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

今天美国的一个核心政策假设是，扩大医疗保险覆盖面将改善医疗保险的质量。 获得医疗保健，改善健康结果，并使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），“医疗保健领域最重要的立法”， 自医疗保险和医疗补助法案通过以来，“为减少种族/民族差异， 医疗服务和人口健康。 目的是评估2014年ACA覆盖范围扩大对种族/族裔的影响， 在卫生保健获取、利用、结果和质量方面的差距，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（艾德）检查措施 利用率其次，更好地关注西班牙裔，这是最大的种族/少数民族， 比非西班牙裔白人（15%），非西班牙裔黑人（21%）和亚洲人（26%），我们将 通过结合来自22个州的州住院患者出院数据，开发一个接近全国的数据库， 占全国西班牙裔人口的88%以上;相应的艾德数据可从 13个州的子集。第三，ACA的扩张远不是一种统一的干预， 在实施中的变化，特别是在各州;我们将评估改革如何影响拉美裔人 受语言障碍、国籍、基线不保险、州医疗补助慷慨程度的影响， 供应商可用性。 为了估计与2014年ACA保险扩展相关的变化，我们将使用 差异中的差异设计，其中，扩展前（2010-2013）至扩展后（2014-2017） 研究结果指标的变化与对照组中的变化进行了对比， 没有保险扩张。我们的具体目标是估计与ACA覆盖率相关的变化 （1）门诊护理敏感性疾病入院率和艾德访视率增加，（2）重大择期 程序，（3）住院死亡率和30天再入院率，以及（4）使用安全网医院与非安全网医院的比较， 安全网医院，以及按种族/族裔分列的这类比率的差异。我们将研究结果的变化 西班牙裔美国人的英语语言能力，民族血统，性别和社会经济 status. 我们的提案具有独特的优势：所使用的数据代表了西班牙裔的近全国人口;它 描绘了对拉美裔弱势群体的影响;它确定了潜在的促进作用， 抑制因素，如供应商的可用性和国家医疗补助政策。

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.