Medicaid Expansion: Good First Step, but No Panacea for CV Care

Patrice Wendling

June 06, 2022

Medicaid expansion under the Affordable Care Act led to substantial gains in insurance coverage and access to care but not in cardiovascular risk factor management or treatment, new research suggests.

"We have a lot of work to do to improve cardiovascular care delivery to low-income vulnerable populations, irrespective of where they live," Rishi K. Wadhera, MD, MPP, MPhil, Beth Israel Deaconess Medical Center, Boston, told | Medscape Cardiology.

Wadhera and colleagues examined data from a weighted population of just over 28 million working-age adults, aged 18-64 years, with an annual household income of 138% or less than the federal poverty limit from the CDC's Behavioral Risk Factor Surveillance System from January to December 2019. Those living in Medicaid nonexpansion states were more likely to be female and Black.

Results showed that the rate of noninsurance was 42.4%, or nearly twice as high, in the 12 states that did not expand Medicaid compared with 23.8% in the expansion states (P < .001).

Persistent barriers in access to care were also found for low-income adults in nonexpansion states. For example, they were significantly:

  • less likely to have a usual source of care (55.4% vs 65.4%; adjusted risk difference [RD], -11.4%)

  • less likely to have had a routine examination within 2 years (78.9% vs 84.4%; RD, -6.2%)

  • more likely to have avoided care because of cost (36.1% vs 21.8%; RD, 14.2%).

As reported in JAMA Cardiology, there was also a trend in these states toward receiving less indicated monitoring of cholesterol (RD, -2.6%) and hemoglobin A1c (RD, -8.7%) levels.

"What surprised us was that there were no significant differences in treatment rates of cardiovascular risk factors," Wadhera said. "They were actually low in both groups of states."

Treatment rates in nonexpansion and expansion Medicaid states were: 66.1% vs 62.9% for antihypertensive drugs; 49.5% vs 46.7% for cholesterol medications; 32.8% vs 37.8% for insulin; and 44.9% vs 47.3% for daily aspirin.

"While we do need to address the major gaps in health insurance coverage that exist in nonexpansion states, whether it be at the state level or through federal policy, we also need to recognize that insurance coverage alone, while being critically important, is not a panacea for healthcare delivery," Wadhera said.

One possible explanation for the lack of differences in treatment, he suggested, is that insured patients who are interacting with the healthcare system may be getting the cardiovascular treatments they need more frequently in nonexpansion states than in expansion states.

"We need to continue our efforts to make sure that even when people have insurance coverage, they are able to easily access clinicians and healthcare providers and that they are receiving the high-quality guideline recommended care that they need to stay healthy," he said.

The 12 Nonexpansion States

The findings are in line with previous studies including those from a large literature review and a recent quasi-experimental study.

However, Wadhera and colleagues Andrew Oseran, MD, MBA, and Tianyu Sun, PhD, also with Beth Israel, provide new insights from a second analysis that zeroed in on the 12 Medicaid nonexpansion states (Alabama, Florida, Georgia, Kansas, Mississippi, North Carolina, South Carolina, South Dakota, Tennessee, Texas, Wisconsin, and Wyoming).

"Under the Build Back Better bill, the Biden administration has attempted to work around the political polarization and expand insurance coverage in nonexpansion states through the provision of premium subsidies in the ACA marketplaces," Wadhera explained. "We wanted to understand what the potential impact might be and just what is the state of things now."

This weighted analysis included 4.26 million uninsured and 5.77 million insured low-income residents in the 12 nonexpansion states, many of which have the highest cardiovascular disease and mortality rates in the country. Consistent with prior work, the uninsured population was disproportionately composed of Black (17%) and Hispanic (53.6%) adults.

"The punchline here is within nonexpansion states, we found pretty stark differences in access to care between uninsured and insured working-age adults, as well as much lower rates of monitoring and treatment of cardiovascular risk factors for uninsured adults," he said.

Uninsured adults in the nonexpansion states were significantly less likely to have a usual source of care (30.4% vs 73.8%; RD, -38.5%) and a routine examination within 2 years (64.1% vs 89.7%; RD. -23.1%) than their insured counterparts, and were twice as likely to defer care owing to cost (51% vs 25.2%; RD, 27.6%).

Cholesterol was monitored in 72.6% vs 93.7% (RD, -17.2%), respectively, and hemoglobin A1c in 55.2% vs 88.5% (RD, -25.8%), respectively.

Uninsured adults received significantly less treatment for hypertension (49.4% vs 74.7%, RD, -16.3%) and high cholesterol (30.2% vs 58.7%; RD, -19.3%), whereas the use of insulin (21.1% vs 37.8%; RD, -10.1%) and daily aspirin (27.1% vs 50.2%; RD, -18.4%) was numerically lower.

"Expanding insurance coverage in nonexpansion states could be a key step toward addressing these inequities," Wadhera said.

Although the study used the most recent data, a limitation is that it didn't capture changes in poverty and insurance status related to the 2020 economic downturn because of the COVID-19 pandemic, the authors noted. Some state-specific estimates of the uninsured also differ from previous work, which may reflect differences in the survey design.

This work was supported by a grant from the National Heart, Lung, and Blood Institute (NHLBI). Wadhera reports receiving grants from the NHLBI and personal fees from CVS Health and Abbott outside the submitted work.

JAMA Cardiol. Published online June 1, 2022. Abstract

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