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

Abstract

Background Black and Hispanic patients are less likely to receive cardiac resynchronization therapy (CRT) than White patients. Medicaid expansion has been associated with increased access to cardiovascular care among racial and ethnic groups with higher prevalence of underinsurance. It is unknown whether the Medicaid expansion was associated with increased receipt of CRT by race and ethnicity. Methods and Results Using Healthcare Cost and Utilization Project Data State Inpatient Databases from 19 states and Washington, DC, we analyzed 1061 patients from early‐adopter states (Medicaid expansion by January 2014) and 745 patients from nonadopter states (no implementation 2013–2014). Estimates of change in census‐adjusted rates of CRT with or without defibrillator by race and ethnicity and Medicaid adopter status 1 year before and after January 2014 were conducted using a quasi‐Poisson regression model. Following the Medicaid expansion, the rate of CRT did not significantly change among Black individuals from early‐adopter states (1.07 [95% CI, 0.78–1.48]) or nonadopter states (0.79 [95% CI, 0.57–1.09]). There were no significant changes in rates of CRT among Hispanic individuals from early‐adopter states (0.99 [95% CI, 0.70–1.38]) or nonadopter states (1.01 [95% CI, 0.65–1.57]). There was a 34% increase in CRT rates among White individuals from early‐adopter states (1.34 [95% CI, 1.05–1.70]), and no significant change among White individuals from nonadopter states (0.77 [95% CI, 0.59–1.02]). The change in CRT rates among White individuals was associated with the timing of the Medicaid implementation ( P =0.003). Conclusions Among states participating in Healthcare Cost and Utilization Project Data State Inpatient Databases, implementation of Medicaid expansion was associated with increase in CRT rates among White individuals residing in states that adopted the Medicaid expansion policy. Further work is needed to address disparities in CRT among Black and Hispanic patients.

Heart Failure with Reduced Ejection Fraction and COVID-19, when the Sick Get Sicker

“…U.S. healthcare policies which expanded access to healthcare insurance such as the Affordable Care Act (ACA) Medicaid Expansion have been associated with increased prescribing of one form of HF GDMT in Hispanic patients, 42 increased listing for heart transplant among Black patients, 41 but has not increased delivery rates across minoritized racial and ethnic groups to proportionate levels of disease prevalence. Furthermore, this policy was not associated with improvement in delivery of cardiac resynchronization therapies 44 , nor ventricular assist devices (VAD) 43 across racial and ethnic groups. This does not negate the importance of adequate insurance but stresses the need for insurance that is broadly accepted, appropriately reimbursed, and not associated with additional biased care.…”

“… 5 Access to insurance has helped improve some disparities among patients with HF such as heart transplants 41 , but many remain in respect to access to other devices and therapies. 42 , 43 , 44 , 45 Related to redlining, neighborhood deprivation is associated with 12% increase in incident HF, 46 and food deserts are associated with increased HF risk, which are more prevalent among minoritized racial and ethnic communities. SDOH must be addressed to reduce racial and ethnic HF disparities 47 .…”