Heart Failure Coverage Success Seen in Medicaid Expansion States

After the Affordable Care Act (ACA) was signed into law on March 23, 2010, overall uninsured rates in the United States dropped from 46.5 million in 2010 to 26.7 million in 2016. There was a slight uptick in 2017, to 27.5 million, and by 2018, the total rate was 8.5% of the United States.

Having no health insurance carries with it a host of adverse consequences that include more advanced stages of disease when presenting to a physician, avoidable deaths, and not receiving lifesaving treatments for chronic, but sometimes manageable, conditions, such as heart failure. Despite the numbers above, and although there remains a coverage gap for certain racial and ethnic minorities, there have been improvements in the heart failure space.

"Lack of insurance contributes to racial and ethnic health inequities among US heart failure patients. We were pleased to find that ACA Medicaid expansion was associated with increased delivery of cardiovascular care to racial and ethnic minority groups," said study author Khadijah Breathett, MD, MS, FAHA, assistant professor of cardiology at the University of Arizona College of Medicine in Tucson.

Using data on close to 272,200 patients from the American Heart Association’s Get With the Guidelines Heart Failure registry—57.5% in early-adopter states—Breathett and a team of researchers compared rates of heart failure care following a hospitalization (ie, receipt of medication, education, and follow-up) before and after implementation of the ACA. Their results were recently presented at the AHA’s Quality of Care & Outcomes Research Scientific Sessions 2020.

The team compared early adopter states who had expanded their Medicaid coverage by 2014 with those who had not by 2019, looking at 4 ethnic groups: African Americans (22.8%), Asians (2.9%), Hispanics (8.9%), and whites (65.5%).

Their results are mixed, yet promising:

• Medication use for heart failure at discharge (eg, angiotensin converting enzyme inhibitors, angiotensin receptor blockers, and angiotensin receptor-neprilysin inhibitors) exploded in use, by 146%, among Hispanics after ACA expansion compared with before (after ACA: odds ratio [OR], 2.46; 95% CI, 1.10-5.51; before ACA: OR, 0.40; 95% CI, 0.13-1.23; P < .01)
• Follow-up appointments for Asians grew by 44% after Medicaid expansion versus before (after ACA: OR, 1.44; 95% CI, 0.50-4.15; before ACA: OR, 0.64; 95% CI, 0.20-2.06; P = .03)
• There was an overall greater likelihood that Hispanics would receive therapy for their heart failure if they lived in an expansion state, no matter what year that state increased coverage (P = .01).
• Significant improvements lacked among other racial and ethnic groups in receipt of heart failure therapies.

“Based on these findings, increased adoption of the ACA Medicaid expansion may reduce racial and ethnic disparities in heart failure treatment and outcomes,” Breathett concluded. “However, health equity will require substantial changes in policy and additional investigation of interventions that may reduce barriers to care."

To move forward and close the health care gap even more, the authors suggest that practices and their administrators should look at what barriers still exist within their walls. Ideally, Breathett noted, they suggest additional ACA expansion, “to assure that policy keeps up with the needs of the people."

Reference

Breathett KK, Xu H, Sweitzer NK, et al. Affordable Care Act Medicaid expansion then and now: racial/ethnic differences in receipt of guideline-directed medical therapy during heart failure hospitalizations. Presented at: American Heart Association's Quality of Care & Outcomes Research Scientific Sessions 2020; May 15-16, 2020. Abstract 22. https://www.ahajournals.org/doi/10.1161/hcq.13.suppl_1.22