Medicaid Expansion Didn’t Improve Acute MI Care for Low-Income Patients

While uninsured rates fell in states that opted for 2014 Medicaid expansion under the Affordable Care Act, quality of hospital care didn’t rise for low-income individuals with acute MI, a registry study found.

From 2012 to 2016, uninsured status declined faster among those hospitalized for an acute MI when the hospital was located in these expansion states (18.0% to 8.4% vs 25.6% to 21.1% in nonexpansion states, P<0.001). At the same time, Medicaid coverage increased more dramatically in expansion states (from 7.5% to 14.4%) than in nonexpansion states (6.2% to 6.6%, P<0.001).

Yet for a low-income cohort relying only on Medicaid or no insurance at all for their hospitalization, the expansion of Medicaid did not translate to better odds of defect-free care for MI, according to Karen Joynt Maddox, MD, MPH, of Washington University School of Medicine in St. Louis, and colleagues reporting online in JAMA Cardiology.

Defect-free care meant 100% compliance with 11 required performance measures, including aspirin at arrival, beta-blocker prescribed at discharge, and cardiac rehabilitation patient referral. In expansion states, low-income patients improved in their odds of receiving such care only modestly (adjusted OR 1.11, 95% CI 1.02-1.21) and to a lesser extent than those in nonexpansion states (adjusted OR 1.38, 95% CI 1.30-1.47, P<0.001 for interaction).

“Health insurance plays an important role mediating access to health care services, but these data indicate that lack of insurance may not necessarily influence care quality and clinician decision making once a patient is hospitalized for an acute condition,” the investigators said.

“The takeaway is really that there were no major changes in quality of care or outcomes associated with expansion,” Joynt Maddox told MedPage Today.

She and her colleagues based their study on data from participating hospitals in the National Cardiovascular Data Registry ACTION Registry, a large ongoing quality improvement registry of acute MI.

Included were adults younger than 65 years who were hospitalized in 2012-2016 (n=325,343) at more than 700 acute care hospitals.

After Medicaid expansion, states didn’t improve use of diagnostic and therapeutic interventions for acute MI (such as percutaneous coronary intervention for non-ST-segment elevation MI), which may partly explain why they didn’t make better strides in in-hospital mortality compared to nonexpansion states either, according to Joynt Maddox’s group.

“This isn’t entirely surprising, as the putative mechanisms for improved survival among insured patients, i.e., (a) better pre-hospital care among newly insured patients, (b) less patient hesitancy to seek emergency care, and (c) less physician hesitancy to use expensive hospital-based therapies, are all a bit dubious,” commented Peter Groeneveld, MD, MS, of University of Pennsylvania’s Perelman School of Medicine in Philadelphia, who was not involved with the study.

It’s not clear that better health care in the months before an MI helps the patient survive one, he told MedPage Today in an email.

Moreover, “although it’s possible that insured acute MI patients called 911 ‘earlier’ and thus improved their hospital’s outcomes, it’s also possible that insured patients who were inevitably destined to die of their acute MI also called 911 earlier, but then they died in the hospital and not at home, therefore worsening their hospital’s outcomes,” he continued.

Acute MI care is “fairly standardized at most hospitals, so it seems unlikely that a patient’s insurance status makes much of a difference,” Groeneveld noted. “I suspect insurance status is much more likely to affect management of chronic diseases like diabetes rather than acute life-threatening illnesses like acute MI.”

Sites participating in the registry may not be representative of all U.S. sites, Joynt Maddox and colleagues acknowledged, nor could the observational study eliminate the potential for confounding.