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

基本信息

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
项目类别：
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

项目摘要

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.

项目概要肾衰竭是一种困扰近 75 万美国人的危及生命的疾病，其负担下降不成比例地发生在美国社会最弱势的社区。获得护理和服务的机会不足缺乏医疗保险覆盖是造成种族/族裔和社会经济差异的关键因素肾衰竭的发生率和开始肾脏替代治疗后的结果。在我们目前的资助中 (R01DK113298)，我们发现，在开始透析的非老年患者中，医疗补助范围扩大了平价医疗法案 (ACA) 减少了无保险，增加了开始长期血液透析的可能性具有成熟或功能性动静脉通路，并降低了一年死亡率。与白色相比患者中，黑人患者在扩张后死亡率绝对下降了 3 倍。尽管有越来越多的证据表明医疗补助扩大对获得护理和健康的影响，这些先前的研究考察了经济持续增长和不保险率下降的时期。但在经济困难时期，扩大医疗补助覆盖范围的影响可能会被放大。期间在 COVID-19 大流行的前六周，前所未有的 4000 万美国人申请了失业救济金，预计保险覆盖面将大幅下降，特别是在非扩张州。此外，少数族裔/族裔人群以及患有以下疾病的患者中 COVID-19 的死亡率较高慢性疾病，包括肾脏疾病。大流行还扰乱了护理，可能带来不利影响对具有复杂医疗需求和社会风险因素的人群产生的后果。国家估计需要了解 COVID-19 和扩大医疗补助覆盖范围对获得护理和结果的影响有效的公共卫生应对措施。此 R01 续签申请将审查覆盖范围、获得服务的机会方面的差异大流行期间和之后肾衰竭患者的护理、移植评估和死亡率（目标 1），以及医疗补助扩大对治疗和结果差异的保护作用肾衰竭（目标 2）和发病率（目标 3）。我们研究的理由是 COVID-19 大流行对肾病患者获得护理和健康结果构成根本威胁，但是扩大医疗补助覆盖范围可能会减弱这些影响，减少种族/民族和社会经济差异，从而为卫生政策提供信息。我们通过地理定位事件 ESKD 患者的地址数据进行创新，从而得出有关邻里劣势的详细信息，对小范围内的发生率进行建模地理区域，并识别生活在感染率高地区的患者。此外，我们考虑医疗补助扩大对移植和家庭透析（两种替代方案）差异的长期影响 2019 年推进美国肾脏健康行政命令优先考虑血液透析。我们期望这提案可以通过及时、严格地估计扩大医疗补助的影响来为政策提供信息关于 COVID-19 大流行及其经济后果后肾脏健康差异的报道。