METHODS: We employ a county-level time-varying heterogenous treatment effects difference-in-difference analysis of Medicaid expansion on all-cause age-adjusted mortality for those 64 years of age or younger from 2009 to 2019. For all counties within the 50 US States and the District of Columbia, we use restricted-access vital statistics data to estimate Average Treatment Effect on the Treated (ATET) for all combinations of racial and ethnic group (Black, Latino/a, White), rurality (rural, urban), and sex. We then assess aggregate ATET, as well as how the ATET changed as time from expansion increased.
RESULTS: Medicaid expansion led to a reduction in all-cause age-adjusted mortality for urban Black populations, but not rural Black populations. Urban White populations experienced mixed effects dependent on years after expansion. Latino/a populations saw no appreciable impact. While no effect was observed for rural Black and Latino/a populations, rural White all-cause age-adjusted mortality unexpectedly increased due to Medicaid expansion. These effects reduced rural- and urban-specific Black-White mortality disparities but did not shrink the rural-urban mortality gap.
CONCLUSIONS: The mortality-reducing impact of Medicaid expansion has been uneven across racial and ethnic groups and rural-urban status; suggesting that many populations-particularly rural individuals-are not seeing the same benefits as others. It is imperative that states work to ensure Medicaid expansion is being appropriately implemented in rural areas.
方法:我们采用县级随时间变化的异质性治疗效果差异分析,对2009年至2019年64岁以下人群的全因年龄调整死亡率进行医疗补助扩大。对于美国50个州和哥伦比亚特区内的所有县,我们使用限制访问的重要统计数据来估计所有种族和族裔组合对被治疗者(ATET)的平均治疗效果(Black,Latino/a,白色),农村(农村,城市),和性爱。然后我们评估总ATET,以及ATET随着扩展时间的增加而变化。
结果:医疗补助扩大导致城市黑人人口的全因年龄调整死亡率降低,但不是农村黑人人口。城市白人人口经历了混合效应,这取决于扩张后的几年。拉丁美洲人/人口没有明显的影响。虽然对农村黑人和拉丁裔人口没有观察到影响,由于医疗补助扩大,农村白人全因年龄调整死亡率意外增加。这些影响减少了农村和城市特有的黑人-白人死亡率差距,但并没有缩小城乡死亡率差距。
结论:医疗补助扩大对降低死亡率的影响在种族和族裔群体以及城乡状况之间是不均衡的;这表明许多人群,特别是农村个体,没有看到与其他人相同的好处。各州必须努力确保在农村地区适当实施医疗补助计划。