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Uninsured hospitalizations for CV events decreased after Medicare expansion
The number of uninsured hospitalizations for major CV events decreased in states that expanded Medicaid while the Affordable Care Act was being implemented compared with states that did not expand the program, according to a study published in JAMA Network Open.
Non-Medicare hospitalizations
Ehimare Akhabue, MD, instructor of medicine in the division of cardiology at Northwestern University Feinberg School of Medicine, and colleagues analyzed data from 30 states from the Agency for Healthcare Research and Quality (AHRQ) Healthcare Cost and Utilization Project (HCUP) State Inpatient Databases from 2009 to 2014. This included 524,848 non-Medicare hospitalizations in 2014 and an annual mean of 516,811 non-Medicare hospitalizations from 2009 to 2013.
Hospitalizations included in this study were for major CV events, which was defined as a composite of stroke, MI and HF. Patient information included sex, age, payer, race/ethnicity and residential classification.
There were 801,819 hospitalizations (53% men; 64% white; 46% aged 65-84 years) in 17 expansion states in 2014. In 13 states that did not expand Medicare in 2014, there were 719,459 hospitalizations (53% men; 68% white; 47% aged 65-84 years).
Major CV events accounted for 281,184 non-Medicare hospitalizations in expansion states in 2014 vs. 243,664 hospitalizations in nonexpansion states.
Multivariable difference-in-difference regression analyses found that expansion states had a 5.8-percentage point decrease in non-Medicare hospitalizations after the expansion took place compared with nonexpansion states (adjusted difference-in-differences estimate, –0.058; 95% CI, –0.075 to –0.042). There was also an 8.4-percentage point increase in Medicaid hospitalizations after the expansion in nonexpansion states (adjusted difference-in-differences estimate, 0.084; 95% CI, 0.065-0.102).
In-hospital mortality rates
In-hospital mortality did not significantly change after the ACA was implemented in expansion states (3.7% in 2014 vs. 3.8% from 2009-2013) or nonexpansion states (4% in 2014 vs. 4% from 2009-2013).
“Any decrease in cost burden for individuals and hospitals because of the Medicaid expansion might be expected to shift to the states and the federal government,” Akhabue and colleagues wrote. “Thus, discussions of economic impact and costs must take into account all of these factors in addition to effects on hospital, state and federal expenditures. Adequate time is unlikely to have passed to draw conclusions on the association of the ACA with costs related to CVD — the unclear direction of federal policy on health insurance coverage adds complexity to what is already a complicated assessment.”
In a related editorial, Rishi K. Wadhera, MD, MPhil, clinical fellow in medicine at Brigham and Women’s Hospital, and Karen E. Joynt Maddox, MD, MPH, assistant professor of medicine in the division of cardiology at Washington University School of Medicine in St. Louis, wrote: “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. Insurance could influence the care delivered during hospitalization by removing any financial barriers to optimal care delivery.” – by Darlene Dobkowski
Disclosures: The authors, Wadhera and Joynt Maddox report no relevant financial disclosures.