Effects of National Insurance Reforms and State Medicaid Expansions Under the Affordable Care Act on Insurance Coverage Among American Indian and Alaska Native People
研究评估了《平价医疗法案》下国家保险改革和州医疗补助扩展对美国印第安人和阿拉斯加原住民保险覆盖的影响，发现医疗补助扩展是降低其未保险率的主要因素。
OBJECTIVE: To test whether national health insurance reforms under the Affordable Care Act (ACA) and state Medicaid expansions affected insurance coverage among American Indian and Alaska Native (AIAN) people and estimate comparative effects for other racial-ethnic groups. STUDY SETTING AND DESIGN: We use a difference-in-differences approach that decomposes effects of national insurance reforms from state Medicaid expansions. DATA SOURCES AND ANALYTIC SAMPLE: Data are from the 2011 to 2019 American Community Survey. The analytic sample includes respondents aged 19-64 who identify as non-Hispanic AIAN, non-Hispanic white (NHW), non-Hispanic Black (NHB), or Hispanic and live in areas with a minimum of 50 respondents in each racial-ethnic group for 2009-2013. PRINCIPAL FINDINGS: Medicaid expansions were associated with a 9.0 pp. reduction in uninsurance (p < 0.001), and a 4.4 pp. increase in Medicaid coverage (p = 0.049) among AIAN respondents, with stronger effects among those who reported having Indian Health Services. However, national insurance reforms were not associated with AIAN respondents' insurance coverage. Similarly, Medicaid expansions rather than national reforms improved Hispanic respondents' insurance coverage. Among NHW and NHB respondents, both Medicaid expansions and national reforms improved insurance coverage. CONCLUSION: Medicaid expansions were the driving force behind the ACA's positive effects on insurance coverage among AIAN people between 2011 and 2019.