Medicaid Expansion Curbs Uninsured Hospitalization for CV Events

Megan Brooks

September 06, 2018

In the first year, states that expanded Medicaid coverage under the Affordable Care Act (ACA) had fewer uninsured hospital admissions for acute myocardial infarction, stroke, and heart failure than states that opted not to expand Medicaid, show results of a study by researchers at Northwestern University Feinberg School of Medicine in Chicago, Illinois.

"These are three of the top causes of hospitalizations for cardiovascular (CV) disease in this country," first author Ehimare Akhabue, MD, now with Rutgers University Robert Wood Johnson Medical School, New Brunswick, New Jersey, noted in an interview with the heart.org | Medscape Cardiology.

Akhabue said he wasn't surprised by the data, given prior studies that have shown marked declines in the proportion of uninsured non–CV-related hospital discharges in Medicaid expansion states vs nonexpansion states.

However, "we thought it was really important to document this for cardiovascular disease because it is the number one cause of death in the country," he noted. "These data suggest a consistent signal that we have seen in other studies."

The study was published August 24 in JAMA Network Open.

For this study, the researchers analyzed more than 3 million non-Medicare hospitalizations from inpatient databases in 30 states (17 that expanded Medicaid and 13 that did not). They looked at the years preceding expansion (2009 to 2013) and the first year after expansion (2014).

In 2014, there were 801,819 hospitalizations in expansion states and 719,459 hospitalizations in the nonexpansion states. Major CV events accounted for 281,184 non-Medicare hospitalizations in expansion states in 2014 and 243,664 hospitalizations in nonexpansion states.

In multivariable difference-in-differences regression analyses, expansion states had a significant 5.8–percentage point decrease in the uninsured proportion of non-Medicare hospitalizations after Medicaid expansion relative to the nonexpansion states (adjusted difference-in-differences estimate, −0.058; 95% confidence interval [CI], −0.075 to −0.042; P < .001).

Expansion states also had a significant 8.4–percentage point increase in the proportion of Medicaid hospitalizations after expansion relative to nonexpansion states (adjusted difference-in-differences estimate, 0.084; 95% CI, 0.065 - 0.102; P < .001).

The proportions of uninsured and Medicaid hospitalizations were unchanged in nonexpansion states during the study period.

No Change in In-Hospital Death Rates

There was no significant change in in-hospital mortality in expansion states (3.7% in 2014 vs 3.8% from 2009 to 2013) or nonexpansion states (4.0% in 2014 vs 4.0% from 2009 to 2013). But Akhabue and colleagues say further study is needed to determine how state-level policy regarding Medicaid expansion could differentially affect cardiovascular outcomes.

The authors of an editorial agree, noting that a growing body of evidence suggests that Medicaid expansion has had many benefits. 

"For cardiovascular care in particular, the identification and treatment of risk factors, such as high cholesterol level, hypertension, and diabetes, have improved since expansion, as has the use of prescription cardiovascular drugs," write Rishi Wadhera, MD, Brigham and Women's Hospital Heart & Vascular Center, Boston, Massachusetts, and Karen Joynt Maddox, MD, Washington University School of Medicine, St Louis, Missouri. 

It's possible, they say, that the single postexpansion year examined in this study was "too short to appreciate the incremental, cumulative health benefits of access to preventive care, medications, and treatment of chronic illnesses…. Or, perhaps in the immediate aftermath of insurance expansion, we are seeing pent-up demand, and longer follow-up will be required before these patterns settle out," they write.

Echoing the authors, the editorial writers say future research should evaluate more years after expansion, all states, and outcomes in the period following discharge to provide a complete picture of expansion and outcomes in the context of acute hospitalization.

This study, they add, comes at a time when Medicaid expansion is particularly contentious.

"Recently, residents of Maine decisively voted to expand Medicaid even further, although the state's governor is now being sued for refusing to do so. Other states, such as Idaho, are considering moving forward with efforts to expand. As such, Akhabue and colleagues make an important contribution to our understanding of Medicaid expansion and acute hospitalizations for cardiovascular conditions at a time when it is vital that evidence inform the ongoing policy debate," say Wadhera and Joynt Maddox.

The study was supported by a grant from the American Heart Association. The authors have disclosed no relevant financial relationships. Joynt Maddox has reporting doing contract work for the US Department of Health and Human Services.

JAMA Netw Open. Published online August 24, 2018. Full text, Editorial

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