Signs of Improved CV Mortality in States Expanding Medicaid Under ACA

April 08, 2019

ARLINGTON, Virginia — Recent upward trends in cardiovascular (CV) mortality in the United States overall were blunted in states that chose to expand Medicaid coverage under terms of the Affordable Care Act (ACA), suggests a study that used county-level 2010 to 2016 data covering adults aged 45 to 64.

The "alternative scenario" analysis explored what would have happened to CV mortality in Medicaid-expansion states, 29 of them plus the District of Columbia, had they emulated states that did not expand Medicaid under the ACA, Sameed Ahmed M. Khatana, MD, University of Pennsylvania, Philadelphia, told | Medscape Cardiology.

"For the expansion states, cardiovascular mortality stayed stable from the pre-expansion to the postexpansion period. But for the nonexpansion states, it actually increased."

If the expansion states had not expanded Medicaid during those years, "and had followed the same trends as the nonexpansion states," their adjusted CV mortality would have risen a projected 4.3 deaths per 1000 persons per year (P < .001), Khatana said the analysis suggests.

Most of the states that expanded the program did so in 2014, Khatana observed. So to some degree, the analysis, based on Centers for Disease Control and Prevention (CDC) data, can be seen as comparing CV outcomes by county from 2010 to 2014 versus 2014 to 2016.

Khatana had presented the analysis here last week at the American Heart Association Quality of Care and Outcomes Research (QCOR 2019) Scientific Sessions.

A massive expansion of Medicaid, the healthcare coverage program for people with limited income or disabilities, among others, was one of the ACA's central components. Although it is a federal program, Medicaid is administered by the states.

In subgroup analyses, Khatana said, the association between Medicare expansion and improved CV mortality became stronger the more people lacking health coverage were newly able to acquire coverage.

That points to greater access to healthcare owing to Medicaid expansion as a possible mechanism behind the projected CV mortality improvements, he said. "The ACA is complex, and this is an observational study, but the associations that we saw do suggest that."

Worsening Trends Overall

"It's concerning that in the last couple of years in this country we've actually seen a decrement in lifespan, and we've seen worsening cardiovascular mortality," Larry A. Allen, MD, MHS, University of Colorado School of Medicine, Aurora, told | Medscape Cardiology.

But in the current analysis, he said, CV mortality stayed stable in states that expanded Medicaid under ACA, whereas it worsened in states that didn't expand the program.

"So it looks like if you expand Medicaid, you attenuate some of the effects on cardiovascular mortality. I think that was the study's big take-home," said Allen, who had been the invited discussant for Khatana's presentation at QCOR 2019.

The analysis covered people who were 45 to 64 years of age during the 6- to 7-year period after the ACA was passed for all states except Massachusetts and Wisconsin, which had expanded Medicaid independently of the federal legislation.

Age-adjusted CV mortality rates were determined for 1960 counties in the 29 states plus the District of Columbia that had expanded Medicaid under the ACA by 2016 and the 19 states that did not expand the program.

"There was a decrease in the percentage of county residents that was uninsured in both expansion and nonexpansion states, but to a larger degree in the expansion states," Khatana observed.

When considering only low-income individuals by county, he said, "the difference between the two groups of states is actually more significant." Increases in that subgroup averaged 19.8% in the expansion states and 13.5% in nonexpansion states (P < .001), he reported.

Cardiovascular mortality in the expansion states went only from 146.5 to 146.4 deaths per 1000 residents per year, whereas it increased from 176.3 to 180.9 deaths per 1000 residents per year in nonexpansion states. That corresponds to about 1800 fewer deaths per year in states that expanded Medicaid under the ACA, Khatana and colleagues report.

The difference in the rate of change was 4.3 deaths per 1000 residents per year (= .001) in an analysis adjusted for sex, race, poverty rates, county unemployment rate, household income, per capita prevalence of primary-care providers and of cardiologists, metropolitan vs nonmetropolitan county classification, and prevalence of low-income residents with health insurance in 2010.

Dose–Response Effect

Counties with the smallest increases in coverage from 2010 to 2016 tended to be those with the biggest jumps in cardiovascular mortality.

That "dose–response" effect supports Medicaid coverage as a factor in the blunting of change in trajectory of CV mortality in the expansion states, strengthening the researchers' conclusions, Allen said.

In a sensitivity analysis, the researchers explored a population not greatly affected by Medicaid expansion, people 65 to 74 years of age who are covered by Medicare. There was indeed a difference in mortality change of 6.6 deaths per 1000 residents per year that went in the same direction as the finding in younger people, but without reaching statistical significance.

"You'd expect, if the blunting of cardiovascular death in expansion states was truly attributable to the expansion of Medicaid and health insurance, that you would not see a see a change in the Medicare population," Allen observed. Because there in fact seemed to be such a trend, it may be because "ACA had far-reaching effects that reach beyond age."

Although speculation, he cautioned, it may be that states that expanded Medicaid under the legislation "also took up other parts of the ACA that may have bolstered care for the Medicare population as well."

Khatana reports he has no relevant disclosures. Allen has reported serving as a consultant or on an advisory board for ACI Clinical, Boston Scientific, Janssen/Johnson & Johnson, and Cytokinetics/Amgen.

American Heart Association Quality of Care and Outcomes Research (QCOR 2019) Scientific Sessions: Abstract 3. Presented April 5, 2019.

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