Association of State Medicaid Expansion With Rate of Uninsured Hospitalizations for Major Cardiovascular Events, 2009-2014
Authors: Ehimare Akhabue, Lindsay R. Pool, Clyde W. Yancy, Philip Greenland, Donald Lloyd-Jones
Journal: JAMA Network Open (2018)

<h3>Importance</h3> Cardiovascular disease is the leading primary diagnosis among all hospital discharges, and insurance status is associated with patient outcomes. The association of state-level policy decisions regarding the Affordable Care Act (ACA) Medicaid expansion with rates of uninsured hospitalizations for major cardiovascular events and in-hospital mortality has not been investigated to date. <h3>Objective</h3> To investigate whether the rates of uninsured hospitalizations for major cardiovascular events and in-hospital mortality varied by state-level policy on ACA Medicaid expansion. <h3>Design, Setting, and Participants</h3> For this cohort study, difference-in-differences analysis of data from the Healthcare Cost and Utilization Project State Inpatient Databases of 30 US states on 524 848 non-Medicare hospitalizations in 2014 and a mean of 516 811 non-Medicare hospitalizations per year from 2009 to 2013 was performed for major cardiovascular events (defined as a composite of acute myocardial infarction, stroke, and heart failure) from January 1, 2009, through December 31, 2014. Analyses were completed September 1, 2017. <h3>Exposure</h3> State Medicaid expansion as of January 1, 2014. <h3>Main Outcomes and Measures</h3> Comparison of mean payer mix proportions (uninsured, Medicaid, and privately insured) and in-hospital mortality between expansion and nonexpansion states for the years preceding the ACA Medicaid expansion (2009-2013) and the year after the ACA Medicaid expansion (2014). <h3>Results</h3> Of the 801 819 hospitalizations in the 17 expansion states in 2014, 428 503 (53.4%) patients were men, 514 036 (64.1%) were white, and 365 797 (45.6%) were aged 65 to 84 years. Of 719 459 hospitalizations in the 13 nonexpansion states in 2014, 383 311 (53.3%) patients were men, 492 136 (68.4%) were white, and 335 781 (46.7%) were aged 65 to 84 years. There were 281 184 non-Medicare hospitalizations for major cardiovascular events in the 17 expansion states and 243 664 non-Medicare hospitalizations in the 13 nonexpansion states in 2014. In multivariable regression analyses, the expansion states had a significant 5.8–percentage point decrease in the proportion of uninsured hospitalizations after Medicaid expansion relative to the nonexpansion states (adjusted difference-in-differences estimate, −0.058; 95% CI, −0.075 to −0.042;<i>P</i> &lt; .001). The expansion states also had a significant 8.4–percentage point increase in the Medicaid share after Medicaid expansion relative to the nonexpansion states (adjusted difference-in-differences estimate, 0.084; 95% CI, 0.065 to 0.102;<i>P</i> &lt; .001). In-hospital mortality did not change significantly after Medicaid expansion in either the expansion states (before ACA, 3.8% vs after ACA, 3.7%) or the nonexpansion states (4.0% vs 4.0%). <h3>Conclusions and Relevance</h3> States that expanded Medicaid during the ACA implementation had a significantly greater reduction in the proportion of uninsured hospitalizations for major cardiovascular events compared with the nonexpansion states. This study suggests that expansion status was not associated with in-hospital mortality rates in the first year after ACA implementation.