Background:Multiple states have not expanded Medicaid under the Affordable Care Act, resulting in higher uninsured rates in states with high stroke burdens. This study aimed to evaluate the association of Medicaid expansion with changes in health insurance coverage, severity of presentation, access to care, and outcomes among patients with acute ischemic stroke.Methods:A retrospective, difference-in-differences analysis of Get With The Guidelines–Stroke registry data. The study population comprised first-time ischemic stroke admissions from 2012 to 2018 for patients aged 19 to 64 in 45 states (27 that expanded Medicaid and 18 that did not). A probable low-income cohort was defined based on having Medicaid, no insurance/self-pay, or undocumented insurance. Outcomes analyzed were indicators of health insurance status, stroke severity, use of emergency services, time to acute care, in-hospital mortality, receipt of rehabilitation, discharge disposition, and level of disability.Results:In the starting population (N=342 765), Medicaid-covered stroke admissions rose from 12.2% to 18.1% in expansion states and from 10.0% to only 10.6% in nonexpansion states, while uninsured admissions declined from 15.0% to 6.7% in expansion states and from 24.0% to 19.2% in nonexpansion states. In the low-income cohort (N=95 086; 28% of starting population), Medicaid expansion was associated with increased odds of discharge to a skilled nursing facility (adjusted odds ratio, 1.33 [95% CI, 1.12–1.59]) and transfer to any rehabilitation facility among those eligible (adjusted odds ratio, 1.24 [95% CI, 1.08–1.41]) and lower odds of discharge home (adjusted odds ratio, 0.89 [95% CI, 0.80–0.98]). Expansion was not associated with any other outcomes.Conclusions:Medicaid expansion is associated with fewer uninsured hospitalizations for acute ischemic stroke and increased rehabilitation at skilled nursing facilities. More targeted interventions may be needed to improve other stroke outcomes in the low-income US population. Future research should evaluate the impact of health care reform on primary stroke prevention.

中文翻译：

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医疗补助扩张与急性缺血性中风获得护理、严重程度和结果的关联

背景：多个州尚未根据《平价医疗法案》扩大医疗补助计划，导致卒中负担高的州未投保率较高。本研究旨在评估医疗补助扩大与急性缺血性卒中患者的医疗保险覆盖面、就诊严重程度、获得护理的机会以及结果的变化之间的关联。 –中风注册表数据。研究人群包括 2012 年至 2018 年 45 个州（27 名扩大医疗补助计划，18 名未扩大医疗补助计划）的 19 至 64 岁患者的首次缺血性中风入院。一个可能的低收入群体是根据有医疗补助、没有保险/自费或无证保险来定义的。分析的结果是健康保险状况、中风严重程度、急救服务的使用、急诊时间、住院死亡率、康复接受、出院处置和残疾程度。 结果：在起始人群（N=342 765）中，Medicaid 承保的中风入院率从 12.2% 上升到扩张州为 18.1%，非扩张州从 10.0% 降至仅 10.6%，而扩张州未投保入院率从 15.0% 降至 6.7%，非扩张州从 24.0% 降至 19.2%。在低收入队列（N = 95 086；起始人口的 28%）中，医疗补助扩展与出院到专业护理机构的几率增加有关（调整后的几率比，1.33 [95% CI，1.12–1.59]）和转入任何符合条件的康复机构（调整后的比值比，1.24 [95% CI，1.08-1.41]）和出院回家的比值较低（调整后的比值比，0.89 [95% CI，0.80-0.98]）。扩展与任何其他结果无关。结论：医疗补助扩展与急性缺血性中风的无保险住院率减少和专业护理机构的康复增加有关。可能需要更有针对性的干预措施来改善美国低收入人群的其他卒中结局。未来的研究应评估医疗改革对卒中初级预防的影响。