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Invited Commentary
Health Policy
August 24, 2018

Medicaid Expansion and In-Hospital Cardiovascular Mortality: Failure or Unrealistic Expectations?

Author Affiliations
  • 1Brigham and Women’s Hospital Heart & Vascular Center, Harvard Medical School, Boston, Massachusetts
  • 2Richard and Susan Smith Center for Outcomes Research in Cardiology, Division of Cardiology, Beth Israel Deaconess Medical and Harvard Medical School, Boston, Massachusetts
  • 3Cardiovascular Division, Department of Medicine, Washington University School of Medicine in St Louis, St Louis, Missouri
JAMA Netw Open. 2018;1(4):e181303. doi:10.1001/jamanetworkopen.2018.1303

A central objective of the Affordable Care Act was to expand insurance coverage for low-income, uninsured Americans. Prior to the Affordable Care Act, eligibility for Medicaid varied greatly among states. Texas, for example, did not offer Medicaid insurance to poor adults without children, but the same adults living in Maine were eligible for Medicaid if they earned less than 100% of the federal poverty level in income. To ensure that low-income persons could access insurance regardless of their state of residence, the Affordable Care Act required states to expand Medicaid eligibility to any individual with an income at or below 138% of the federal poverty level. A subsequent US Supreme Court ruling in 2012, however, effectively made Medicaid expansion optional rather than mandatory. To date, 33 states (including the District of Columbia) have expanded Medicaid, while 18 states have elected to not implement expansion. This distinction has created an opportunity for researchers and policy makers to evaluate the relationship between Medicaid expansion and care delivery and outcomes.

Akhabue and colleagues1 do just that, exploring whether uninsured hospitalizations for major cardiovascular events (acute myocardial infarction, heart failure, and stroke) and in-hospital mortality changed after states implemented Medicaid expansion, compared with states that elected to not expand Medicaid. To do so, they evaluated rates of uninsured and Medicaid hospitalizations among all non-Medicare hospitalizations from 17 expansion states and 13 nonexpansion states in the years preceding expansion (2009-2013) and the year after expansion (2014).

Overall, the authors found that among expansion states, the proportion of uninsured hospitalizations declined by 5.0% (95% CI, −6.2% to −3.8%) and Medicaid hospitalizations increased by 10.2% (95% CI, 8.8% to 11.6%). In contrast, among nonexpansion states, the proportions of uninsured and Medicaid hospitalizations were unchanged. A multivariable adjusted difference-in-differences analysis demonstrated that expansion states experienced a significant reduction in uninsured hospitalizations after expansion relative to nonexpansion states (adjusted difference-in-differences estimate, −5.8%; 95% CI, −7.5% to −4.2%; P < .001), as well as a significant increase in Medicaid hospitalizations (adjusted difference-in-differences estimate, 8.4%; 95% CI, 6.5% to 10.2%; P < .001).

There are a number of reasons one might think insurance coverage would translate into better in-hospital outcomes. First, uninsured patients lack longitudinal, reliable access to outpatient care services required to identify and treat comorbid conditions. Insurance could plausibly improve outpatient management and reduce severity at presentation, reducing in-hospital mortality. In addition, lack of insurance is associated with delays in seeking emergency care in part out of concern for financial liability; insurance could remove this important barrier. Finally, prior studies have shown that uninsured patients hospitalized for acute cardiovascular conditions are less likely to receive guideline-directed medical therapy, aggressive care, and invasive cardiac procedures, which may explain their worse outcomes compared with insured patients.2,3 Insurance could influence the care delivered during hospitalization by removing any financial barriers to optimal care delivery.

However, Akhabue and colleagues observed no significant change in in-hospital mortality in expansion vs nonexpansion states during the study period. Does this mean that Medicaid expansion was a failure? Have we put billions of dollars into health reform for no good reason?

To the contrary, a growing body of evidence suggests that Medicaid expansion has had a number of benefits. Medicaid expansion is associated with greater access to primary and preventive care in the outpatient setting, as well as better detection and treatment of some chronic conditions such as depression.4,5 This perhaps explains why expansion has also been associated with improved self-reported health.4,6 For cardiovascular care in particular, the identification and treatment of risk factors, such as high cholesterol level, hypertension, and diabetes, have improved since expansion,7,8 as has the use of prescription cardiovascular drugs.4,9 It is possible that the single postexpansion 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; 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. Future research should evaluate more years after expansion, all states, and outcomes in the period following discharge to provide a comprehensive picture of expansion and outcomes in the context of acute hospitalization.

Finally, the most important aspect of Medicaid expansion may not be a direct health effect at all. Insurance protects against unbearable financial risk associated with health care costs, particularly among low-income individuals who are most susceptible, which explains why Medicaid expansion has been associated with reduced catastrophic expenditures, out-of-pocket spending, and bankruptcies.5 In this context, the decline in uninsured cardiovascular hospitalizations observed by Akhabue and colleagues in expansion states is extremely important regardless of whether it changed inpatient outcomes, as prior to Medicaid expansion, an estimated three-quarters of uninsured persons hospitalized for acute myocardial infarction or stroke in the United States experienced catastrophic health expenditures.10 Protection against bankruptcy brought on by cardiovascular disease may have many positive downstream effects, both for individuals and for society more broadly.

Akhabue and colleagues’ investigation comes at a time when Medicaid expansion is particularly contentious. Recently, residents of Maine decisively voted to expand Medicaid even further, although the state’s governor is now being sued for refusing to do so. Other states, such as Idaho, are considering moving forward with efforts to expand. As such, Akhabue and colleagues 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.

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Article Information

Published: August 24, 2018. doi:10.1001/jamanetworkopen.2018.1303

Open Access: This is an open access article distributed under the terms of the CC-BY License. © 2018 Wadhera RK et al. JAMA Network Open.

Corresponding Author: Karen E. Joynt Maddox, MD, MPH, Cardiovascular Division, Department of Medicine, Washington University School of Medicine in St Louis, 660 S Euclid Ave, St Louis, MO 63110 (kjoyntmaddox@wustl.edu).

Conflict of Interest Disclosures: Dr Joynt Maddox reported doing contract work for the US Department of Health and Human Services, Office of the Assistant Secretary for Planning and Evaluation. No other disclosures were reported.

Akhabue  E, Pool  LR, Yancy  CW, Greenland  P, Lloyd-Jones  D.  Association of state Medicaid expansion with rate of uninsured hospitalizations for major cardiovascular events, 2009-2014.  JAMA Netw Open. 2018;1(4):e181296. doi:10.1001/jamanetworkopen.2018.1296Google ScholarCrossref
Canto  JG, Rogers  WJ, French  WJ, Gore  JM, Chandra  NC, Barron  HV.  Payer status and the utilization of hospital resources in acute myocardial infarction: a report from the National Registry of Myocardial Infarction 2.  Arch Intern Med. 2000;160(6):817-823. doi:10.1001/archinte.160.6.817PubMedGoogle ScholarCrossref
Shen  JJ, Washington  EL.  Disparities in outcomes among patients with stroke associated with insurance status.  Stroke. 2007;38(3):1010-1016. doi:10.1161/01.STR.0000257312.12989.afPubMedGoogle ScholarCrossref
Sommers  BD, Blendon  RJ, Orav  EJ, Epstein  AM.  Changes in utilization and health among low-income adults after Medicaid expansion or expanded private insurance.  JAMA Intern Med. 2016;176(10):1501-1509. doi:10.1001/jamainternmed.2016.4419PubMedGoogle ScholarCrossref
Baicker  K, Taubman  SL, Allen  HL,  et al; Oregon Health Study Group.  The Oregon experiment—effects of Medicaid on clinical outcomes.  N Engl J Med. 2013;368(18):1713-1722. doi:10.1056/NEJMsa1212321PubMedGoogle ScholarCrossref
Sommers  BD, Gawande  AA, Baicker  K.  Health insurance coverage and health—what the recent evidence tells us.  N Engl J Med. 2017;377(6):586-593. doi:10.1056/NEJMsb1706645PubMedGoogle ScholarCrossref
Wherry  LR, Miller  S.  Early coverage, access, utilization, and health effects associated with the Affordable Care Act Medicaid expansions: a quasi-experimental study.  Ann Intern Med. 2016;164(12):795-803. doi:10.7326/M15-2234PubMedGoogle ScholarCrossref
Cole  MB, Galárraga  O, Wilson  IB, Wright  B, Trivedi  AN.  At federally funded health centers, Medicaid expansion was associated with improved quality of care.  Health Aff (Millwood). 2017;36(1):40-48. doi:10.1377/hlthaff.2016.0804PubMedGoogle ScholarCrossref
Ghosh  A, Simon  K, Sommers  BD.  The Effect of State Medicaid Expansions on Prescription Drug Use: Evidence From the Affordable Care Act. Cambridge, MA: National Bureau of Economic Research; 2017. doi:10.3386/w23044
Khera  R, Hong  JC, Saxena  A,  et al.  Burden of catastrophic health expenditures for acute myocardial infarction and stroke among uninsured in the United States.  Circulation. 2018;137(4):408-410. doi:10.1161/CIRCULATIONAHA.117.030128PubMedGoogle ScholarCrossref
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