Abstract 1: The Impact of State Medicaid Expansions on Care Quality and Outcomes for Low-Income Patients Hospitalized With Heart Failure

Abstract

Background: Heart failure (HF) is the leading cause of morbidity and mortality in the United States. Despite considerable advancement in the management of HF, outcomes remain suboptimal, particularly among the uninsured. In 2014, the ACA expanded Medicaid eligibility, and millions of low-income, non-elderly adults gained insurance coverage in 32 states. Little is known about Medicaid expansion’s effect on quality and outcomes of inpatient care for HF. Methods: We used the American Heart Association’s Get With The Guidelines-HF registry to assess changes in inpatient care quality and outcomes among low income, non-elderly patients hospitalized for HF prior to and following Medicaid expansion, in expansion and non-expansion states. Patients were classified as low income if covered by Medicaid, uninsured, or missing insurance. We considered expansion states to be those that implemented expansions in 2014. We constructed piecewise logistic multivariable regression models to track quarterly trends over time of quality and outcome measures in the pre-expansion (1/1/2010-12/31/2013) and post-expansion (1/1/14 - 6/30/17) periods, by state expansion status. Results: The cohort included 58,804 patients hospitalized across 391 sites - 53% were covered by Medicaid, 21.3% uninsured, and 25.6% missing insurance. Among expansion states, defect-free HF care increased significantly during the pre-expansion period (aOR 1.06, 95% CI 1.03-1.08) but did not change after expansion (aOR 0.99, 95% CI 0.97-1.02). Similarly, other quality measures, such as use of aldosterone antagonists, evidence-based beta blockers, and ICD implantation significantly increased prior to expansion, but did not change following expansion (Table). In-hospital mortality rates remained similar during the pre-expansion (aOR 0.99, 95% CI 0.96-1.02) and post-expansion periods (aOR 1.00, 95% CI 0.97-1.03). Trends in quality and outcome measures for non-expansion states are also shown in the table. Conclusion: The ACA Medicaid state expansions were not associated with improvements in quality of care or in-hospital mortality in expansion states among sites participating in a national quality improvement initiative. Future investigation should evaluate the long-term impact of expansion on HF care during the post-discharge period.

Association Between the Affordable Care Act Medicaid Expansion and Receipt of Cardiac Resynchronization Therapy by Race and Ethnicity

“…This HCUP SID study adds to published data demonstrating the ACA Medicaid expansion did not narrow racial and ethnic disparities in cardiovascular care. 10 , 13 , 15 Both eligible Black and Hispanic individuals remain statistically less likely to receive CRT than White individuals. 16 , 17 , 18 , 19 These results are in contrast to the observed increase in transplant listings among Black patients from early‐adopter states, 11 lower cardiovascular mortality in early‐adopter states, 20 and reported narrowing of racial disparities following the Medicaid expansion.…”

“… 6 , 7 Advances in US health policy may help. The Affordable Care Act (ACA) Medicaid expansion narrowed uninsurance disparities across US racial subgroups, 8 increased access to quality health care, 4 , 5 , 9 and was associated with reduced HF hospitalization among Medicaid beneficiaries 10 and increased heart transplant listings among Black patients in early‐adopter states. 11 …”