The Early Impact of Medicaid Expansion on Health Center Grantees: Effects on Quality Performance and Capacity to Provide Care

 描述(由申请人提供)：由于2012年6月最高法院的裁决，各州可以选择扩大医疗补助，许多没有扩大范围的州的没有子女的低收入成年人无法获得负担得起的保险。这一扩展决定不仅影响个人，而且对服务于这些个人的提供者(包括健康中心)具有重要的、未知的影响。在扩大规模的29个州和地区，医疗中心服务的大多数以前没有保险的患者将获得保险。在截至2015年1月尚未扩大覆盖范围的22个州中，大多数原本可以获得保险的100%以下的联邦贫困水平(FPL)以下的个人都没有保险；对于这些州的医疗中心来说，这可能会导致患者收入减少。鉴于维持人员编制水平、满足需求和提供高质量护理需要足够的收入，这也可能影响提供护理的能力和提供的护理质量。它还可能损害卫生中心继续抗击种族/民族质量差异的能力。这一点很重要，因为卫生中心在为弱势人口提供优质初级保健方面发挥着关键作用，否则他们将无法获得这种保健。鉴于对初级保健服务的预期需求增加，再加上各州和地方实体对卫生中心资金的削减，了解扩大还是不扩大医疗补助的决定如何影响卫生中心的质量表现及其提供护理的能力对于保护卫生中心及其服务的弱势群体至关重要。我们的具体目标是：(1)评估扩大医疗补助对卫生中心受赠者质量绩效的早期影响，其中将包括对11项过程和3项结果措施的前(2007-2013年)和后(2014-2015)评估；次要目标将是评估扩大医疗补助对种族/族裔质量差异的影响程度，以及(2)评估扩大医疗补助对卫生中心受资助者提供护理能力的早期影响，其中将包括按服务类别对提供的服务总数和服务总人数的变化进行事前(2007-2013年)和事后(2014-2015)的评估。我们的假设是，与非扩张州的医疗中心相比，医疗补助扩张州的医疗中心在扩张后的两年内将经历更高的质量表现，以及缩小种族/民族质量差异。我们还假设，与非扩张状态相比，处于扩张状态的中心提供护理的能力将更高。我们将使用HRSA 2007-2015年的统一数据系统(UDS)数据，这些数据每年在卫生中心一级报告。将在卫生中心一级进行病例(扩大)与对照(非扩大)的倾向得分匹配，并将使用计量经济学差异框架来估计影响。这些发现将有助于寻求潜在扩大医疗补助计划的州获得证据基础，同时帮助各州更好地了解医疗补助计划扩大对一些最脆弱人口的影响。

 DESCRIPTION (provided by applicant): As a result of the June 2012 Supreme Court decision that made Medicaid expansion optional for states, many childless low-income adults in non-expansion states are left without access to affordable coverage. Not only does this expansion decision affect individuals, but it has important, unknown impacts on providers serving these individuals, including health centers. In the 29 states and districts that have expanded, most previously uninsured patients served by health centers will gain coverage. In the 22 states that have not expanded as of January 2015, most individuals under 100% of the federal poverty level (FPL) who would have otherwise gained coverage are left uninsured; for health centers in these states, this will likely result in lesser patient revenue. Given that sufficient revenue is required to maintain staffing levels, meet demand, and provide high quality care, this may also affect capacity to provide care and the quality of care delivered. It may also compromise health centers' continued ability to combat racial/ethnic disparities in quality. This is important becaus health centers play a critical role in providing access to quality primary care for vulnerable populations who would otherwise be without access to such care. Given the projected increase in demand for primary care services coupled with health center funding reductions from states and local entities, understanding how the decision to expand versus not expand Medicaid affects the quality performance of health centers and their capacity to provide care is essential to protecting health centers and the vulnerable populations they serve. Our specific aims are: (1) to assess the early impact of Medicaid expansion on the quality performance of health center grantees, which will include a pre (2007-2013) and post (2014-2015) assessment of 11 process and 3 outcome measures; a sub-aim will be to assess to what extent, if any, Medicaid expansion affects racial/ethnic disparities in quality, and (2) to assess the early impact of Medicaid expansion on health center grantees' capacity to provide care, which will include a pre (2007-2013) and post (2014-2015) assessment of change in total number of services provided and total number of patients served, by category of service. Our hypothesis is that compared to health centers in non-expansion states, centers in Medicaid expansion states will experience higher quality performance in the two years following expansion, as well as reduced racial/ethnic disparities in quality. We also hypothesize that capacity to provide care will be higher in centers in expansion states compared to non-expansion states. We will use HRSA's 2007-2015 Uniform Data System (UDS) data, which are reported annually at the health center level. Propensity score matching of cases (expansion) versus controls (non-expansion) will be done at the health center level and an econometric difference-in-differences framework will be used to estimate the effect. Findings will contribute to the evidence base available to states looking to potentially expand their Medicaid programs, while helping states better understand how some of their most vulnerable populations are affected by Medicaid expansion.