Association of the Affordable Care Act’s Medicaid Expansion With Care Quality and Outcomes for Low-Income Patients Hospitalized With Heart Failure

Wadhera, Rishi K.; Maddox, Karen E. Joynt; Fonarow, Gregg C.; Zhao, Xin; Heidenreich, Paul A.; DeVore, Adam D.; Matsouaka, Roland; Hernandez, Adrian F.; Yancy, Clyde W.; Bhatt, Deepak L.

doi:10.1161/circoutcomes.118.004729

Cited by 33 publications

(35 citation statements)

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“…By 1 January 2014, 24 U.S. states and the District of Columbia had elected to expand Medicaid eligibility requirements under the Affordable Care Act (ACA). While Medicaid expansion increased coverage of millions of previously uninsured patients and has been associated with lower cardiovascular hospitalizations (9) and mortality (10), it has not been consistently linked with greater provision of evidence-based therapies and quality of care in expansion states (11)(12)(13)(14). Understanding whether Medicaid expansion increased access to antihyperglycemic therapies for socioeconomically disadvantaged populations is critically important, given the high burden of T2DM in this population.…”

Section: Division Of Cardiology University Of Texas Southwestern Medical Center and Parklandmentioning

confidence: 99%

Medicaid Expansion and Utilization of Antihyperglycemic Therapies

et al. 2020

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Certain antihyperglycemic therapies modify cardiovascular and kidney outcomes among patients with type 2 diabetes, but early uptake in practice appears restricted to particular demographics. We examine the association of Medicaid expansion with use of and expenditures related to antihyperglycemic therapies among Medicaid beneficiaries. RESEARCH DESIGN AND METHODSWe employed a difference-in-difference design to analyze the association of Medicaid expansion on prescription of noninsulin antihyperglycemic therapies. We used 2012-2017 national and state Medicaid data to compare prescription claims and costs between states that did (n 5 25) and did not expand (n 5 26) Medicaid by January 2014. RESULTSFollowing Medicaid expansion in 2014, average noninsulin antihyperglycemic therapies per state/1,000 enrollees increased by 4.2%/quarter in expansion states and 1.6%/quarter in nonexpansion states. For sodium-glucose cotransporter 2 inhibitors (SGLT2i) and glucagon-like peptide 1 receptor agonists (GLP-1RA), quarterly growth rates per 1,000 enrollees were 125.3% and 20.7% for expansion states and 87.6% and 16.0% for nonexpansion states, respectively. Expansion states had faster utilization of SGLT2i and GLP-1RA than nonexpansion states. Differencein-difference estimates for change in volume of prescriptions after Medicaid expansion between expansion versus nonexpansion states was 1.68 (95% CI 1.09-2.26; P < 0.001) for all noninsulin therapies, 0.125 (20.003 to 0.25; P 5 0.056) for SGLT2i, and 0.12 (0.055-0.18; P < 0.001) for GLP-1RA. CONCLUSIONSUse of noninsulin antihyperglycemic therapies, including SGLT2i and GLP-1RA, increased among low-income adults in both Medicaid expansion and nonexpansion states, with a significantly greater increase in overall use and in GLP-1RA use in expansion states. Future evaluation of the population-level health impact of expanded access to these therapies is needed.Over 34 million U.S. patients live with diabetes including an estimated 6 million enrolled in Medicaid (1). Metrics of income and health care access are key predictors of mortality among patients with diabetes (2). Unfortunately, there has been a resurgence of cardiovascular complications among young and middle-aged adults with diabetes in the U.S. (3).

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Section: Division Of Cardiology University Of Texas Southwestern Medical Center and Parklandmentioning

confidence: 99%

Medicaid Expansion and Utilization of Antihyperglycemic Therapies

et al. 2020

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“…This approach has been taken in other Medicaid expansion studies where income and poverty data were unavailable. 37 – 39 The SID contain a variable for median household income quartile of the patient’s ZIP code, but this was not used due to lack of precision and the potential for ecological fallacy when ZIP codes are economically heterogenous. Nonetheless, we conducted a sensitivity analysis using the lowest quartile of median household income in the ZIP code to identify low-income patients instead of using primary payer.…”

Section: Methodsmentioning

confidence: 99%

Medicaid Expansion and Racial/Ethnic Differences in Readmission After Acute Ischemic Stroke

McGee

Kim

Aycock

et al. 2021

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To examine whether rates of 30-day readmission after acute ischemic stroke changed differentially between Medicaid expansion and non-expansion states, and whether race/ethnicity moderated this change, we conducted a difference-in-differences analysis using 6 state inpatient databases (AR, FL, GA, MD, NM, and WA) from the Healthcare Cost and Utilization Project. Analysis included all patients aged 19-64 hospitalized in 2012–2015 with a principal diagnosis of ischemic stroke and a primary payer of Medicaid, self-pay, or no charge, who resided in the state where admitted and were discharged alive (N=28 330). No association was detected between Medicaid expansion and readmission overall, but there was evidence of moderation by race/ethnicity. The predicted probability of all-cause readmission among non-Hispanic White patients rose an estimated 2.6 percentage points (or 39%) in expansion states but not in non-expansion states, whereas it increased by 1.5 percentage points (or 23%) for non-White and Hispanic patients in non-expansion states. Therefore, Medicaid expansion was associated with a rise in readmission probability that was 4.0 percentage points higher for non-Hispanic Whites compared to other racial/ethnic groups, after adjustment for covariates. Similar trends were observed when unplanned and potentially preventable readmissions were isolated. Among low-income stroke survivors, we found evidence that 2 years of Medicaid expansion promoted rehospitalization, but only for White patients. Future studies should verify these findings over a longer follow-up period.

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“…Existing research on the impact of the ACA Medicaid expansions on health outcomes is limited to studies that rely on self-reported health status or disease diagnosis, 6,7,[15][16][17] studies that focus on a specific population, [18][19][20][21][22] or an ecological study using aggregated data at the regional level 23 (therefore, susceptible to "ecological fallacy" 24 ). To our knowledge, there has been no national study that used individual-level clinically measured health data (e.g., blood pressure, blood glucose level, cholesterol level) to examine the relationship between the ACA's Medicaid expansions and cardiovascular risk factors.…”

Section: Introductionmentioning

confidence: 99%

Association Between the ACA Medicaid Expansions and Changes in Cardiovascular Risk Factors Among Low-Income Individuals

et al. 2021

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BACKGROUND: Evidence is limited as to whether the introduction of the Affordable Care Act (ACA)'s Medicaid expansions was associated with improvements in cardiovascular risk factors at the population level. OBJECTIVE: To examine the association between the ACA Medicaid expansions and changes in cardiovascular risk factors among low-income individuals during the first 3 years of the implementation of the ACA Medicaid expansions at the national level. DESIGN: A quasi-experimental difference-in-differences (DID) analysis to compare outcomes before (2005)(2006)(2007)(2008)(2009)(2010)(2011)(2012) and after (2015)(2016) the implementation of the ACA Medicaid expansions between individuals in states that expanded Medicaid and individuals in non-expansion states. PARTICIPANTS: A nationally representative sample of individuals aged 19-64 years with family incomes below 138% of the federal poverty level from the 2005-2016 National Health and Nutrition Examination Survey (NHANES). INTERVENTION: ACA Medicaid expansions.MAIN MEASURES: Cardiovascular risk factors included (1) systolic and diastolic blood pressure, (2) hemoglobin A1c (HbA1c) level, and (3) cholesterol levels (low-density lipoprotein cholesterol, triglyceride, and high-density lipoprotein cholesterol). KEY RESULTS: A total of 9177 low-income individuals were included in our analysis. We found that the ACA Medicaid expansions were associated with a lower systolic blood pressure (DID estimate, − 3.03 mmHg; 95% CI, − 5.33 mmHg to − 0.73 mmHg; P = 0.01; P = 0.03 after adjustment for multiple comparisons) and lower HbA1c level (DID estimate, − 0.14 percentage points [pp]; 95% CI, − 0.24 pp to − 0.03 pp; P = 0.01; P = 0.03 after adjustment for multiple comparisons). We found no evidence that diastolic blood pressure and cholesterol levels changed following the ACA Medicaid expansions. CONCLUSION: Using the nationally representative data of individuals who were affected by the ACA, we found that the ACA Medicaid expansions were associated with a related to hypertension and diabetes during the first 3 years of implementation.

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Association of the Affordable Care Act’s Medicaid Expansion With Care Quality and Outcomes for Low-Income Patients Hospitalized With Heart Failure

Cited by 33 publications

References 28 publications

Medicaid Expansion and Utilization of Antihyperglycemic Therapies

Medicaid Expansion and Utilization of Antihyperglycemic Therapies

Medicaid Expansion and Racial/Ethnic Differences in Readmission After Acute Ischemic Stroke

Association Between the ACA Medicaid Expansions and Changes in Cardiovascular Risk Factors Among Low-Income Individuals

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