Toyoda Yoshiko, Jeong Oh Eun, Premaratne Ishani D, Chiuzan Codruta, Rohde Christine H
From the Division of Plastic and Reconstructive Surgery, Department of Surgery, Columbia University Irving Medical Center/NewYork-Presbyterian Hospital, New York, NY; Department of Biostatistics, Mailman School of Public Health, Columbia University, New York, NY.
J Am Coll Surg. 2020 May 1;230(5):775-783. doi: 10.1016/j.jamcollsurg.2020.01.031.
Under the Affordable Care Act, states were given the option to expand Medicaid in 2014. By the end of 2014, 32 states had opted to expand Medicaid and 19 did not. Previous quasi-experimental studies took advantage of this state-specific policy implementation and found increased insurance coverage in expansion compared with nonexpansion states. With longer-term data now available, we studied the effect of Medicaid expansion on changes in insurance coverage and mammography rates in expansion and nonexpansion states. Seven states that expanded Medicaid eligibility in 2014 and 6 nonexpansion states were selected based on available data. The US Census American Community Survey was queried for insurance coverage from 2011 to 2016 and the CDC Behavioral Risk Factor Surveillance System from 2010 to 2018. Difference-in-difference linear mixed models were used to estimate and compare insurance coverage and screening mammogram rates between expansion and nonexpansion states before and after 2014. The increase in insurance rates for all persons covered by some type of health insurance after Medicaid expansion was significantly different in expansion than nonexpansion states (p = 0.001). The increase in Medicaid coverage was significant in expansion compared with nonexpansion states (p < 0.001). A similar trend was seen in screening mammogram rates in women from low-income households in expansion vs nonexpansion states (p = 0.049). Medicaid expansion states saw greater improvement in total insurance and Medicaid coverage, and in mammogram rates in lower-income women compared with nonexpansion states after Medicaid legislation was passed. Our study demonstrates that people do take advantage of expanded eligibility by acquiring insurance and this can improve access to preventive measures, such as screening mammography.
根据《平价医疗法案》，各州在2014年有权选择扩大医疗补助计划。到2014年底，32个州选择扩大医疗补助计划，19个州未选择。以往的准实验研究利用了这种特定于州的政策实施情况，发现与未扩大计划的州相比，扩大计划的州保险覆盖率有所提高。现在有了更长期的数据，我们研究了医疗补助计划扩大对扩大计划和未扩大计划的州保险覆盖率和乳房X光检查率变化的影响。根据现有数据，选取了2014年扩大医疗补助资格的7个州和6个未扩大计划的州。查询了美国人口普查局的美国社区调查，以获取2011年至2016年的保险覆盖率数据，并查询了疾病控制与预防中心的行为风险因素监测系统，以获取2010年至2018年的数据。采用差分线性混合模型来估计和比较2014年前后扩大计划和未扩大计划的州之间的保险覆盖率和乳房X光筛查率。医疗补助计划扩大后，某种类型医疗保险覆盖的所有人的保险费率增长在扩大计划的州与未扩大计划的州之间存在显著差异（p = 0.001）。与未扩大计划的州相比，扩大计划的州医疗补助覆盖率的增长显著（p < 0.001）。在扩大计划和未扩大计划的州中，低收入家庭女性的乳房X光筛查率也出现了类似趋势（p = 0.049）。与未扩大计划的州相比，医疗补助计划扩大的州在医疗补助立法通过后，总保险和医疗补助覆盖率以及低收入女性的乳房X光检查率有了更大改善。我们的研究表明，人们确实通过获取保险利用了扩大的资格，这可以改善获得预防性措施的机会，如乳房X光筛查。
