The Affordable Care Act’s Role in Aging Disparities Before and After Medicare Eligibility

项目摘要/摘要 尽管美国的总体预期寿命最近有所提高，但老年人(年龄)的种族/民族健康差距 (≥65)持续并在扩大。这包括健康状况、慢性病负担、残疾和 黑人和西班牙裔老年人的预期寿命与白人相比。我们之前的工作已经发现 中年(50岁-) 可能会受到干预。2014年《平价医疗法案》的覆盖范围扩大显示出 缩小了获得机会和健康方面的差距，但对中老年人的影响主要是 未得到充分研究。 这项提案的首要目标是检查暴露在ACA保险范围内(医疗补助和 市场计划)和对中年人(50岁-)的护理可能会影响下游健康 老年人的差异(65岁的≥)。我们将在所有目标中使用两种建模方法：a)中断时间 一系列分析，以评估整个ACA覆盖范围扩大对种族/民族差距的影响 与2014年后的对比；以及b)比较医疗补助的差异(DID)分析和事件研究模型 估计每个种族/民族(黑人、西班牙裔、白人)的扩张和非扩张状态以进行评估 医疗补助对贫富差距的具体影响。在所有分析中，我们还将检查治疗的异质性 个人层面交叉身份(种族、族裔、性别、社会经济地位)和地区层面的影响 结构性种族主义。 通过这种方法，我们将实现以下具体目标：1)评估种族/民族差距如何 中年人的医疗保险覆盖面在ACA覆盖范围扩大之前与之后发生了变化， 使用美国社区调查；2)估计中年人医疗保健中的种族/民族差异 ACA覆盖范围扩展前后的访问和自付成本，使用健康和 退休研究(HRS)和当前人口调查；以及3)调查#年的种族/族裔差距 中老年人健康状况、老年人医疗服务利用情况和医疗费用 ACA，使用与HRS相关的医疗保险数据。 拟议的工作意义重大，因为在经济困难和健康差距日益恶化的时期，它 将直接告知美国医疗保险政策，以改善弱势群体的健康公平。这个 方法在使用ACA的自然实验和明确关注结构性种族主义方面具有创新性 了解ACA的上游政策干预是否会影响中年人的覆盖率 可能会影响中老年人随着年龄增长的健康和保健差距的轨迹。

PROJECT SUMMARY / ABSTRACT Despite recent gains in overall life expectancy in the US, racial/ethnic health disparities in older adults (age ≥65) persist and are widening. This includes disparities in health status, chronic disease burden, disability, and life expectancy for Black and Hispanic older adults compared with whites. Our previous work has identified mid-life (age 50-64) as a critical period when health disparities for racial/ethnic minorities are set and may potentially be intervened upon. The Affordable Care Act coverage expansions of 2014 have shown promise for reducing disparities in access and health, but the impact on middle-aged and older adults has been largely understudied. The overarching goal of this proposal is to examine whether exposure to ACA coverage (Medicaid and Marketplace plans) and access to care for middle-aged adults (age 50-64) may affect downstream health disparities in older adults (age ≥65). We will use two modeling approaches in all aims: a) interrupted time series analysis to assess the impact of the entire ACA coverage expansion on racial/ethnic disparities before vs. after 2014; and b) difference-in-differences (DID) analysis and event study models comparing Medicaid expansion vs. non-expansion states estimated for each racial/ethnic group (Black, Hispanic, white) to assess the specific impact of Medicaid on disparities. In all analyses, we will also examine heterogeneity of treatment effects by individual-level intersecting identities (race, ethnicity, gender, socioeconomic status) and area-level structural racism. With this approach, we will achieve the following specific aims: 1) Assess how racial/ethnic disparities in middle-aged adults’ health insurance coverage has changed before vs. after the ACA coverage expansions, using the American Community Survey; 2) Estimate racial/ethnic disparities in middle-aged adults’ health care access and out-of-pocket costs before and after the ACA coverage expansions, using the Health and Retirement Study (HRS) and the Current Population Survey; and 3) Investigate racial/ethnic disparities in middle-aged and older adults’ health, and older adults’ health care utilization and costs before and after the ACA, using the HRS-linked Medicare data. The proposed work is significant because, in a time of economic distress and worsening health disparities, it will directly inform US health insurance policies to improve health equity for vulnerable populations. The methods are innovative in using the natural experiment of the ACA and an explicit focus on structural racism to understand whether the upstream policy intervention of the ACA that affected coverage of middle-aged adults may impact trajectories of health and health care disparities of middle-aged and older adults as they age.