Medicaid Expansion Linked to Lower CV Mortality

June 07, 2019

Recent Medicaid expansion is associated with lower cardiovascular mortality in middle-aged adults, a new study suggests.

The study examined differences in cardiovascular mortality before and after the Medicaid expansion in 2014 and compared results in states that accepted the expansion with those that didn't.

Results showed that cardiovascular mortality among middle-aged adults was stable in states that accepted expanding Medicaid coverage but increased in states that did not allow Medicaid expansion.

"This works out to over 2000 fewer cardiovascular deaths per year among the middle-aged in the states that expanded Medicaid coverage compared to states which didn't expand coverage," lead author Sameed Khatana, MD, a fellow in Cardiovascular Disease at the University of Pennsylvania in Philadelphia, told Medscape Medical News.

"Our results suggest there are potential mortality level benefits to expanding Medicaid. This study looked at the situation in 2016 — just 2 years after Medicaid expansion — so the benefits will hopefully get larger.

"Given the high burden of cardiovascular risk factors among individuals without insurance and those with lower socioeconomic status, policymakers may want to consider these results as they debate more changes to Medicaid eligibility and expansion," Khatana added.

The study was published online June 5 in JAMA Cardiology.

The researchers obtained annual, county-level cardiovascular mortality rates, age-adjusted to the 2000 US population, from the Centers for Disease Control and Prevention's Wide-ranging Online Data for Epidemiologic Research mortality database from 2010 to 2016 for all 50 states and Washington, DC. Massachusetts and Wisconsin were excluded as these two states had already expanded Medicaid prior to 2014.

Data on sex, race, poverty, unemployment levels, median inflation-adjusted household income (in 2016 dollars), and percentage of residents with health insurance were obtained from the US Census Bureau and the Bureau of Labor Statistics.

Results showed that compared with counties in 19 states that did not expand Medicaid, counties in 29 expansion states had a greater reduction in the percentage of uninsured residents at all income levels (7.3% vs 5.6%) and in low-income strata (19.8% vs 13.5%) between 2010 and 2016.

Cardiovascular mortality hardly changed between 2010 and 2016 in counties located in Medicaid expansion states (146.5 to 146.4 deaths per 100,000 residents per year), but the figures rose in the non-expansion states (176.3 to 180.9 deaths per 100,000 residents per year).

After accounting for demographic, clinical, and economic differences, counties in expansion states had 4.3 fewer deaths per 100,000 residents per year from cardiovascular causes after Medicaid expansion compared with the deaths that would have occurred had they followed the same trends as counties in non-expansion states.

Khatana noted that the publicity surrounding the changes led to raised awareness of Medicaid among the country's entire population, so that even in the areas that didn't formally adopt the expansion (the control group in this study) more people became covered by Medicaid. This is because more individuals who were previously eligible actually accessed the insurance coverage.

When comparing all counties in states that adopted the Medicaid expansion with the non-expansion counties in the bottom 50th percentile for change in number of residents with low income and health insurance, there were 12.2 fewer deaths per 100,000 residents per year.

This compares with 3.2 fewer deaths per 100,000 residents per year when counties in Medicaid expansion states were compared with non-expansion counties that had a higher change in the number of people with health insurance.

"This shows that the cardiovascular death rate does seem to be linked to changes in insurance status," Khatana commented.

The researchers also report a reduction in cardiovascular deaths in the older population (ages 65-74) in Medicaid expansion states even though Medicaid is not directly applicable to this age group. They suggest that this supports the idea that the mechanisms behind the observations may involve factors other than just better access to care, such as the strengthening of the financial health of institutions that provide care to low-income residents throughout the age spectrum (eg, community health centers and safety net hospitals).

Khatana pointed out that some states are considering introducing barriers to Medicaid, such as a requirement to demonstrate that an individual is actively seeking employment. "These conditions may dilute or reverse the benefits we have seen in this study," he said.  

Commenting on the results for Medscape Medical News, Khurram Nasir, MD, associate professor of internal medicine at Yale School of Medicine in New Haven, Connecticut, said the findings were in line with other studies indicating that patients have improved access and quality of care with expanded Medicaid spending for other conditions.

He speculated that multiple factors may have contributed to benefits noted in this study. "In the past, reports have suggested that Medicaid expansion has led to more preventive screening, availability of needed prescription medications, and enhanced access to primary care that have translated into lower rates of emergency room visits," Nasir said. "Furthermore, our group has shown significantly lower financial burden for Medicaid members who have heart disease."

"Based on multiple studies, including this current one, I think now we can all agree on the benefit of Medicaid expansion as well as the observation that it has not shown any unintended harm," Nasir added.

"In the future," he continued, "we need to identify whether access to preventive or acute care contributed to these favorable results, as this will allow policymakers to ensure that those specific, most cost-effective mechanisms are further strengthened in our future healthcare reforms."

JAMA Cardiol. Published online June 5, 2019. Full text

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