Drake Coleman, Abraham Jean M, McCullough Jeffrey S
Division of Health Policy and Management, University of Minnesota, Minneapolis, Minnesota.
J Rural Health. 2016 Jun;32(3):332-9. doi: 10.1111/jrh.12149. Epub 2015 Sep 24.
We sought to examine the demographic, market, and policy-related factors influencing first year enrollment rates for the population targeted by the Health Insurance Marketplaces (HIMs) established as part of the Affordable Care Act. In particular, we analyzed differences in enrollment rates across urban and rural counties in 32 states served by the Federally Facilitated Marketplace.
We used enrollment data from the Assistant Secretary for Planning and Evaluation of the US Department of Health and Human Services and demographic data from the American Community Survey, supplemented with other market and policy-related information. Using multivariate regression, we investigated how county-level enrollment rates are associated with demographic, market and policy-related characteristics, including rurality.
Relative to an adjusted mean enrollment rate of 17.1% for large metropolitan counties, small metropolitan counties have a 2.8% lower enrollment rate and rural counties have a 2.7% lower enrollment rate. States' decisions to expand Medicaid and to have the federal government fully manage the HIM are both negatively associated with enrollment rates. Partnership HIMs exhibit a positive association with enrollment rates as do navigator grants, but the latter relationship is only present in counties located in Medicaid expansion states.
Enrollment rates vary by rurality, but differences are statistically significant only between large metropolitan counties and all other types of counties-small metropolitan, micropolitan, and noncore. State-level policies, particularly Medicaid expansion, have the largest association with enrollment rates among the explanatory variables examined in the model.
我们试图研究影响《平价医疗法案》设立的医疗保险市场（HIM）所针对人群首年参保率的人口统计学、市场及政策相关因素。具体而言，我们分析了联邦政府提供便利的医保市场所服务的32个州城乡县份参保率的差异。
我们使用了美国卫生与公众服务部规划与评估助理部长提供的参保数据以及美国社区调查的人口统计数据，并补充了其他市场及政策相关信息。通过多元回归分析，我们研究了县级参保率如何与人口统计学、市场及政策相关特征（包括农村地区特征）相关联。
相对于大型都市县调整后的平均参保率17.1%，小型都市县的参保率低2.8%，农村县的参保率低2.7%。各州扩大医疗补助计划以及让联邦政府全面管理医疗保险市场的决定均与参保率呈负相关。合作型医疗保险市场与参保率呈正相关，导航员补助也是如此，但后者的关系仅存在于医疗补助计划扩大州的县份。
参保率因农村地区情况而异，但差异仅在大型都市县与所有其他类型的县（小型都市县、微型都市县和非核心县）之间具有统计学意义。在模型中所考察的解释变量中，州级政策，尤其是医疗补助计划的扩大，与参保率的关联最为密切。
