The association of Medicaid expansion and racial/ethnic inequities in access, treatment, and outcomes for patients with acute myocardial infarction

Abstract

Introduction After having an acute myocardial infarction (AMI), racial and ethnic minorities have less access to care, decreased rates of invasive treatments such as percutaneous coronary intervention (PCI), and worse outcomes compared with white patients. The objective of this study was to determine whether the Affordable Care Act’s expansion of Medicaid eligibility was associated with changes in racial disparities in access, treatments, and outcomes after AMI. Methods Quasi-experimental, difference-in-differences-in-differences analysis of non-Hispanic white and minority patients with acute myocardial infarction in California and Florida from 2010–2015, using linear regression models to estimate the difference-in-differences. This population-based sample included all Medicaid and uninsured patients ages 18–64 hospitalized with acute myocardial infarction in California, which expanded Medicaid through the Affordable Care Act beginning as early as July 2011 in certain counties, and Florida, which did not expand Medicaid. The main outcomes included rates of admission to hospitals capable of performing PCI, rates of transfer for patients who first presented to hospitals that did not perform PCI, rates of PCI during hospitalization and rates of early (within 48 hours of admission) PCI, rates of readmission to the hospital within 30 days, and rates of in-hospital mortality. Results A total of 55,991 hospital admissions met inclusion criteria, 32,540 of which were in California and 23,451 were in Florida. Among patients with AMI who initially presented to a non-PCI hospital, the likelihood of being transferred increased by 12 percentage points (95% CI 2 to 21) for minority patients relative to white patients after the Medicaid expansion. The likelihood of undergoing PCI increased by 3 percentage points (95% CI 0 to 5) for minority patients relative to white patients after the Medicaid expansion. We did not find an association between the Medicaid expansion and racial disparities in overall likelihood of admission to a PCI hospital, hospital readmissions, or in-hospital mortality. Conclusions The Medicaid expansion was associated with a decrease in racial disparities in transfers and rates of PCI after AMI. We did not find an association between the Medicaid expansion and admission to a PCI hospital, readmissions, and in-hospital mortality. Additional factors outside of insurance coverage likely continue to contribute to disparities in outcomes after AMI. These findings are crucial for policy makers seeking to reduce racial disparities in access, treatment and outcomes in AMI.

Barriers to Technology Use and Endocrinology Care for Underserved Communities With Type 1 Diabetes

“…Given the limited size of the cohorts in both states, caution should be used when examining the significance testing from the pre–focus group survey data. Additionally, the differences in technology use in both states might be related to larger policy-level differences related to insurance coverage ( 43 ). Finally, focus groups did not allow for a systemic analysis of potential differences in experiences related to racial and ethnic minority status.…”

Association of insurance status with potentially avoidable transfers to an academic emergency department: A retrospective observational study

“…29 Potential interventions to reduce unnecessary transfers may include the development of interfacility transfer protocols 30 and telehealth. 31,32 Other potential policy interventions such as expanded Medicaid access (ie, the Affordable Care Act) may address potential racial inequities in the transfer of for patients with acute myocardial infarction for percutaneous coronary intervention in California 33 but remain to be explored in other acute care settings and conditions. Finally, reducing potentially avoidable transfers must be balanced with the unintended consequences of compromising necessary transfers.…”

Interfacility Transfer of Uninsured vs Insured Patients With ST-Segment Elevation Myocardial Infarction in California

“…A key factor that may contribute to the reduced odds of transfer for uninsured patients with STEMI from facilities with PCI capabilities is California’s robust STEMI regionalization, which was completed in 2014 . Combined with early Medicaid expansion, regionalization was associated with reduced racial disparities in transfer rates and PCI after acute myocardial infarction . However, although regionalization enhanced access to PCI facilities, disparities in access, particularly among minoritized communities, remain in California .…”