Boudreaux Michel, Barath Deanna, Blewett Lynn A
School of Public Health, University of Maryland, 4200 Valley Dr #3310A, College Park, MD.
School of Public Health, University of Minnesota, 420 Delaware St SE #Mmc88, Minneapolis, MN.
Mil Med. 2019 Jan 1;184(1-2):e76-e82. doi: 10.1093/milmed/usy053.
Prior to the Affordable Care Act, as many as 1.3 million veterans lacked health insurance. With the passage of the Affordable Care Act, veterans now have new pathways to coverage through Medicaid expansion in those states that chose to expand Medicaid and through private coverage options offered through the Health Insurance Marketplace. We examined the impact of the ACA on health insurance coverage for veterans in expansion and non-expansion states and for urban and rural veterans.
We examined changes in veterans' health insurance coverage following the first year of the ACA, focusing on whether they lived in an urban or rural area and whether they live in a Medicaid expansion state. We used data on approximately 200,000 non-elderly community-dwelling veterans, obtained from the 2013-2014 American Community Survey and estimated differences in the adjusted probability of being uninsured between 2013 and 2014 for both urban and rural areas. Adjusted probabilities were computed by fitting logistic regressions controlling for age, gender, race, marital status, poverty status, education, and employment.
There were an estimated 10.1 million U.S. non-elderly veterans in 2013; 82% lived in predominantly urban areas (8.3 million), and the remaining 18% (1.8 million) lived in predominately rural areas. Most veterans lived in the South (43.6%), and rural veterans were more likely to be Southerners than their urban counterparts. On every marker of economic well-being, rural veterans fared worse than urban veterans. They had a statistically significant higher chance of having incomes below 138% of FPG (20.0% versus 17.0%), of being out of the labor force (29.1% versus 23.0%), and of having no more than a high school education (39.6% versus 28.8%). Rural veterans were also more likely to experience at least one functional limitation. Overall, veterans in Medicaid expansion states experienced a significantly larger increase in insurance compared to veterans living in non-expansion states. For rural veterans in Medicaid expansion states, the increase in insurance was 3.5 percentage points, compared with 1.2 percentage points in non-expansion states.
Our analysis found a substantial 24% relative decline in the rate of uninsurance for U.S. Veterans, from 9.3 to 7.1% between 2013 and 2014. We found that coverage gains in rural areas were due to gains in Medicaid and individual market coverage. Residence in a Medicaid expansion state was particularly influential for rural veterans - the increase in the insured rate was three times larger in Medicaid expansion states versus non-expansion states. The ACA has had a positive and significant impact on the ability of U.S. Veterans to obtain health insurance coverage specifically for low-income veterans living in rural areas. The poverty rate among Veterans is rising and is particularly an issue for the more recent Gulf War veterans. Providing affordable and accessible health insurance options is part of our commitment to those who have served our country. Our analysis also presents yet another reason for the 17 non-expansion states to consider a Medicaid expansion.
在《平价医疗法案》出台之前，多达130万退伍军人没有医疗保险。随着《平价医疗法案》的通过，退伍军人现在有了新的医保途径，在那些选择扩大医疗补助计划的州可通过扩大医疗补助获得医保，也可通过医保市场提供的私人医保选项获得医保。我们研究了《平价医疗法案》对扩大医疗补助计划州和未扩大该计划州的退伍军人以及城市和农村退伍军人医保覆盖情况的影响。
我们研究了《平价医疗法案》实施第一年退伍军人医保覆盖情况的变化，重点关注他们居住在城市还是农村地区以及是否居住在扩大医疗补助计划的州。我们使用了约20万非老年社区居住退伍军人的数据，这些数据来自2013 - 2014年美国社区调查，并估计了2013年至2014年城市和农村地区未参保调整概率的差异。调整概率通过拟合逻辑回归计算得出，该回归控制了年龄、性别、种族、婚姻状况、贫困状况、教育程度和就业情况。
2013年美国估计有1010万非老年退伍军人；82%居住在主要城市地区（830万），其余18%（180万）居住在主要农村地区。大多数退伍军人居住在南方（43.6%），农村退伍军人比城市退伍军人更有可能是南方人。在经济福祉的每一个指标上，农村退伍军人的情况都比城市退伍军人更差。他们的收入低于联邦贫困线138%的可能性在统计学上显著更高（20.0%对17.0%），不在劳动力队伍中的可能性更高（29.1%对23.0%），且接受的教育不超过高中水平的可能性更高（39.6%对28.8%）。农村退伍军人也更有可能至少经历一种功能限制。总体而言，与居住在未扩大医疗补助计划州的退伍军人相比，扩大医疗补助计划州的退伍军人保险覆盖的增加幅度显著更大。对于扩大医疗补助计划州的农村退伍军人，保险覆盖的增加为3.5个百分点，而在未扩大该计划的州为1.2个百分点。
我们的分析发现，美国退伍军人的未参保率相对大幅下降了24%，从2013年的9.3%降至2014年的7.1%。我们发现农村地区医保覆盖的增加得益于医疗补助计划和个人市场医保覆盖的增加。居住在扩大医疗补助计划的州对农村退伍军人特别有影响——扩大医疗补助计划州的参保率增幅是未扩大该计划州的三倍。《平价医疗法案》对美国退伍军人，特别是居住在农村地区的低收入退伍军人获得医保覆盖的能力产生了积极且显著的影响。退伍军人中的贫困率在上升，这对最近的海湾战争退伍军人来说尤其成问题。提供负担得起且可及的医保选项是我们对为国服役者承诺的一部分。我们的分析还为17个未扩大医疗补助计划的州考虑扩大该计划提供了另一个理由。
