National estimates of the impact of the affordable care act on healthcare utilization, outcomes and quality among hispanics

当今美国的一个核心政策假设是，扩大医疗保险覆盖面将改善 获得医疗保健，改善健康结果，并使每个人对所有美国人更加公平。尽管 其不确定的未来，2010年的《平价医疗法案》(ACA)是医疗保健领域最重要的立法 自《医疗保险和医疗补助》通过以来，《医疗保险和医疗补助》对减少#年的种族/族裔差距大有希望。 医疗保健服务和人口健康。 目的是评估2014年ACA覆盖面扩大对种族/族裔的影响 鉴于医疗保健服务在获取、利用、结果和质量方面的差异，拟议的研究有三个重点。 首先，我们将根据实际的医疗住院和急诊科(ED)来研究措施 利用率。第二，更好地关注拉美裔美国人，这是最大的种族/民族，保险覆盖率较高 比率(41%)高于非西班牙裔白人(15%)、非西班牙裔黑人(21%)和亚裔(26%)，我们将 通过将22个州的州住院患者出院数据结合在一起，开发一个接近全国的数据库 占全国拉美裔人口的88%以上；相应的ED数据可从 13个州的子集。第三，ACA的扩张远远不是一种统一的干预，而是产生了广泛的 实施方面的差异，特别是在各州之间；我们将评估改革在拉美裔中的影响 受到语言障碍、民族血统、基线保险、州医疗补助慷慨程度以及 提供商是否可用。 要按种族/民族估计与2014年ACA保险扩展相关的变化，我们将使用 差异设计，从扩张前(2010-2013)到扩张后(2014-2017) 将研究结果指标的变化与经历过的比较队列中的变化进行对比 不能扩大保险范围。我们的具体目标是估计与ACA覆盖相关的变化 扩大(1)门诊护理敏感情况入院和急诊就诊的比率，(2)主要选修课 程序，(3)住院死亡率和30天再入院，以及(4)使用安全网医院与不使用安全网医院 安全网医院，以及按种族/族裔划分的这类比率的差异。我们将检查结果的变化 在按英语语言水平、国籍、性别和社会经济状况划分的拉美裔亚群中 状态。 我们的提案有独特的优势：使用的数据代表了接近全国的拉美裔人口；它 描绘了对拉美裔弱势群体的影响；它确定了潜在的促进和 抑制因素，如提供者的可用性和州医疗补助政策。

A central policy assumption in the U.S. today is that expanding health insurance coverage will improve access to health care, improve health outcomes, and make each more equitable for all Americans. Despite its uncertain future, the Affordable Care Act (ACA) of 2010, "the most important legislation in health care since the passage of Medicare and Medicaid", holds great promise for reducing racial/ethnic disparities in healthcare access and population health. With the objective of evaluating the impact of the 2014 ACA coverage expansion on racial/ethnic disparities in healthcare access, utilization, outcomes and quality, the proposed study has three foci. First, we will examine measures based on actual healthcare inpatient and emergency department (ED) utilization. Second, to better focus on Hispanics, the largest racial/ethnic minority with higher uninsurance rate (41%) than among non-Hispanic whites (15%), non-Hispanic blacks (21%) and Asians (26%), we will develop a near-national database by combining state inpatient discharge data from 22 states that together account for over 88 percent of the national Hispanic population; corresponding ED data is available from a subset of 13 states. Third, far from being an uniform intervention, ACA expansion engendered wide variation in implementation, particularly across states; we will evaluate how reform effects among Hispanics are modified by language barriers, national origin, baseline uninsurance, state Medicaid generosity, and provider availability. To estimate changes associated with the 2014 ACA insurance expansion by race/ethnicity, we will use a difference-in-differences design, wherein pre-expansion (2010-2013) to post-expansion (2014-2017) changes in the study outcome measures are contrasted with those in a comparison cohort that experienced no insurance expansion. Our specific aims are to estimate the changes associated with ACA coverage expansion in rates of (1) ambulatory care sensitive condition admissions and ED visits, (2) major elective procedures, (3) inpatient mortality and 30-day readmission, and (4) use of safety-net hospitals vs. non- safety-net hospitals, and disparities in such rates by race/ethnicity. We will examine changes in outcomes among subgroups of Hispanics by English language proficiency, national origin, sex and socioeconomic status. Our proposal has unique strengths: the data used represents a near-national population of Hispanics; it delineates impact across vulnerable subgroups of Hispanics; it identifies the role of potential facilitating and inhibiting factors, such as, provider availability and state Medicaid policy.