Medicaid Expansion, Coverage Loss, and Disparities in Kidney Health in the COVID-19 Era

COVID-19 时代的医疗补助范围扩大、覆盖范围缩小以及肾脏健康方面的差异

• 批准号: 10447753
• 负责人: AMAL N. TRIVEDI
• 金额: $ 22.95万
• 依托单位: BROWN UNIVERSITY
• 依托单位国家: 美国
• 财政年份: 2017
• 资助国家: 美国
• 起止时间: 2017-02-01 至 2024-04-30
• 项目状态: 已结题
• 来源: https://reporter.nih.gov/project-details/10447753
• 关键词: Address; Adult; Affordable Care Act; American; Area; Attenuated; COVID-19; COVID-19 impact; COVID-19 pandemic; COVID-19 pandemic effects; Caring; Chronic; Chronic Disease; Communities; Complex; Data; Death Rate; Diabetes Mellitus; Dialysis procedure; Distress; Donor person; Economics; Evaluation; Geographic Locations; Goals; Grant; Growth; Health; Health Insurance; Health Policy; Health Services Accessibility; Healthcare; Hemodialysis; Home; Hypertension; Incidence; Insurance Coverage; Kidney; Kidney Diseases; Kidney Failure; Life; Link; Long-Term Effects; Low income; Medicaid; Medical; Minority; Modeling; Nephrology; Outcome; Patients; Persons; Policies; Population; Preventive; Public Health; Renal Replacement Therapy; Risk Factors; Role; Time; Transplantation; Treatment outcome; Unemployment; Uninsured; Waiting Lists; Work; adverse outcome; black patient; care outcomes; cost; ethnic disparity; ethnic minority population; evidence base; expectation; experience; falls; health disparity; infection rate; innovation; insight; mortality; neighborhood disadvantage; pandemic disease; prevent; racial and ethnic; racial and ethnic disparities; racial disparity; response; social; social disadvantage; socioeconomic disparity; treatment disparity

Project Summary The burden of kidney failure, a life-threatening condition that afflicts nearly 750,000 Americans, falls disproportionately on the most socially disadvantaged communities in the US. Inadequate access to care and lack of health insurance coverage are critical drivers of racial/ethnic and socioeconomic disparities in the incidence of kidney failure and outcomes after initiating kidney replacement therapy. In our current grant (R01DK113298), we found that, among nonelderly patients initiating dialysis, Medicaid expansions under the Affordable Care Act (ACA) reduced uninsurance, increased the likelihood of starting long-term hemodialysis with maturing or functional arteriovenous access, and lowered one-year mortality. Compared with white patients, Black patients experienced a 3-fold greater absolute decline in mortality following expansion. Although there is a growing evidence base of the impact of Medicaid expansion on access to care and health, these prior studies have examined a period of sustained economic growth and declining rates of uninsurance. But the effects of expanded Medicaid coverage may be magnified during times of economic distress. During the first six weeks of the COVID-19 pandemic, an unprecedented forty million Americans have filed unemployment benefits, with expectations of stark coverage losses, particularly in nonexpansion states. Moreover, death rates from COVID-19 are higher in racial/ethnic minority populations and among patients with chronic conditions, including kidney disease. The pandemic has also disrupted care, with potential adverse consequences for populations with complex medical needs and social risk factors. National estimates of the impact of COVID-19 and expanded Medicaid coverage on access to care and outcomes are needed to inform effective public health responses. This R01 renewal application will examine disparities in coverage, access to care, transplant evaluation, and mortality among patients with kidney failure during and after the pandemic (Aim 1), as well as the protective role of Medicaid expansion on disparities in treatment and outcomes of kidney failure (Aim 2), and incidence (Aim 3). The rationale for our study is that the COVID-19 pandemic presents fundamental threats to access to care and health outcomes for persons with kidney disease, but expanded Medicaid coverage may attenuate these effects, reduce racial/ethnic and socioeconomic disparities, and therefore inform health policy. We innovate by geolocating address data for incident ESKD patients, thereby deriving granular information on neighborhood disadvantage, modeling incidence within small geographic areas, and identifying patients living in areas with high infection rates. Further, we consider the long-term effects of Medicaid expansion on disparities in transplantation and home dialysis, two alternatives to hemodialysis prioritized by the 2019 Advancing American Kidney Health Executive Order. We expect that this proposal can inform policy by providing timely and rigorous estimates of the effects of expanded Medicaid coverage on disparities in kidney health following the COVID-19 pandemic and its economic aftermath.

项目摘要 肾衰竭的负担是一种威胁生命的状况，遭受了近75万美国人 在美国最弱势社区的社区不成比例。无法获得护理的机会 缺乏健康保险是种族/种族和社会经济差异的关键驱动因素 肾功能衰竭的发生率和肾脏替代疗法后的发生率。在我们目前的赠款中 （R01DK113298），我们发现，在非透析的非遗传患者中，医疗补助的扩张 负担得起的护理法（ACA）降低了不保险，增加了开始长期血液透析的可能性 具有成熟或功能性的动静脉通路，并降低了一年的死亡率。与白色相比 患者，黑人患者在扩张后死亡率的绝对绝对下降增加了3倍。 尽管越来越多的证据基础是医疗补助扩张对获得护理和健康的影响，但 这些先前的研究检查了一段持续的经济增长和不保险率下降的时期。 但是，在经济困扰时期，扩大的医疗补助覆盖范围的影响可能会受到放大。期间 共同-19大流行的前六个星期，一个前所未有的美国人提出了 失业福利，期望覆盖范围损失，尤其是在非专业国家。 此外，在种族/族裔少数群体中，COVID-19的死亡率较高，患有 慢性病，包括肾脏疾病。大流行也破坏了护理，潜在的不利 对具有复杂医疗需求和社会风险因素的人群的后果。国家估计 COVID-19和扩大医疗补助覆盖范围对获得护理和结果的影响以告知 有效的公共卫生反应。此R01更新申请将检查覆盖范围的差异，访问 大流行期间和之后的肾衰竭患者的护理，移植评估和死亡率 （AIM 1），以及医疗补助扩张在治疗和结果中的差异的保护作用 肾衰竭（AIM 2）和发病率（AIM 3）。我们研究的理由是Covid-19大流行 提出对肾脏疾病患者获得护理和健康成果的基本威胁，但 扩大的医疗补助覆盖范围可能会削弱这些影响，减少种族/种族和社会经济差异， 因此为卫生政策提供了信息。我们通过地址为事件ESKD患者的数据进行地址来进行创新， 从而得出有关邻里劣势的颗粒信息，在小型中建模发生率 地理区域，并确定生活在高感染率地区的患者。此外，我们考虑 医疗补助扩张对移植和家庭透析差异的长期影响，两种替代方案 血液透析优先于2019年推进美国肾脏健康执行命令。我们期望这 提案可以通过及时，严格地估算扩大的医疗补助的影响来为政策提供信息 Covid-19-19大流行及其经济后果之后肾脏健康差异的报道。