Angier Heather, Hoopes Megan, Marino Miguel, Huguet Nathalie, Jacobs Elizabeth A, Heintzman John, Holderness Heather, Hood Carlyn M, DeVoe Jennifer E
Oregon Health & Science University, Portland, Oregon.
OCHIN, Inc, Portland, Oregon.
Ann Fam Med. 2017 Sep;15(5):434-442. doi: 10.1370/afm.2125.
Health insurance coverage affects a patient's ability to access optimal care, the percentage of insured patients on a clinic's panel has an impact on the clinic's ability to provide needed health care services, and there are racial and ethnic disparities in coverage in the United States. Thus, we aimed to assess changes in insurance coverage at community health center (CHC) visits after the Patient Protection and Affordable Care Act (ACA) Medicaid expansion by race and ethnicity.
We undertook a retrospective, observational study of visit payment type for CHC patients aged 19 to 64 years. We used electronic health record data from 10 states that expanded Medicaid and 6 states that did not, 359 CHCs, and 870,319 patients with more than 4 million visits. Our analyses included difference-in-difference (DD) and difference-in-difference-in-difference (DDD) estimates via generalized estimating equation models. The primary outcome was health insurance type at each visit (Medicaid-insured, uninsured, or privately insured).
After the ACA was implemented, uninsured visit rates decreased for all racial and ethnic groups. Hispanic patients experienced the greatest increases in Medicaid-insured visit rates after ACA implementation in expansion states (rate ratio [RR] = 1.77; 95% CI, 1.56-2.02) and the largest gains in privately insured visit rates in nonexpansion states (RR = 3.63; 95% CI, 2.73-4.83). In expansion states, non-Hispanic white patients had twice the magnitude of decrease in uninsured visits compared with Hispanic patients (DD = 2.03; 95% CI, 1.53-2.70), and this relative change was more than 2 times greater in expansion states compared with nonexpansion states (DDD = 2.06; 95% CI, 1.52-2.78).
The lower rates of uninsured visits for all racial and ethnic groups after ACA implementation suggest progress in expanding coverage to CHC patients; this progress, however, was not uniform when comparing expansion with nonexpansion states and among all racial and ethnic minority subgroups. These findings suggest the need for continued and more equitable insurance expansion efforts to eliminate health insurance disparities.
医疗保险覆盖范围会影响患者获得最佳医疗服务的能力，诊所登记在册的参保患者比例会影响诊所提供所需医疗服务的能力，并且美国在医保覆盖方面存在种族和族裔差异。因此，我们旨在评估《患者保护与平价医疗法案》（ACA）扩大医疗补助计划后，社区卫生中心（CHC）就诊患者的保险覆盖情况按种族和族裔划分的变化。
我们对19至64岁的CHC患者的就诊支付类型进行了一项回顾性观察研究。我们使用了来自10个扩大医疗补助计划的州和6个未扩大的州、359家CHC以及870319名患者（超过400万次就诊）的电子健康记录数据。我们的分析包括通过广义估计方程模型进行的差分（DD）和双重差分（DDD）估计。主要结局是每次就诊时的医疗保险类型（医疗补助参保、未参保或私人保险参保）。
ACA实施后，所有种族和族裔群体的未参保就诊率均下降。在扩大医疗补助计划的州，西班牙裔患者在ACA实施后医疗补助参保就诊率增长幅度最大（率比[RR]=1.77；95%置信区间，1.56 - 2.02），在未扩大医疗补助计划的州，私人保险参保就诊率增长幅度最大（RR = 3.63；95%置信区间，2.73 - 4.83）。在扩大医疗补助计划的州，非西班牙裔白人患者未参保就诊率的下降幅度是西班牙裔患者的两倍（DD = 2.03；95%置信区间，1.53 - 2.70），并且与未扩大医疗补助计划的州相比，扩大医疗补助计划的州的这种相对变化要大2倍多（DDD = 2.06；95%置信区间，1.52 - 2.78）。
ACA实施后所有种族和族裔群体未参保就诊率的降低表明在扩大CHC患者的保险覆盖范围方面取得了进展；然而，在比较扩大医疗补助计划的州与未扩大的州以及所有种族和族裔少数群体亚组时，这一进展并不一致。这些发现表明需要持续且更公平地努力扩大保险覆盖范围以消除医疗保险差异。
