Yale School of Medicine, New Haven, CT; Solomon Center for Health Law and Policy, Yale Law School, New Haven, CT; Center for Surgery and Public Health: Brigham and Women's Hospital, Harvard Medical School, and Harvard TH Chan School of Public Health, Boston, MA.
Center for Surgery and Public Health: Brigham and Women's Hospital, Harvard Medical School, and Harvard TH Chan School of Public Health, Boston, MA.
J Am Coll Surg. 2019 Jan;228(1):29-43.e1. doi: 10.1016/j.jamcollsurg.2018.09.022. Epub 2018 Oct 22.
The Affordable Care Act (ACA) changed the landscape of insurance coverage, allowing young adults to remain on their parents' insurance until age 26 (Dependent Coverage Provision [DCP]) and states to optionally expand Medicaid up to 133% of the federal poverty level. Although both improved insurance coverage, little is known about the ACA's impact on observed receipt of timely access to acute care. The objective of this study was to compare changes in insurance coverage and perforation rates among hospitalized adults with acute appendicitis "after vs before" Medicaid expansion and the DCP using an Agency for Healthcare Research and Quality (AHRQ)-certified metric designed to measure pre-hospital access to care.
We performed a quasi-experimental, difference-in-difference (DID) analysis of 2008-2015 state-level inpatient claims.
Adults, aged 19 to 64, in expansion states experienced an absolute 7.7 percentage point decline in uninsured (95% CI 7.5 to 7.9) after Medicaid expansion compared with nonexpansion states. This coincided with a 5.4 percentage point drop in admissions for perforated appendicitis (95% CI 5.0 to 5.8) that was most pronounced among young adults, aged 26 to 34, just age-ineligible for the DCP (DID: 11.5 percentage points). Medicaid expansion insurance changes were 4.1 times larger than those encountered under the DCP (DID: 1.9). They affected all population subgroups and significantly reduced access-related disparities in race/ethnicity and lower-income communities. Although both Medicaid expansion and the DCP were associated with significant insurance gains, those attributable to the DCP were more concentrated among more privileged patients. Despite this trend, both policies resulted in larger reductions in perforation rates for historically uninsured and underserved groups.
Reductions in uninsured after Medicaid expansion and the DCP were associated with significant reductions in perforated appendix admission rates. Improvements in access to acute surgical care suggest that maintained/continued insurance expansion could lead to fewer delays, better patient outcomes, and reductions in disparities among the most at-risk populations.
《平价医疗法案》（ACA）改变了保险覆盖范围的格局，允许年轻人在父母的保险下保留至 26 岁（受抚养人保险条款[DCP]），并允许各州选择将医疗补助扩大到联邦贫困线的 133%。尽管这两项措施都提高了保险覆盖范围，但对于 ACA 对急性护理及时获得的影响知之甚少。本研究的目的是使用 AHRQ 认证的衡量标准，比较急性阑尾炎住院成年人在医疗补助扩大和 DCP 前后的保险覆盖范围和穿孔率的变化，该标准旨在衡量获得医疗服务的前期情况。
我们对 2008 年至 2015 年各州的住院患者索赔进行了准实验性差异-差异（DID）分析。
在医疗补助扩大的州，19 至 64 岁的成年人未参保的比例绝对下降了 7.7 个百分点（95%CI7.5-7.9），而在未扩大的州则没有下降。这与穿孔性阑尾炎入院率下降 5.4 个百分点（95%CI5.0-5.8）相吻合，而这在刚刚超过 DCP 年龄限制的 26 至 34 岁的年轻人中最为明显（DID：11.5 个百分点）。医疗补助扩大带来的保险变化是 DCP 的 4.1 倍（DID：1.9）。这些变化影响了所有人群亚组，并显著减少了种族/民族和低收入社区中与获得医疗服务相关的差异。尽管医疗补助扩大和 DCP 都与显著的保险收益有关，但 DCP 带来的收益更集中于更有特权的患者。尽管存在这种趋势，但这两项政策都导致了历史上没有保险和服务不足的群体穿孔率的显著下降。
医疗补助扩大和 DCP 后未参保人数的减少与穿孔性阑尾入院率的显著下降有关。急性外科护理获得情况的改善表明，维持/继续扩大保险范围可能会减少延迟，改善患者结局，并减少高危人群中的差异。
