Department of Health Policy and Management, University of Pittsburgh School of Public Health, Pittsburgh, Pennsylvania.
Department of Health Care Policy, Harvard Medical School and Brigham and Women's Hospital, Boston, Massachusetts.
JAMA Intern Med. 2023 Jun 1;183(6):534-543. doi: 10.1001/jamainternmed.2023.0512.
Medicaid supplemental insurance covers most cost sharing in Medicare. Among low-income Medicare beneficiaries, the loss of Medicaid eligibility above this program's income eligibility threshold (100% of federal poverty level [FPL]) may exacerbate racial and ethnic disparities in Medicare beneficiaries' ability to afford care.
To examine whether exceeding the income threshold for Medicaid, which results in an abrupt loss of Medicaid eligibility, is associated with greater racial and ethnic disparities in access to and use of care.
DESIGN, SETTING, AND PARTICIPANTS: This cross-sectional study used a regression discontinuity design to assess differences in access to and use of care associated with exceeding the income threshold for Medicaid eligibility. We analyzed Medicare beneficiaries with incomes 0% to 200% of FPL from the 2008 to 2018 biennial waves of the Health and Retirement Study linked to Medicare administrative data. To identify racial and ethnic disparities associated with the loss of Medicaid eligibility, we compared discontinuities in outcomes among Black and Hispanic beneficiaries (n = 2885) and White beneficiaries (n = 5259). Analyses were conducted between January 1, 2022, and October 1, 2022.
Patient-reported difficulty accessing care due to cost and outpatient service use, medication fills, and hospitalizations measured from Medicare administrative data.
This cross-sectional study included 8144 participants (38 805 person-years), who when weighted represented 151 282 957 person-years in the community-dwelling population of Medicare beneficiaries aged 50 years and older and incomes less than 200% FPL. In the weighted sample, the mean (SD) age was 75.4 (9.4) years, 66.1% of beneficiaries were women, 14.8% were non-Hispanic Black, 13.6% were Hispanic, and 71.6% were White. Findings suggest that exceeding the Medicaid eligibility threshold was associated with a 43.8 percentage point (pp) (95% CI, 37.8-49.8) lower probability of Medicaid enrollment among Black and Hispanic Medicare beneficiaries and a 31.0 pp (95% CI, 25.4-36.6) lower probability of Medicaid enrollment among White beneficiaries. Among Black and Hispanic beneficiaries, exceeding the threshold was associated with increased cost-related barriers to care (discontinuity: 5.7 pp; 95% CI, 2.0-9.4), lower outpatient use (-6.3 services per person-year; 95% CI, -10.4 to -2.2), and fewer medication fills (-6.9 fills per person-year; 95% CI, -11.4 to -2.5), but it was not associated with a statistically significant discontinuity in hospitalizations. Discontinuities in these outcomes were smaller or nonsignificant among White beneficiaries. Consequently, exceeding the threshold was associated with widened disparities, including greater reductions in outpatient service use (disparity: -6.2 services per person-year; 95% CI, -11.7 to -0.6; P = .03) and medication fills (disparity: -7.2 fills per person-year; 95% CI, -13.4 to -1.0; P = .02) among Black and Hispanic vs White beneficiaries.
This cross-sectional study found that loss of eligibility for Medicaid supplemental insurance above the federal poverty level, which increases cost sharing in Medicare, was associated with increased racial and ethnic health care disparities among low-income Medicare beneficiaries. Expanding eligibility for Medicaid supplemental insurance may narrow these disparities.
重要性：医疗补助附加保险涵盖了医疗保险的大部分费用分担。在低收入的医疗保险受益人中，超过该计划收入资格门槛（联邦贫困线的 100%）的医疗补助资格丧失可能会加剧医疗保险受益人的经济负担能力方面的种族和民族差异。
目的：研究超过医疗补助资格的收入门槛（这会导致医疗补助资格突然丧失）是否与获得和使用医疗保健方面的更大的种族和民族差异有关。
设计、地点和参与者：本横断面研究使用回归不连续性设计来评估与超过医疗补助资格收入门槛相关的获得和使用医疗保健的差异。我们分析了健康与退休研究的 2008 年至 2018 年双年波次中，收入在联邦贫困线的 0%至 200%之间的医疗保险受益人，并将其与医疗保险管理数据相关联。为了确定与医疗补助资格丧失相关的种族和民族差异，我们比较了黑人受益人和西班牙裔受益人和白人受益人的结果中断情况（n=2885）。分析于 2022 年 1 月 1 日至 2022 年 10 月 1 日进行。
主要结局测量：患者报告由于费用和门诊服务使用、药物填充和住院治疗而导致的获得医疗服务的困难，这些数据是从医疗保险管理数据中测量得出的。
结果：本横断面研究包括 8144 名参与者（38805 人年），加权后代表了年龄在 50 岁及以上、收入低于 200%联邦贫困线的医疗保险受益人群体中 151282957 人的社区居住人口。在加权样本中，平均（标准差）年龄为 75.4（9.4）岁，66.1%的受益人为女性，14.8%为非西班牙裔黑人，13.6%为西班牙裔，71.6%为白人。研究结果表明，超过医疗补助资格门槛与黑人受益人和西班牙裔医疗保险受益人的医疗补助入保概率降低 43.8 个百分点（95%置信区间，37.8-49.8），与白人受益人的医疗补助入保概率降低 31.0 个百分点（95%置信区间，25.4-36.6）相关。在黑人受益人和西班牙裔受益人中，超过门槛与更高的与费用相关的获得医疗服务的障碍有关（不连续性：5.7 个百分点；95%置信区间，2.0-9.4），门诊使用减少（每人每年减少 6.3 次就诊；95%置信区间，10.4-2.2），药物填充减少（每人每年减少 6.9 次填充；95%置信区间，11.4-2.5），但与住院治疗的不连续性无统计学意义。在白人受益人中，这些结果的不连续性较小或不显著。因此，超过门槛与更大的差距有关，包括门诊服务使用的更大减少（差异：每人每年减少 6.2 次就诊；95%置信区间，11.7-0.6；P=.03）和药物填充减少（差异：每人每年减少 7.2 次填充；95%置信区间，13.4-1.0；P=.02），黑人受益人和西班牙裔受益人与白人受益人的差距更大。
结论和相关性：本横断面研究发现，医疗保险补充保险的资格丧失超过联邦贫困线，这增加了医疗保险的费用分担，与低收入医疗保险受益人的医疗保健种族和民族差异增加有关。扩大医疗补助补充保险的资格可能会缩小这些差距。
