Medicaid expansion tied to fewer heart disease deaths

(Reuters Health) - With increased access to insurance under the Affordable Care Act (ACA), known as Obamacare, fewer middle-aged people are dying from heart disease, a U.S. study suggests.

Under the ACA, some U.S. states expanded coverage through Medicaid - a joint federal and state insurance program for the poor - starting in 2014. The current study compared death rates from cardiovascular disease for people 45 to 64 years old from 2010 to 2016 in 29 states that expanded Medicaid and 19 states that didn’t.

Annual death rates from cardiovascular causes remained constant - at about 146 fatalities for every 100,000 people - in states that expanded Medicaid coverage, the study found.

But in states that didn’t make it possible for more people to get Medicaid coverage, cardiovascular death rates rose during the study from about 176 to 181 fatalities for every 100,000 people.

“Our study is one of the first to show that Medicaid expansion is associated with lower mortality rates from cardiovascular causes,” said lead study author Dr. Sameed Khatana of the Perelman School of Medicine at the University of Pennsylvania in Philadelphia.

“Given the intense debate surrounding the Affordable Care Act and Medicaid expansion, it is important for patients, providers and policy makers to know that Medicaid expansion so far has been associated with actual changes in the number of people dying from heart disease,” Khatana said by email.

The study wasn’t a controlled experiment designed to prove whether or how expanded Medicaid coverage might directly impact death rates from heart disease. And it’s possible other state policies or factors unique to certain states impacted the results.

But extending coverage to many people who were previously uninsured likely played a role, Khatana said.

“This could lead to better access to preventive care and protective heart medications such as aspirin and cholesterol medications,” Khatana added. “Additionally, prior studies have shown that lack of insurance leads people to delay care, even when having a heart attack.”

For the study, researchers examined county-level data on age-adjusted mortality rates from cardiovascular causes in 48 states and Washington, D.C. - excluding Massachusetts and Wisconsin.

In states that expanded Medicaid, the percentage of uninsured residents at all incomes declined by an average of 7.3 percent, and the percentage of poor people without insurance dropped almost 20 percent, researchers report in JAMA Cardiology.

By comparison, in states that didn’t expand Medicaid, the percentage of uninsured residents at all incomes decreased just 5.6 percent and the proportion of poor people without insurance dipped only 13.5 percent.

One limitation of the study is that states that expanded Medicaid had lower cardiovascular death rates than other states even before they implemented the expansion.

“As a result, it becomes challenging to account for how other factors beyond Medicaid expansion contributed to the decline in these states,” said Dr. Khurram Nasir, a researcher at Yale University in New Haven, Connecticut, who wasn’t involved in the study.

“Unfortunately, states that declined Medicaid expansion were likely the ones that most needed it,” Nasir said by email.

There also may be a limit to how far death rates can be lowered by expanding Medicaid coverage, said Dr. David Himmelstein of Albert Einstein College of Medicine and Montefiore Medical Center in New York City.

“Medicaid is not really adequate coverage, since it pays such low fees in most states that patients often have trouble finding a doctor willing to treat them,” Himmelstein, who wasn’t involved in the study, said by email.

“Moreover, many people with coverage still can’t afford care because of high deductibles and copayments,” Himmelstein added. “Although Medicaid generally carries low or no copayments or deductibles, even very low out-of-pocket expenses discourage care, particularly among poor people.”

SOURCE: JAMA Cardiology, online June 5, 2019.