Department of Health Law, Policy, and Management, Boston University School of Public Health, Boston, Massachusetts.
Ariadne Labs, Brigham and Women's Hospital, Harvard T.H. Chan School of Public Health, Boston, Massachusetts.
JAMA Health Forum. 2021 Sep 10;2(9):e212375. doi: 10.1001/jamahealthforum.2021.2375. eCollection 2021 Sep.
State decisions to expand Medicaid eligibility were particularly consequential for federally qualified health centers (FQHCs), which serve 30 million low-income patients across the US. The longer-term association of Medicaid expansion with health outcomes at FQHCs is unknown.
To assess the 5-year association of Medicaid expansion with uninsurance rates and hypertension and diabetes outcome measures by race and ethnicity in a nationally representative population of FQHCs.
Using a difference-in-differences analysis of a retrospective cohort from the universe of US FQHCs, changes in uninsurance rates and intermediate health outcomes for hypertension and diabetes by race and ethnicity were compared between Medicaid expansion and nonexpansion states before (2012-2013) vs after (2014-2018) expansion. Data were analyzed from September 2020 to March 2021.
Location in a state that expanded Medicaid eligibility as of 2014.
Rates of uninsurance, the proportion of patients with hypertension with a blood pressure less than 140/90 mm Hg, and the proportion of patients with diabetes with glycosylated hemoglobin levels of 9% or less, as stratified by race and ethnicity.
Of the patients at 578 expansion-state FQHCs (serving 13.0 million patients per year) and 368 nonexpansion-state FQHCs (serving 6.0 million patients per year) in our study sample, 64.4% were age 18 to 64 years, 57.4% were women, 18.9% were non-Hispanic Black, and 27.3% were Hispanic. Following expansion, FQHCs in Medicaid expansion states experienced a 9.24 percentage point (PP) (95% CI, 7.94-10.54) decline in rates of uninsurance over the pooled 5-year expansion period compared with nonexpansion-state FQHCs. Across this 5-year period, expansion was associated with a 1.61-PP (95% CI, 0.58-2.64) comparative improvement in hypertension control and a 1.84-PP (95% CI, 0.71-2.98) comparative improvement in glucose control. Stratified results suggest that improvements were consistently observed in Black and Hispanic populations. The magnitude of change tended to increase with implementation time. For instance, by year 5, expansion was associated with a 3.38-PP (95% CI, 0.80-5.96) comparative improvement in hypertension control and a 3.88-PP (95% CI, 0.86-6.90) comparative improvement in glucose control among Black populations.
In this nationally representative cohort study, Medicaid expansion was associated with sustained increases in insurance coverage and improvements in chronic disease outcome measures at FQHCs after 5 years overall and among Black and Hispanic populations. States considering Medicaid expansion may benefit from improved longer-run health measures for underserved patients with chronic conditions.
重要性：扩大医疗补助资格的州决策对符合联邦资格的医疗中心（FQHCs）尤为重要，这些中心为美国各地的 3000 万低收入患者提供服务。扩大医疗补助计划与 FQHC 健康结果之间的长期关联尚不清楚。
目的：评估 Medicaid 扩张在全国代表性的 FQHC 人群中，按种族和民族分类的保险率和高血压及糖尿病结果测量的 5 年关联。
设计、设置和参与者：利用美国 FQHC 整体的回顾性队列的差异差异分析，比较 Medicaid 扩张和非扩张州在扩张前（2012-2013 年）与扩张后（2014-2018 年）之间的保险率和高血压及糖尿病中间健康结果的变化。数据于 2020 年 9 月至 2021 年 3 月进行分析。
暴露：位于 2014 年扩大医疗补助资格的州。
主要结果和措施：按种族和民族分类的保险率、高血压患者中血压低于 140/90mmHg 的比例以及糖尿病患者中糖化血红蛋白水平为 9%或更低的比例。
结果：在我们的研究样本中，578 家扩张州 FQHC（每年服务 1300 万患者）和 368 家非扩张州 FQHC（每年服务 600 万患者）的 578 家患者中，64.4%的患者年龄在 18 至 64 岁之间，57.4%为女性，18.9%为非西班牙裔黑人，27.3%为西班牙裔。在扩张后，与非扩张州的 FQHC 相比，扩张州的 FQHC 在整个 5 年扩张期间的保险率下降了 9.24 个百分点（95%CI，7.94-10.54）。在这 5 年期间，扩张与高血压控制的 1.61 个百分点（95%CI，0.58-2.64）的比较改善以及葡萄糖控制的 1.84 个百分点（95%CI，0.71-2.98）的比较改善相关。分层结果表明，在黑人和西班牙裔人群中始终观察到改善。变化的幅度往往随着实施时间的增加而增加。例如，到第 5 年，扩张与黑人人群中高血压控制的 3.38 个百分点（95%CI，0.80-5.96）的比较改善以及葡萄糖控制的 3.88 个百分点（95%CI，0.86-6.90）的比较改善相关。
结论和相关性：在这项全国代表性队列研究中， Medicaid 扩张与 FQHC 整体保险覆盖范围的持续增加以及黑人及西班牙裔人群中慢性病结果测量的改善相关，持续 5 年。考虑 Medicaid 扩张的州可能会从改善服务不足的慢性病患者的长期健康指标中受益。
