Becker Mikaela M, Hussein Mustafa
Joseph J. Zilber School of Public Health, University of Wisconsin-Milwaukee, Milwaukee, WI, USA.
Graduate School of Public Health, The City University of New York, New York, NY, USA.
Prev Med Rep. 2022 Sep 19;30:101996. doi: 10.1016/j.pmedr.2022.101996. eCollection 2022 Dec.
Since before the Affordable Care Act (ACA), states have partnered with the National Breast and Cervical Cancer Early Detection Program (NBCCEDP) to support access to cancer screening and treatment for uninsured/underinsured women. The Wisconsin Well Woman Program (WWWP) was one such program, supporting low-income women across the state. With ACA introduction, Wisconsin substantially downsized/restructured the WWWP, expecting the reduction in services to be offset by the rise in ACA-provided insurance coverage. This study assesses whether retrenchment in the WWWP following the ACA indeed prompted a differential rise in insurance coverage among the program's target population. We use a difference-in-differences (DID) design to contrast changes in county-level, target-population insurance rates, over 2008-2018, in Wisconsin counties previously most served by the WWWP vs those least served, adjusting for systematic differences across counties, including pre-policy trends. Pre-ACA (2011-2013), most-served counties had lower insurance rates by 2.5 percentage points (pp) than least-served counties; WWWP services likely compensated for some of that gap. In 2014-2015, along with WWWP's steep contraction, insurance rates rose sharply across all counties. Our primary DID analysis and event study suggest that WWWP contraction might have differentially driven more insurance take-up in most-served counties, by 1.88 pp [95 % Confidence Interval: 0.23,3.54], thus narrowing the pre-ACA gap. Sensitivity analyses suggest much smaller gains. Notwithstanding such potential insurance gains following program contraction, continued support for care navigation and coordination remain necessary to truly meet the needs of the vulnerable women previously served by the WWWP and similar programs across states.
早在《平价医疗法案》（ACA）出台之前，各州就已与国家乳腺癌和宫颈癌早期检测项目（NBCCEDP）合作，以支持未参保/参保不足的女性获得癌症筛查和治疗。威斯康星州健康女性项目（WWWP）就是这样一个项目，为该州的低收入女性提供支持。随着ACA的推出，威斯康星州大幅缩减/重组了WWWP，预计服务减少将被ACA提供的保险覆盖范围的增加所抵消。本研究评估了ACA实施后WWWP的缩减是否确实促使该项目目标人群的保险覆盖范围出现了差异增长。我们采用差异中的差异（DID）设计，对比2008 - 2018年期间，威斯康星州此前WWWP服务最多的县与服务最少的县在县级目标人群保险费率的变化，并对各县之间的系统差异（包括政策前趋势）进行调整。在ACA实施前（2011 - 2013年），服务最多的县的保险费率比服务最少的县低2.5个百分点（pp）；WWWP服务可能弥补了部分差距。在2014 - 2015年，随着WWWP的大幅收缩，所有县的保险费率都大幅上升。我们的主要DID分析和事件研究表明，WWWP的收缩可能在服务最多的县推动了更多的保险参保，幅度为1.88个百分点[95%置信区间：0.23，3.54]，从而缩小了ACA实施前的差距。敏感性分析表明收益要小得多。尽管项目收缩后可能有这样的保险收益，但为了真正满足此前由WWWP及各州类似项目服务的弱势女性的需求，持续支持护理导航和协调仍然是必要的。
