和获得医疗服务方面的经验。后扩张时代通过将这些数据与癌症登记和医疗保险和医疗补助索赔数据相结合，并通过建立数据链接，以及与州立医院出院数据库建立新的数据链接，我们的目标是量化覆盖范围扩大对以下方面的影响：（目标1）获得护理，癌症筛查和使用预防性临床服务;（目标2）自我报告的健康结果，死亡率和使用紧急和住院护理;（3）乳腺癌、肺癌和结直肠癌成人患者的诊断和癌症护理质量的癌症分期。我们将包括在保险改革之前可能没有保险的群体，以及先前有保险的成年人，他们获得医疗服务的机会可能会因其他人的保险范围扩大而受到影响。为了确定这些效应，我们将采用严格的准实验差异设计， 在覆盖范围扩展中利用状态内和状态间的变化。我们的分析方法还将结合回归和基于倾向评分的调整，以平衡比较组之间观察到的特征。最后，由于我们数据的纵向性质和队列中观察到的高死亡率，我们将在适当的情况下使用先进的方法学方法来联合建模死亡和健康结局。简而言之，我们及时的准实验分析将有助于描述ACA覆盖范围改革的价值，将为未来关于覆盖范围扩大的政策辩论提供信息，并将促进对保险覆盖范围对医疗保健使用和健康结果影响的理解。

DESCRIPTION (provided by applicant): This project will provide timely and rigorous analysis of the effect of the Affordable Care Act's (ACA) insurance coverage expansions on health care use and outcomes among a large cohort of low-income adults in 12 southern states (VA, WV, KY, TN, NC, SC, FL ,GA, AL, MS, LA, AR). The ACA's coverage reforms encompass the largest insurance expansion since Medicare and Medicaid in 1965. Examining the effects of expansions on health care and outcomes for socio-demographic and clinical groups intended to benefit from expanded coverage will be critical to advancing scientific knowledge about the relationship between insurance coverage and health and to informing state decisions to expand Medicaid over the next several years. In no region of the country are rates of uninsurance higher, the prevalence of chronic conditions and cancer greater, and the implementation of the ACA's coverage expansions expected to be more varied, than in the South. The proposed 5-year research project will draw on these regional characteristics and the largest cohort of low- income, uninsured, and minority adults ever recruited in the US (nearly 85,000 in total), the Southern Community Cohort Study (SCCS). We will augment existing baseline and follow-up SCCS survey data from 2002-2014 by fielding a timely additional survey in the second year of ACA reforms (2015) and by adding questions to a planned round of follow-up in 2016-2017 to support consistent assessment of early and later effects of the reforms on health and to explore patient experiences obtaining coverage and accessing care in the post-expansions era. By combining these data with cancer registry and Medicare and Medicaid claims data through established data linkages, as well as establishing novel data linkages with state hospital discharge databases, we aim to quantify the effects of coverage expansion on: (Aim 1) access to care, cancer screening and use of preventive clinical services; (Aim 2) self-reported health outcomes, mortality and use of emergent and inpatient care; and (Aim 3) cancer stage at diagnosis and quality of cancer care for adults with breast, lung, and colorectal cancer. We will groups likely to be uninsured before coverage reforms as well as adults with prior coverage whose access to care could plausibly be compromised by coverage expansions for others. To identify these effects, we will apply rigorous quasi-experimental difference-in-difference designs, exploiting both within- and between-state variation in coverage expansions. Our analytic approach will also incorporate regression and propensity score-based adjustment to balance observed characteristics between comparison groups. Finally, due to the longitudinal nature of our data and high observed mortality rates in the cohort, where appropriate we will use advanced methodological approaches to modeling death and health outcomes jointly. In short, our timely quasi-experimental analyses will help characterize the value of the ACA's coverage reforms, will inform policy debates over coverage expansions moving forward, and will advance understanding of the effects of insurance coverage on health care use and health outcomes.