Division of Health Systems Management and Policy, University of Memphis, Memphis, Tennessee, USA.
Department of Health Management and Policy, University of Iowa, Iowa City, Iowa, USA.
J Womens Health (Larchmt). 2021 Sep;30(9):1278-1287. doi: 10.1089/jwh.2020.8776. Epub 2021 Feb 8.
This study explores the heterogeneity in effects of the 2014 Affordable Care Act (ACA) Medicaid expansions on insurance coverage, health care access, and health status of low-income women with dependent children by pre-expansion state-level income eligibility. We employ a quasiexperimental difference-in-differences design comparing outcome changes in Medicaid expansion states to nonexpansion states. We estimate effects separately for three groups of expansion states based on pre-expansion (2013) parent income eligibility: low pre-expansion eligibility (<90% of federal poverty level [FPL]), high eligibility (90% to <138% FPL), and full eligibility (≥138% FPL). Study samples include women with dependent children below 138% FPL from the 2011 to 2018 American Community Survey for the insurance outcomes, and from the 2011 to 2018 Behavioral Risk Surveillance System for the access and health outcomes. There is stark heterogeneity in changes of health insurance and health care access by pre-expansion income eligibility levels. In comparison to Medicaid non-expansion states, there are large increases in insured rate (9 percentage-points) and Medicaid coverage (16 percentage-points) in expansion states with low pre-expansion eligibility. Insurance changes are much smaller in states with high or full pre-expansion eligibility. Changes in access largely mirror those in coverage. There are no significant changes in health status regardless of pre-expansion eligibility. The ACA Medicaid expansions increased coverage and access for low-income women with dependent children primarily in states with low pre-expansion parent eligibility, and therefore, reduced differences in these outcomes between expansion states.
本研究通过预先设定的州级收入资格，探讨了 2014 年平价医疗法案（ACA）医疗补助扩张对有受抚养子女的低收入女性的保险覆盖、医疗保健获得和健康状况的影响的异质性。我们采用准实验差分差异设计，比较了扩张州和非扩张州的结果变化。我们根据预先设定的（2013 年）父母收入资格，将扩张州的影响分别估计为三组：低预先设定资格（低于联邦贫困线[FPL]的 90%）、高资格（90%至低于 138% FPL）和完全资格（≥138% FPL）。研究样本包括来自 2011 年至 2018 年美国社区调查的低于 138%FPL 的有受抚养子女的女性，以及来自 2011 年至 2018 年行为风险监测系统的医疗保健获得和健康结果。在预先设定的收入资格水平下，医疗保险和医疗保健获得的变化存在明显的异质性。与医疗补助非扩张州相比，低预先设定资格扩张州的保险参保率（增加 9 个百分点）和医疗补助覆盖范围（增加 16 个百分点）有大幅增加。在高或完全预先设定资格的州，保险变化要小得多。获得途径的变化在很大程度上反映了覆盖范围的变化。无论预先设定的资格如何，健康状况都没有显著变化。ACA 医疗补助扩张主要在低预先设定父母资格的州增加了有受抚养子女的低收入女性的覆盖范围和获得机会，从而缩小了扩张州在这些结果方面的差距。
