Population Studies and Training Center, Brown University, Providence, Rhode Island.
Department of Health Services, Policy, and Practice, Brown University School of Public Health, Providence, Rhode Island.
JAMA Health Forum. 2021 Dec 17;2(12):e214167. doi: 10.1001/jamahealthforum.2021.4167. eCollection 2021 Dec.
Non-Hispanic Black individuals are disproportionally covered by Medicaid during pregnancy and, compared with non-Hispanic White individuals, have higher rates of postpartum coverage loss and mortality. Expanded Medicaid coverage under the Affordable Care Act may have increased continuity of coverage and access to care in the critical postpartum period in expansion states.
To examine the association of Medicaid expansion in Arkansas with continuous postpartum coverage, postpartum health care use, and change in racial disparities in the study outcomes.
This cohort study with a difference-in-differences analysis compared persons with Medicaid and commercially financed childbirth, stratified by race, using Arkansas' All-Payer Claims Database for persons with a childbirth between 2013 and 2015. Race and ethnicity from birth certificate data were classified as Hispanic, non-Hispanic Black (hereafter Black), non-Hispanic White (hereafter White), and other (including Asian, Native American or Alaska Native, and Pacific Islander) or unknown race. Data were analyzed between June 2020 and August 2021.
Medicaid-paid childbirth after January 1, 2014.
Continuous health insurance coverage and the number of outpatient visits during the first 6 months postpartum.
A total of 60 990 childbirths (mean [SD] age of birthing person, 27 [5.3] years; 67% White, 22% Black, and 7% Hispanic) were included, among which 72.3% were paid for by Medicaid and 27.7% were paid for by a commercial payer. Medicaid expansion in Arkansas was associated with a 27.8 (95% CI, 26.1-29.5) percentage point increase in continuous insurance coverage and an increase in outpatient visits of 0.9 (95% CI, 0.7-1.1) during the first 6 months postpartum, representing relative increases of 54.9% and 75.0%, respectively. Racial disparities in postpartum coverage decreased from 6.3 (95% CI, 3.9-8.7) percentage points before expansion to -2.0 (95% CI, -2.8 to -1.2) percentage points after expansion. However, disparities in outpatient care between Black and White individuals persisted after Medicaid expansion (preexpansion difference, 0.4 [95% CI, 0.2-0.6] visits; postexpansion difference, 0.5 [95% CI, 0.4-0.6] visits).
In this cohort study with a difference-in-differences analysis of 60 990 childbirths, Medicaid expansion was associated with higher rates of postpartum coverage and outpatient visits and lower racial and ethnic disparities in postpartum coverage. However, disparities in outpatient visits between Black and White individuals were unchanged. Additional policy approaches are needed to reduce racial and ethnic disparities in postpartum care.
在怀孕期间，非西班牙裔黑人个体不成比例地获得医疗补助覆盖，与非西班牙裔白人个体相比，他们在产后失去保险覆盖和死亡的比例更高。平价医疗法案下的医疗补助扩大覆盖范围，可能增加了在扩张州产后关键时期的保险覆盖连续性和获得护理的机会。
通过差异分析比较阿肯色州医疗补助扩大与连续产后覆盖、产后医疗保健使用以及研究结果中种族差异变化的关系。
设计、地点和参与者：本队列研究采用差异分析比较了 2013 年至 2015 年间有分娩的阿肯色州所有支付者索赔数据库中按种族分层的有医疗补助和商业付费分娩的人，将种族和民族从出生证明数据中分为西班牙裔、非西班牙裔黑人（简称黑人）、非西班牙裔白人（简称白人）和其他（包括亚洲人、美洲原住民或阿拉斯加原住民、和太平洋岛民）或未知种族。数据于 2020 年 6 月至 2021 年 8 月进行分析。
2014 年 1 月 1 日后的医疗补助支付分娩。
产后 6 个月内的连续健康保险覆盖和门诊就诊次数。
共纳入 60990 例分娩（分娩者的平均[标准差]年龄为 27[5.3]岁；67%为白人，22%为黑人，7%为西班牙裔），其中 72.3%由医疗补助支付，27.7%由商业支付者支付。阿肯色州的医疗补助扩大与连续保险覆盖增加 27.8（95%置信区间，26.1-29.5）个百分点以及产后 6 个月内门诊就诊次数增加 0.9（95%置信区间，0.7-1.1）有关，分别代表 54.9%和 75.0%的相对增加。产后覆盖范围的种族差异从扩大前的 6.3（95%置信区间，3.9-8.7）个百分点下降到扩大后的-2.0（95%置信区间，-2.8 至-1.2）个百分点。然而，黑人与白人之间的门诊护理差异在医疗补助扩大后仍然存在（扩大前差异，0.4[95%置信区间，0.2-0.6]次就诊；扩大后差异，0.5[95%置信区间，0.4-0.6]次就诊）。
在这项对 60990 例分娩的差异分析队列研究中，医疗补助扩大与更高的产后覆盖率和门诊就诊率以及产后覆盖范围的种族和民族差异降低相关。然而，黑人与白人之间的门诊就诊差异保持不变。需要采取额外的政策措施来减少产后护理方面的种族和民族差异。
