States that approved Medicaid expansion see fewer uninsured CVD hospitalizations
A JAMA analysis of more than three million non-Medicaid hospitalizations has found states that opted to expand Medicaid under the Affordable Care Act years ago are now seeing lower rates of uninsured hospitalizations for major heart events, adding evidence to the growing body of research supporting expansion efforts.
Though the ACA’s bylaws initially required all states to expand Medicaid eligibility to any patients at or below 138 percent of the federal poverty level, a 2012 Supreme Court ruling allowed states to decide on expansion themselves, first author Ehimare Akhabue, MD, and colleagues wrote. Since then, 32 states and the District of Columbia have elected to expand Medicaid, but 18 states have decided against it.
Since uninsured patients usually fall lower on the socioeconomic scale, they often can’t afford insurance and subsequently bear a disproportionate burden of cardiovascular disease, Akhabue et al. said. Insurance status has been directly linked to clinical outcomes in the case of CVD, coronary heart disease and stroke.
“Given the potential for CVD-related morbidity along with data suggesting mortality may have recently increased, understanding the association of particular components of the ACA with uninsured hospitalizations for major CV events has potentially significant health policy implications—especially in the non-Medicaid population,” the authors wrote. “Furthermore, there is currently a dearth of data on the possible associations of expanded insurance coverage with CV outcomes.”
Akhabue and his team evaluated rates of uninsured and Medicaid hospitalizations among all non-Medicaid hospitalizations in 17 expansion states and 13 non-expansion states for their study. They assessed data collected both before expansion and after the policy was implemented in 2013.
The authors found that, among expansion states, the proportion of uninsured hospitalizations related to major adverse CVD events like acute MI, stroke and heart failure had dropped by 5 percent. In the same group, Medicaid hospitalizations increased by more than 10 percent. No changes were noted in hospitalizations among non-expansion states.
Rishi K. Wadhera, MD, MPhil, and Karen E. Joynt Maddox, MD, MPH, said in a related editorial that despite the lack of change in non-expansion states, a growing body of evidence suggests Medicaid expansion has numerous benefits, like extending better access to primary and preventive care in the outpatient setting and better identification and treatment of chronic conditions like depression.
“It is possible that the single post-expansion year examined by Akhabue and colleagues was too short to appreciate the incremental, cumulative health benefits of access to preventive care, medications and treatment of chronic illnesses,” they wrote. “It is also possible that better care of chronic illness before an acute exacerbation might not be associated with better outcomes for that event. 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.”
Wadhera and Maddox said future research should include more post-expansion years and all states, but for now, what Akhabue and his team have found is crucial. The decline in uninsured CVD hospitalizations in expansion states is significant regardless of whether it changed patient outcomes, they said, because before expansion most MI and stroke patients were slapped with “catastrophic” hospital bills they couldn’t pay. Now, more affordable insurance can offer those patients protection against bankruptcy in the case of a medical emergency.
“Akhabue and colleagues’ investigation comes at a time when Medicaid expansion is particularly contentious,” Wadhera and Maddox wrote. “As such, [they] 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.”
After graduating from Indiana University-Bloomington with a bachelor’s in journalism, Anicka joined TriMed’s Chicago team in 2017 covering cardiology. Close to her heart is long-form journalism, Pilot G-2 pens, dark chocolate and her dog Harper Lee.