Dornsife School of Public Health, Drexel University, Philadelphia, Pennsylvania.
University of Nebraska Medical Center, College of Public Health, Omaha.
JAMA Netw Open. 2019 Jul 3;2(7):e197136. doi: 10.1001/jamanetworkopen.2019.7136.
Although nearly 1 in 5 persons in the United States has a physical or mental disability, little is known about the association of the Patient Protection and Affordable Care Act (ACA) with health insurance coverage among persons with a disability.
To determine the association of Medicaid expansion with health insurance coverage among persons with a disability.
DESIGN, SETTING, AND PARTICIPANTS: Cross-sectional analysis of adults eligible for Medicaid expansion (aged 26-64 years with incomes up to 138% of the federal poverty level), using a triple-differences (difference-in-difference-in-difference) approach to compare the pre-ACA with post-ACA trend in health insurance rates by disability status between expansion and nonexpansion states using nationally representative, repeated cross-sectional sample data obtained from the American Community Survey in the United States from January 1, 2010, to December 31, 2016. Time was defined as either pre-ACA (January 1, 2010, to December 31, 2013) or post-ACA (January 1, 2014, to December 31, 2016). Treatment status was defined as whether a state implemented Medicaid expansion after January 1, 2014. States that expanded Medicaid between January 1, 2014, to December 31, 2016, were classified as the treatment group, and states that did not expand Medicaid during the study period were classified as the control group. Data were analyzed from December 12, 2018, to May 21, 2019.
Self-reported health insurance coverage (uninsured, Medicaid, private) and self-reported disability status (≥1 condition limiting activity, including cognitive, ambulatory, self-care, independent living, and sensory difficulties).
Of 2 549 376 Medicaid-eligible adults, 1 348 620 (52.9%) were female; 1 218 602 (47.8%) were non-Hispanic white, 497 128 (19.5%) were non-Hispanic black, 211 598 (8.3%) were Hispanic, and 206 499 (8.1%) were of other race/ethnicity; and 619 498 (24.3%) reported at least 1 disability. The percentage of persons without health insurance was greatest for persons without a disability who lived in a nonexpansion state before the ACA's Medicaid expansion provision went into effect (236 645 of 426 387 [55.5%]), and the smallest proportion of persons without health insurance was reported for persons with a disability living in an expansion state after the ACA went into effect (19 552 of 176 145 [11.1%]). Triple-differences analysis suggested that Medicaid expansion was associated with a decrease in the uninsured rate for both persons with a disability (7.1% - 16.2% = -9.1%) and without a disability (21.2% - 34.9% = -13.7%) and that Medicaid expansion was associated with a 4.6% decrease in the uninsurance rate for persons without a disability and a 2.6% decrease in persons with a disability (P < .001). Although Medicaid expansion was associated with an increase in Medicaid coverage for both persons with a disability (49.3% pre-ACA to 62.3% post-ACA; change, 13.0%) and persons without a disability (21.6% pre-ACA to 40.3% post-ACA; change, 17.7%), the triple difference-estimated Medicaid coverage was -4.7% for persons with a disability and 0.4% for persons without a disability, a difference of 5.1% (P < .001). Medicaid expansion was associated with a 3% higher private insurance rate for persons with a disability than for persons without a disability.
Medicaid expansion appeared to be associated with lower uninsurance rates and higher Medicaid and private insurance coverage for persons with a disability. This study's findings suggest that the reduction in the uninsured rate and gains in Medicaid coverage were greater for persons without a disability than for persons with a disability.
尽管美国近五分之一的人有身体或精神残疾，但对于《平价医疗法案》（ACA）与残疾人士的医疗保险覆盖范围之间的关联，人们知之甚少。
确定医疗补助扩展与残疾人士医疗保险覆盖范围之间的关联。
设计、设置和参与者：使用三重差分（差异中的差异中的差异）方法对符合医疗补助扩展条件的成年人（年龄在 26-64 岁，收入为联邦贫困水平的 138%以下）进行横断面分析，比较了残疾状况的健康保险费率在扩张州和非扩张州之间的 ACA 前后趋势，使用全国代表性、重复横断面样本数据，该数据来自美国从 2010 年 1 月 1 日至 2016 年 12 月 31 日的美国社区调查。时间定义为 ACA 之前（2010 年 1 月 1 日至 2013 年 12 月 31 日）或 ACA 之后（2014 年 1 月 1 日至 2016 年 12 月 31 日）。治疗状态定义为一个州是否在 2014 年 1 月 1 日之后实施了医疗补助扩展。在 2014 年 1 月 1 日至 2016 年 12 月 31 日期间实施医疗补助扩展的州被归类为治疗组，而在研究期间没有实施医疗补助扩展的州被归类为对照组。数据于 2018 年 12 月 12 日至 2019 年 5 月 21 日进行分析。
自我报告的医疗保险覆盖范围（无保险、医疗补助、私人）和自我报告的残疾状况（≥1 种限制活动的疾病，包括认知、行动、自理、独立生活和感官困难）。
在 2549376 名符合医疗补助条件的成年人中，1348620 名（52.9%）为女性；1218602 名（47.8%）为非西班牙裔白人，497128 名（19.5%）为非西班牙裔黑人，211598 名（8.3%）为西班牙裔，206499 名（8.1%）为其他种族/族裔；619498 名（24.3%）报告至少有一种残疾。在 ACA 的医疗补助扩大条款生效之前，没有残疾的人在没有保险的人中比例最大（426387 人中的 236645 人[55.5%]），而在 ACA 生效后，有残疾的人没有保险的比例最小（176145 人中的 19552 人[11.1%]）。三重差异分析表明，医疗补助扩大与残疾人和非残疾人士的未保险率下降有关（残疾人士：7.1% - 16.2% = -9.1%；非残疾人士：21.2% - 34.9% = -13.7%），并且医疗补助扩大与非残疾人士未保险率下降 4.6%和残疾人士未保险率下降 2.6%有关（P <.001）。尽管医疗补助扩大与残疾人和非残疾人士的医疗补助覆盖范围分别增加了 4.3%（扩大前为 49.3%，扩大后为 62.3%；变化为 13.0%）和 17.7%（扩大前为 21.6%，扩大后为 40.3%；变化为 17.7%），但三重差异估计的医疗补助覆盖范围为残疾人士-4.7%，非残疾人士 0.4%，差异为 5.1%（P <.001）。医疗补助扩大与残疾人士的私人保险费率增加 3%有关，而非残疾人士的私人保险费率增加 0.4%。
医疗补助扩大似乎与残疾人士的未保险率降低以及医疗补助和私人保险覆盖范围增加有关。本研究的结果表明，与残疾人士相比，非残疾人士的未保险率降低和医疗补助覆盖范围的增加幅度更大。
