Department of Health Policy and Management, University of Arkansas for Medical Sciences, Little Rock, AR.
Institute for Medicaid Innovation, Washington, DC.
Med Care. 2020 Jun;58(6):497-503. doi: 10.1097/MLR.0000000000001313.
Rates of low birthweight and prematurity vary 2-fold across states in the United States, with increased rates among states with higher concentrations of racial minorities. Medicaid expansion may serve as a mechanism to reduce geographic variation within states that expanded, by improving health and access to care for vulnerable populations.
The objective of this study was to identify the association of Medicaid expansion with changes in county-level geographic variation in rates of low birthweight and preterm births, overall and stratified by race/ethnicity.
We compared changes in the coefficient of variation and the ratio of the 80th-to-20th percentiles using bootstrap samples (n=1000) of counties drawn separately for all births and for white, black, and Hispanic births, separately.
County-level rates of low birthweight and preterm birth.
Before Medicaid expansion, counties in expansion states were concentrated among quintiles with lower rates of adverse birth outcomes and counties in nonexpansion states were concentrated among quintiles with higher rates. In expansion states, county-level variation, measured by the coefficient of variation, declined for both outcomes among all racial/ethnic categories. In nonexpansion states, geographic variation reduced for both outcomes among Hispanic births and for low birthweight among white births, but increased for both outcomes among black births.
The decrease in county-level variation in adverse birth outcomes among expansion states suggests improved equity in these states. Further reduction in geographic variation will depend largely on policies or interventions that reduce racial disparities in states that did and did not expand Medicaid.
在美国，各州之间的低出生体重和早产率差异高达两倍，少数族裔比例较高的州的比率更高。医疗补助计划的扩大可能是一种通过改善弱势群体的健康和获得医疗保健服务来减少扩大覆盖范围的州内地理差异的机制。
本研究的目的是确定医疗补助计划扩大与低出生体重和早产率的县际地理差异变化之间的关联，总体上和按种族/族裔分层。
我们比较了使用分别为所有出生和白人、黑人、西班牙裔出生抽取的县样本（n=1000）的 bootstrap 样本，变化了低出生体重和早产的变异系数和第 80 百分位与第 20 百分位的比率。
县一级的低出生体重和早产率。
在医疗补助计划扩大之前，扩大州的县集中在不良出生结局发生率较低的五分位数中，而未扩大州的县则集中在不良出生结局发生率较高的五分位数中。在扩大州，所有种族/族裔类别中，以变异系数衡量的县际差异，两个结局的差异都有所缩小。在未扩大州，两个结局的差异都有所缩小，其中西班牙裔出生的地理差异缩小，白人出生的低出生体重差异缩小，但黑人出生的两个结局的差异都有所增加。
扩大州的县际不良出生结局差异的减少表明这些州的公平性有所提高。在未扩大医疗补助计划的州，要进一步减少地理差异，主要取决于政策或干预措施，以减少种族差异。
