Soni Aparna, Hendryx Michael, Simon Kosali
Department of Business Economics and Public Policy, Kelley School of Business, Indiana University, Bloomington, Indiana.
Department of Applied Health Science, School of Public Health, Indiana University, Bloomington, Indiana.
J Rural Health. 2017 Apr;33(2):217-226. doi: 10.1111/jrh.12234. Epub 2017 Jan 23.
To analyze the differential rural-urban impacts of the Affordable Care Act Medicaid expansion on low-income childless adults' health insurance coverage.
Using data from the American Community Survey years 2011-2015, we conducted a difference-in-differences regression analysis to test for changes in the probability of low-income childless adults having insurance in states that expanded Medicaid versus states that did not expand, in rural versus urban areas. Analyses employed survey weights, adjusted for covariates, and included a set of falsification tests as well as sensitivity analyses.
Medicaid expansion under the Affordable Care Act increased the probability of Medicaid coverage for targeted populations in rural and urban areas, with a significantly greater increase in rural areas (P < .05), but some of these gains were offset by reductions in individual purchased insurance among rural populations (P < .01). Falsification tests showed that the insurance increases were specific to low-income childless adults, as expected, and were largely insignificant for other populations.
The Medicaid expansion increased the probability of having "any insurance" for the pooled urban and rural low-income populations, and it specifically increased Medicaid coverage more in rural versus urban populations. There was some evidence that the expansion was accompanied by some shifting from individual purchased insurance to Medicaid in rural areas, and there is a need for future work to understand the implications of this shift on expenditures, access to care and utilization.
分析《平价医疗法案》医疗补助扩大计划对城乡低收入无子女成年人医疗保险覆盖范围的差异化影响。
利用2011 - 2015年美国社区调查的数据，我们进行了双重差分回归分析，以检验在医疗补助扩大的州与未扩大的州中，农村和城市地区低收入无子女成年人拥有保险的概率变化。分析采用了调查权重，并对协变量进行了调整，还包括一组虚拟检验以及敏感性分析。
《平价医疗法案》下的医疗补助扩大计划增加了农村和城市地区目标人群获得医疗补助的概率，农村地区的增幅显著更大（P < 0.05），但农村人口中个人购买保险的减少抵消了部分增加的幅度（P < 0.01）。虚拟检验表明，正如预期的那样，保险覆盖率的增加特定于低收入无子女成年人，而对其他人群来说在很大程度上并不显著。
医疗补助扩大计划增加了城乡低收入人群拥有“任何保险”的概率，并且在农村人群中比城市人群更显著地增加了医疗补助覆盖率。有证据表明，在农村地区，这种扩大伴随着一些从个人购买保险转向医疗补助的情况，未来有必要开展工作以了解这种转变对支出、医疗服务可及性和利用的影响。
