Fewer Uninsured but Similar MI Outcomes With Medicaid Expansion

Debra L Beck

January 16, 2019

In states that opted to expand Medicaid eligibility under the Patient Protection and Affordable Care Act (ACA), the number of patients hospitalized with acute myocardial infarction (AMI) who were insured increased, but quality of care and in-hospital mortality was similar to that seen in nonexpansion states, a new report shows.

The proportion of uninsured AMI hospitalizations declined from 18.0% to 8.4% in states that opted for expanded eligibility for Medicaid. A more modest decline — from 25.6% to 21.1% — was seen in the states that did not expand their Medicaid criteria to serve more low-income individuals (< .001 for trend).

"Medicaid expansion did what it was supposed to: it significantly reduced the rate of uninsurance among that group, which presumably protected these people from significant financial harm from this acute event," said cardiologist and health policy researcher Karen Joynt Maddox, MD, MPH, Washington University, St. Louis, Missouri.

"But what we did not see was any change in quality of care or mortality in low-income populations in expansion versus nonexpansion states," she said.

Patients in expansion states were more likely to receive defect-free AMI care in the postexpansion period, although the increase was small (= .01). However, the increase in defect-free care in the postexpansion period was actually greater in the nonexpansion states (< .001; P < .001 for interaction).

Improvement in in-hospital mortality was similar in expansion and nonexpansion states (3.2% - 2.8% and 3.3% - 3.0%, respectively; P = .48 for interaction).

Commenting on Twitter, the study's first author, Rishi K. Wadhera, MD, MPP, MPhil, Harvard Medical School, Boston, noted that "hospital care for urgent conditions like AMI may be less sensitive to insurance than has been shown in the past."

The findings from this retrospective cohort study were published online January 16 in JAMA Cardiology.

The authors used data from the National Cardiovascular Data Registry (NCDR) Acute Coronary Treatment and Intervention Outcomes Network (ACTION) Registry to compare insurance status and outcomes in 325,343 patients younger than 65 years hospitalized for AMI.

In 2014, new ACA legislation paved the way for the expansion of Medicaid services and allowed millions of low-income adults to gain insurance coverage in more than 30 states.

The investigators compared data on states that opted to expand Medicaid eligibility in 2014 with those that did not. Outcomes were studied before expansion (January 2012 to December 2013) and 2 years after expansion (January 2015 to December 2016), allowing a lag because some states expanded midway through 2014.

When they restricted the cohort to just those in the lowest-income quartile (median household income ≤$37,060), in-hospital quality of care and mortality improved in expansion states, but not to any greater degree than it did in nonexpansion states.

"What this says to me is that we already treat AMI in a fairly protocolized manner and many of the decisions about what to do for patients are made without thinking about what insurance they have or whether they have insurance — we just treat them," said Joynt Maddox.

The data seem to support this assertion: 95% to 96% of patients in expansion and nonexpansion states received diagnostic catheterization, both before and after expansion. There was also no difference between the two periods in either expansion or nonexpansion states in the use of percutaneous coronary intervention (PCI) for non-ST-segment myocardial infarction (NSTEMI) or in coronary artery bypass grafting rates.

Adjusted odds for the use of primary PCI for STEMI were actually lower in the postexpansion period than in the pre-expansion period.

NCDR Hospitals Not Necessarily Representative

One limitation to the research, acknowledged by the authors, is its reliance on NCDR ACTION data, which might not be representative of all hospitals across the United States, in that it reflects sites that have an interest in quality improvement.

"We know that hospitals that participate in those types of registries tend to be better performing and more adherent to general guidelines than those that don't participate, so it's possible no variation in quality was seen because those hospitals are doing pretty well," Renee Hsia, MD, MSc, told theheart.org | Medscape Cardiology.

Hsia is an emergency department physician and director of health policy studies in the Department of Emergency Medicine at the University of California, San Francisco.

"The other part is that we're not necessarily looking at people who don't have access or don't seek care, and I know that sounds a little silly at first glance, because people, when they're having a heart attack, of course they're going to seek care, but we know that hospitals with PCI capabilities geographically locate in more affluent areas, so we may be missing patients who presented to hospitals that don't report to the registry."

Joynt Maddox agreed and went one step further. "Because it's a specific set of hospitals, what we're seeing here is only a snapshot of people who had a heart attack and went to the hospital. We're not talking about bunch of people who might have had a heart attack and looking at those who did versus didn't based on prevention under Medicaid."

Whether expanding Medicaid will lead to improved outcomes subsequent to better prevention and lower AMI rates has not been shown.

"Just because you get insurance doesn't mean that that automatically changes your health behaviors. We don't know, for example, how long it takes, say, poor or less-educated people who are given insurance to really start utilizing it properly," said Hsia.

Indeed, when the researchers looked at the proportions of low-income patients hospitalized with AMI in expansion and nonexpansion states, the rates of heart failure signs, cardiac arrest, and cardiogenic shock at presentation did not vary much; nor did preadmission medication use.

"If you have people who are struggling with housing insecurity, food insecurity, a lack of social support — all things that are associated with being uninsured — simply giving them insurance does not necessarily make them healthy," said Joynt Maddox.

"I think a very real possibility for what we're seeing is that phenomenon and that insurance is acting like insurance. It's keeping people from financial ruin, but it does not guarantee health."

Joynt Maddox receives research support from the National Heart, Lung, and Blood Institute and does contract work for the US Department of Health and Human Services. Hsia reports no conflict of interest.

JAMA Cardiology. Published online January 16, 2019. Abstract

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