More Insurance Following Medicaid Expansion, but Acute MI Survival Remained Static

Medicaid expansion has not led to decreased in-hospital mortality rates following acute MI, though fewer patients were uninsured over time, according to new data.

Admitting being “a little disappointed” in the findings, senior author Karen Joynt Maddox, MD, MPH (Washington University School of Medicine in St. Louis, MO), told TCTMD, “We may have been a little naive to think that [Medicaid expansion] would change in-hospital mortality.

“One reason it might not is that, in general, people had a very high rate of getting things like cardiac cath and the right medications and that sort of thing whether or not they had Medicaid,” she continued. “So to some degree, the fact that we now treat heart attacks with algorithms and protocols and care pathways means that when someone comes into the emergency department, we don't not take care of them because they don't have insurance.”

For the study, published online this week ahead of print in JAMA Cardiology, Rishi Wadhera, MD, (Brigham and Women’s Hospital, Boston, MA), Joynt Maddox, and colleagues looked at National Cardiovascular Data Registry data from 325,343 patients hospitalized for acute MI between 2012 and 2016. They compared in-hospital care quality, procedure use, and mortality between states that expanded Medicaid coverage in 2014 and those that did not.

Hospitalization of uninsured patients declined more drastically in expansion states (18.0% to 8.4%) than nonexpansion states (25.6% to 21.1%) over the study period (P < 0.001 for trend). Additionally, Medicaid coverage almost doubled in expansion states (7.5% to 14.4%), yet only modestly increased in nonexpansion states (6.2% to 6.6%; P < 0.001 for trend).

Among the 55,737 patients deemed to be low income, those living in states that expanded Medicaid were substantially more likely to be covered after expansion and less likely to be uninsured compared with those in nonexpansion states. The chances of these patients receiving quality care increased in both cohorts, but to a lesser degree in states that did not expand Medicaid (P < 0.001 for interaction).

There were no differences between the study groups in receipt of procedures like PCI for NSTEMI. Also, improvement in in-hospital mortality was similar for expansion (3.2% to 2.8%; adjusted OR 0.93; 95%CI 0.77-1.12) and nonexpansion states (3.3% to 3.0%; adjusted OR 0.85; 95%CI 0.73-0.99) over time (P = 0.48 for interaction).

What’s the Point of Insurance?

“These findings suggest that current care systems for urgent, time-sensitive conditions may be less sensitive to insurance than has been recognized in the past,” Wadhera and colleagues write, explaining that prior research has shown lapses in care for uninsured patients.

This is good news for patients like the 51-year-old uninsured man with an MI who Joynt Maddox rounded on this week. “We didn't turn him away at the emergency department because he isn't insured, . . . and he will get what he needs to get to make sure he's okay,” she said. “Now, downstream, will he get a bill from the hospital? Missouri hasn't expanded Medicaid, so he may not have an option to get Medicaid. Can we get him medication vouchers? How are we going to make sure he gets his Plavix? There are many, many questions. Are we going to put this guy into bankruptcy or make him lose his house because he gets a hospital bill? I don't know. And those are all the things that Medicaid expansion could prevent.”

However, determining the ultimate benefit of Medicaid—increasing health or preventing financial ruin—is a bit more complex. “Many people who are newly eligible for Medicaid have years of accumulated poor health in part related to not having access to healthcare,” Joynt Maddox explained. “Giving them an insurance card overnight isn't going to change that. It's giving people access to care when they're 18. It's making sure that people get their flu shots and that they get their high blood pressure treated when they're 30 and that they are on diabetic medication when they're 40 that will prevent them from having a heart attack when they're 50.”

The available data is missing a couple key components that might clarify whether having insurance makes a difference in outcomes for these patients, she acknowledged. “One is we're missing the people who don't come in with heart attacks, and so if we're actually preventing heart attacks, it's hard to tell that,” Joynt Maddox said. “[Also], we only have in-hospital mortality. So unfortunately, just because of the way that healthcare works in this country, we don't have any good long-term data on people. [Following discharge], we don't know if they came back with another heart attack.”

While she hopes Medicaid beneficiaries would be receiving the proper medications, follow-up care, and cardiac rehab following an acute MI, “we just don't know that when we look at these data,” Joynt Maddox continued. “The test will really be the 1-year, 2-year, 5-year outcomes for these people as they continue to have coverage, can see a cardiologist in the outpatient setting, and can get the medications they need.”

Down the line, “it's going to be really important to follow people longitudinally who gain insurance and look at the change in their health status. . . . That would be helpful in trying to understand sort of how insurance leads to better health,” she concluded. Also, increased effort toward pooling electronic health records and hospitalization data will enable researchers to “start to put together a better understanding of the ways in which poverty, uninsurance, and the combination of those things might impact health,” Joynt Maddox said.