State participation in Medicaid expansion is associated with higher rates of insurance coverage, improved out-of-hospital cardiac outcomes, and some improvements in prevention and screening for Medicaid recipients compared with nonparticipation, a systematic review suggests.

Medicaid eligibility was extended to adults with incomes up to 138% of the federal poverty level as part of a 2014 provision of the Affordable Care Act of 2010.

Currently, all but 10 states participate in Medicaid, which provides health insurance coverage for people who, as of June 2023, are making less than $14,580 a year or for families of four that are making less than $30,000.

The systematic review showed that 64.3% of studies that tracked changes in insurance coverage and use of cardiac treatments showed improvement with Medicaid expansion.

Thirty-six percent showed improvement in morbidity and mortality with the expansion ― specifically, a decrease in out-of-hospital cardiac deaths ― but there was no association with in-hospital deaths.

“If patients do not have access to insurance, they don’t get the incredible range of therapies that are available for individuals with heart disease,” principal author Jason H. Wasfy, MD, of Massachusetts General Physicians Organization Headquarters in Boston told theheart.org | Medscape Cardiology.

“Policymakers should respond to evidence from researchers ― as well as the experiences of patients and caregivers ― to prioritize the extension of health coverage to all Americans,” he said.

“Clinicians should be mindful that individuals who have experienced uninsurance in the past may have undiagnosed and untreated conditions,” he added, “and are likely at higher risk.”

The study was published online June 20 in Circulation: Cardiovascular Quality and Outcomes.

Medicaid Matters

The systematic review included 30 studies published from 2014 to 2022 that evaluated the association between Medicaid expansion and cardiac outcomes.

Fourteen (48%) were difference-in-difference analyses. Forty percent evaluated outcomes for less than 2 post-expansion years; 30% for 2 to 3 years; and 30% for 3 or more years.

A total of 56 outcomes were examined across the 30 studies. Of these, 25% assessed insurance coverage and treatment utilization; 19.6%, morbidity or mortality; 14.3%, disparities in care; and 41.1%, preventive care.

Commonly assessed outcomes included insurance coverage and utilization of cardiac treatments (25%), morbidity/mortality (19.6%), disparities in care (14.3%), and preventive care (41.1%).

As noted, 64% of the studies that tracked changes in insurance coverage for cardiac treatments found improvement with Medicaid expansion, as did 36% of studies that tracked changes in cardiac-related deaths and illnesses.

Although there was a decrease in out-of-hospital deaths from heart disease with the expansion, no association was observed with in-hospital deaths.

Among studies that tracked disparities in care across different socioeconomic and demographic groups, 37.5% found that disparities were reduced with Medicaid expansion.

Among studies that tracked preventive care, such as screening and treatment for hypertension, high cholesterol, and type 2 diabetes, 48% reported improved preventive care with the expansion.

Study limitations include the quasi-experimental comparisons of expansion and nonexpansion states, which cannot account for unmeasured state-level confounders; the use of observational data; conflicting results and the small number of relevant studies on disparities in cardiac care; and the inability to assess longer-term effects of expanded coverage on clinical outcomes such as heart failure and acute myocardial infarction incidence, cardiac hospitalizations, and cardiac mortality.

Business Community Support

“At the American Heart Association (AHA), we’ve long believed that insurance equals better treatment equals better outcomes, and that’s what this article is saying,” Eduardo Sanchez, MD, MPH, the AHA’s chief medical officer for prevention, told theheart.org | Medscape Cardiology when asked to comment on the study.

Since the article was published, he noted, efforts by the AHA and other organizations have helped South Dakota and North Carolina adopt Medicaid expansion, leaving only 10 states that do not yet offer the provision.

“Just bringing folks together to begin to figure out what might make sense can help,” said Sanchez, who is the principal investigator of the National Hypertension Control Initiative and AHA clinical lead on Target: BP and KnowDiabetesbyHeart. “In some states, you have a variety of constituencies that invite medical societies and others to participate in those conversations.

“It’s clear that in most instances, the business community, as well as the healthcare community, support Medicaid expansion because there have been described economic benefits, and not only to the individuals who get Medicaid,” he said. It is likely that individuals with health insurance have more disposable income, and from a business perspective, that means more people will be spending money in the local economy.

Like Wasfy, Sanchez advised clinicians to be aware of their patients’ insurance status. “That might help you make decisions about what medications to prescribe ― for example, more generics. And when there are exceptions, clinicians should know what other services might be available in the local community for persons who do not have insurance.”

Clinicians and other members of the healthcare team also should “assess and address the social needs their patients might be experiencing, such as job loss or lack of money for next month’s rent, and refer them to the right places to get those taken care of,” he said.

“For nonparticipating states, there might be some misunderstanding about the Medicaid’s financial burden on the state,” he added. “Yet, economic analyses have shown over and over and over again that in general, states benefit and the people in those states benefit from expanded Medicaid.”

The study was funded in part by an AHA grant to Wasfy. The authors have disclosed no relevant financial relationships.

Circ Cardiovasc Qual Outcomes. Published online June 20, 2021. Full text

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