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首页> 外文期刊>American journal of public health >Community Health Center Utilization Following the 2008 Medicaid Expansion in Oregon: Implications for the Affordable Care Act
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Community Health Center Utilization Following the 2008 Medicaid Expansion in Oregon: Implications for the Affordable Care Act

机译：俄勒冈州2008年医疗补助计划扩张后社区医疗中心的利用：《平价医疗法案》的含义

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Objectives. To assess longitudinal patterns of community health center (CHC) utilization and the effect of insurance discontinuity after Oregon’s 2008 Medicaid expansion (the Oregon Experiment). Methods. We conducted a retrospective cohort study with electronic health records and Medicaid data. We divided individuals who gained Medicaid in the Oregon Experiment into those who maintained (n?=?788) or lost (n?=?944) insurance coverage. We compared these groups with continuously insured (n?=?921) and continuously uninsured (n?=?5416) reference groups for community health center utilization rates over a 36-month period. Results. Both newly insured groups increased utilization in the first 6 months. After 6 months, use among those who maintained coverage stabilized at a level consistent with the continuously insured, whereas it returned to baseline for those who lost coverage. Conclusions. Individuals who maintained coverage through Oregon’s Medicaid expansion increased long-term utilization of CHCs, whereas those with unstable coverage did not. Policy implications. This study predicts long-term increase in CHC utilization following Affordable Care Act Medicaid expansion and emphasizes the need for policies that support insurance retention. The Affordable Care Act (ACA) provided Americans with new access to health insurance, 1 and many policymakers predicted a subsequent increase in health care utilization. 2–4 Early studies since the ACA’s implementation confirm this increase. 5–7 However, important questions remain about where newly insured individuals will get care, how trends in utilization will evolve over time, and how discontinuity of insurance will have an impact on utilization. 8,9 These important questions will guide allocation of resources and development of needed infrastructure and workforce to meet the primary care demands of a growing population of insured patients. Ensuring access to primary care for the newly insured is critical to optimizing public health and has proven challenging with previous Medicaid expansions. 3,10 Because long-term data from the ACA are not yet available, previous insurance expansions must inform predictions of the ACA’s impact on long-term utilization of primary care. Past studies of policy-driven expansions demonstrate how care-seeking behaviors change when a previously uninsured population receives coverage. 11–14 In Massachusetts, a 2006 insurance expansion resulted in increased utilization among the newly insured, 3,15,16 and community health centers (CHCs) saw utilization increase by 31%. 17 After the 2008 Oregon Experiment Medicaid expansion, ambulatory care utilization increased 18–20 and use of CHC services increased by 22% in the first year. 21 Individuals who gained Medicaid coverage through the Oregon Experiment subsequently had 39% more CHC visits than those who did not gain coverage. 22 We describe trends in CHC utilization for 36 months after Oregon’s 2008 Medicaid expansion to (1) investigate longitudinal utilization patterns, (2) observe the extent to which those gaining coverage experienced subsequent loss in coverage, and (3) better understand the extent to which a coverage loss affected utilization in subsequent years. Although we did not seek to estimate the causal effect of insurance coverage on primary care utilization as have others, 22 this longitudinal investigation of insurance cohorts adds to previous studies reporting that even short coverage gaps can have significant effects on access to care and utilization. 23–27 The use of new electronic health record (EHR) data sources enabled us to overcome some of the biases reported in past studies that used self-report (i.e., nonresponse bias, recall bias). Furthermore, unlike insurance claims data commonly used for tracking utilization rates, EHR data capture utilization among patients gaining and then losing insurance coverage and also allow for inclusion of an uninsured comparison group.
机译：目标。在俄勒冈州2008年医疗补助计划扩张后，评估社区卫生中心（CHC）使用的纵向格局以及保险中断的影响（俄勒冈州实验）。方法。我们使用电子健康记录和Medicaid数据进行了回顾性队列研究。我们将在俄勒冈州实验中获得医疗补助的个人分为那些拥有（n？=？788）或失去（n？=？944）保险的人。我们将这些人群与连续参保（n？=？921）和持续不参保（n？=？5416）的参考人群在36个月内的社区卫生中心利用率进行了比较。结果。两个新保险组在头6个月内均提高了利用率。 6个月后，保持承保范围的人的使用稳定在与连续投保者一致的水平，而失去承保范围的人的使用恢复到基线。结论。通过俄勒冈州的医疗补助计划扩大覆盖范围的个人增加了长期使用CHC的机会，而覆盖范围不稳定的人则没有。政策影响。这项研究预测，随着《 Affordable Care Act Medicaid》的扩大，CHC的使用将长期增加，并强调需要支持保单的保单。 《平价医疗法案》（ACA）为美国人提供了获得医疗保险的新途径1，许多政策制定者预计，随后医疗保健利用率将提高。 2–4自ACA实施以来的早期研究证实了这一增长。 5-7然而，关于新保险的个人将在何处获得护理，使用趋势将随着时间变化以及保险的不连续性将如何对使用产生影响，仍然存在重要的问题。 8,9这些重要问题将指导资源分配以及所需基础设施和劳动力的开发，以满足日益增长的参保患者的初级保健需求。确保新保险人获得基本医疗服务对于优化公共卫生至关重要，并且在以前的医疗补助计划扩展方面已证明具有挑战性。 3,10由于尚无法获得ACA的长期数据，因此，以前的保险扩展必须能预测ACA对长期使用基层医疗的影响。过去对政策驱动型扩张的研究表明，当以前没有保险的人群获得保险时，寻求护理的行为会如何改变。 11-14在马萨诸塞州，2006年的保险扩张导致新投保人，3、15、16和社区卫生中心（CHC）的利用率增加了31％。 17在2008年俄勒冈州实验性医疗补助计划扩展后，第一年的门诊医疗利用率增加了18–20，CHC服务的使用率增加了22％。 21通过俄勒冈实验获得医疗补助的个人随后获得的CHC访问比未获得医疗补助的个人多39％。 22我们描述了俄勒冈州2008年医疗补助计划扩张后36个月内的CHC利用趋势，以（1）研究纵向利用模式，（2）观察获得覆盖的人们随后失去覆盖的程度，（3）更好地了解覆盖损失影响了以后几年的利用率。尽管我们没有像其他人那样试图估计保险覆盖率对基层医疗利用的因果关系，但22对保险队列的纵向调查增加了以前的研究报告，即即使覆盖范围很小，也可能对获得医疗和利用机会产生重大影响。 23–27使用新的电子健康记录（EHR）数据源使我们能够克服过去使用自我报告的研究中报告的一些偏见（即，无应答偏见，回忆偏见）。此外，与通常用于跟踪利用率的保险索赔数据不同，EHR数据可捕获获得保险然后失去保险的患者之间的利用率，并且还可以包括未保险的比较组。

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