Richard A. and Susan F. Smith Center for Outcomes Research in Cardiology, Beth Israel Deaconess Medical Center, Boston, Massachusetts.
Division of Cardiology, Massachusetts General Hospital, Boston.
JAMA Cardiol. 2022 Jul 1;7(7):708-714. doi: 10.1001/jamacardio.2022.1282.
Medicaid expansion led to gains in insurance coverage among working-age adults with low income. To date, the extent to which disparities in access and cardiovascular care persist for this population in Medicaid nonexpansion and expansion states is unknown.
To compare insurance coverage, health care access, and cardiovascular risk factor management between working-age adults (age 18-64 years) with low income in Medicaid nonexpansion and expansion states and between uninsured and insured adults in these states.
DESIGN, SETTING, AND PARTICIPANTS: This cross-sectional study analyzed data on adults aged 18 to 64 years with low income from the Behavioral Risk Factor Surveillance System from January 1 to December 31, 2019.
State Medicaid expansion and insurance status.
The main outcomes were health care access and monitoring and treatment of cardiovascular risk factors. The estimated adjusted risk difference (RD) in outcomes was estimated to compare adults in Medicaid nonexpansion and expansion states and uninsured and insured individuals in nonexpansion and expansion states.
The weighted study population consisted of 28 028 451 working-age adults with low income, including 10 094 994 (36.0%) in Medicaid nonexpansion states (63.4% female) and 17 933 457 (64.0%) in expansion states (59.2% female). Adults in nonexpansion states had higher uninsurance rates (42.4% [95% CI, 40.2%-44.7%] vs 23.8% [95% CI, 22.8%-24.8%]), were less likely to have a usual source of care (55.4% [95% CI, 53.1%-57.6%] vs 65.4% [95% CI, 64.3%-66.5%]; adjusted RD, -11.4% [95% CI, -13.9% to -8.8%]) or a recent examination (78.9% [95% CI, 77.0%-80.9%] vs 84.4% [95% CI, 83.5%-85.2%]; RD, -6.2% [95% CI, -8.4% to -4.0%]), and were more likely to have deferred care owing to cost (36.1% [95% CI, 34.0%-38.2%] vs 21.8% [95% CI, 20.9%-22.8%]; RD, 14.2% [95% CI, 11.9%-16.6%]) than were those in expansion states. There were no significant differences in cardiovascular risk factor management between these groups. In nonexpansion states, uninsured adults had significantly worse access to care across these measures and were less likely to receive indicated monitoring of cholesterol (72.6% [95% CI, 67.7%-77.4%] vs 93.7%; [95% CI, 92.4%-95.0%]; RD, -17.2% [95% CI, -21.8% to -12.6%]) and hemoglobin A1c (55.2% [95% CI, 40.0%-72.5%] vs 88.5% [95% CI, 79.2%-97.9%]; RD, -25.8% [95% CI, -47.6% to -4.1%]) levels or to receive treatment for hypertension (49.4% [95% CI, 43.3%-55.6%] vs 74.7% [95% CI, 71.5%-78.0%]; RD, -16.3% [95% CI, -23.2% to -9.4%]) and hyperlipidemia (30.2% [95% CI, 23.5%-36.8%] vs 58.7% [95% CI, 53.9%-63.5%]; RD, -19.3% [95% CI, -27.9% to -10.7%]) compared with insured adults. These patterns were similar for uninsured and insured adults in expansion states.
In this study, working-age adults with low income in Medicaid nonexpansion states experienced higher uninsurance rates and worse access to care than did those in expansion states; however, cardiovascular risk factor management was similar and treatment rates were low. In nonexpansion states, uninsured adults were less likely to receive appropriate cardiovascular risk factor management compared with insured adults.
重要性：医疗补助计划扩大覆盖范围导致了低收入的成年工作者的保险覆盖范围增加。截至目前，对于这些在医疗补助计划未扩大覆盖范围和扩大覆盖范围内的州的人群，在获得医疗服务和心血管护理方面的差距是否持续存在，尚不清楚。
目的：比较低收⼊的成年工作者（18-64 岁）在医疗补助计划未扩大覆盖范围和扩大覆盖范围内的州与在这些州未参保和参保的成年人之间的保险覆盖范围、获得医疗服务的机会以及心血管风险因素管理情况。
设计、地点和参与者：本横断面研究分析了 2019 年 1 月 1 日至 12 月 31 日期间，来自行为风险因素监测系统的年龄在 18 至 64 岁的低收⼊成年人的数据。
暴露因素：州医疗补助计划的扩大和保险状况。
主要结局和测量指标：主要结局为获得医疗服务的机会和心血管风险因素的监测和治疗。通过对医疗补助计划未扩大覆盖范围和扩大覆盖范围内的州以及未参保和参保的成年人进行调整，估计了结局的风险差异（RD）。
结果：加权研究人群由 28028451 名低收⼊的成年工作者组成，包括 10094994 名（36.0%）在医疗补助计划未扩大覆盖范围的州的成年人（63.4%为女性）和 17933457 名（64.0%）在扩大覆盖范围的州的成年人（59.2%为女性）。未参保的成年人的未参保率更高（42.4%[95%置信区间[CI]，40.2%-44.7%]比 23.8%[95%CI，22.8%-24.8%]），拥有常规医疗服务来源的可能性较低（55.4%[95%CI，53.1%-57.6%]比 65.4%[95%CI，64.3%-66.5%]；调整后的 RD，-11.4%[95%CI，-13.9%至-8.8%]）或最近进行过体检的可能性较低（78.9%[95%CI，77.0%-80.9%]比 84.4%[95%CI，83.5%-85.2%]；RD，-6.2%[95%CI，-8.4%至-4.0%]），并且由于费用而推迟治疗的可能性更高（36.1%[95%CI，34.0%-38.2%]比 21.8%[95%CI，20.9%-22.8%]；RD，14.2%[95%CI，11.9%-16.6%]）。与扩大覆盖范围的州相比，这些人群之间在心血管风险因素管理方面没有显著差异。在未参保的成年人中，无论在哪个指标上，他们的医疗服务获取机会都明显较差，并且更不可能接受胆固醇（72.6%[95%CI，67.7%-77.4%]比 93.7%；[95%CI，92.4%-95.0%]；RD，-17.2%[95%CI，-21.8%至-12.6%]）和糖化血红蛋白（55.2%[95%CI，40.0%-72.5%]比 88.5%[95%CI，79.2%-97.9%]；RD，-25.8%[95%CI，-47.6%至-4.1%]）的监测，也更不可能接受高血压（49.4%[95%CI，43.3%-55.6%]比 74.7%[95%CI，71.5%-78.0%]；RD，-16.3%[95%CI，-23.2%至-9.4%]）和高血脂（30.2%[95%CI，23.5%-36.8%]比 58.7%[95%CI，53.9%-63.5%]；RD，-19.3%[95%CI，-27.9%至-10.7%]）的治疗。在扩大覆盖范围的州中，未参保和参保的成年人也存在类似的模式。
结论和相关性：在这项研究中，医疗补助计划未扩大覆盖范围的州的成年低收入工作者的未参保率较高，医疗服务获取机会较差，而在扩大覆盖范围的州的成年人之间则没有显著差异；然而，心血管风险因素管理情况相似，治疗率较低。在未参保的成年人中，与参保成年人相比，他们接受适当的心血管风险因素管理的可能性较低。
