TY - JOUR
T1 - Association of State Medicaid Expansion with Rate of Uninsured Hospitalizations for Major Cardiovascular Events, 2009-2014
AU - Akhabue, Ehimare
AU - Pool, Lindsay R.
AU - Yancy, Clyde W.
AU - Greenland, Philip
AU - Lloyd-Jones, Donald
N1 - Publisher Copyright:
© 2018 American Medical Association. All rights reserved.
PY - 2018/8
Y1 - 2018/8
N2 - Importance: 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. Objective: 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. Design, Setting, and Participants: 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 524848 non-Medicare hospitalizations in 2014 and a mean of 516811 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. Exposure: State Medicaid expansion as of January 1, 2014. Main Outcomes and Measures: 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). Results: Of the 801819 hospitalizations in the 17 expansion states in 2014, 428503 (53.4%) patients were men, 514036 (64.1%) were white, and 365797 (45.6%) were aged 65 to 84 years. Of 719459 hospitalizations in the 13 nonexpansion states in 2014, 383311 (53.3%) patients were men, 492136 (68.4%) were white, and 335781 (46.7%) were aged 65 to 84 years. There were 281184 non-Medicare hospitalizations for major cardiovascular events in the 17 expansion states and 243664 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; P <.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; P <.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%). Conclusions and Relevance: 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.
AB - Importance: 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. Objective: 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. Design, Setting, and Participants: 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 524848 non-Medicare hospitalizations in 2014 and a mean of 516811 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. Exposure: State Medicaid expansion as of January 1, 2014. Main Outcomes and Measures: 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). Results: Of the 801819 hospitalizations in the 17 expansion states in 2014, 428503 (53.4%) patients were men, 514036 (64.1%) were white, and 365797 (45.6%) were aged 65 to 84 years. Of 719459 hospitalizations in the 13 nonexpansion states in 2014, 383311 (53.3%) patients were men, 492136 (68.4%) were white, and 335781 (46.7%) were aged 65 to 84 years. There were 281184 non-Medicare hospitalizations for major cardiovascular events in the 17 expansion states and 243664 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; P <.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; P <.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%). Conclusions and Relevance: 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.
UR - http://www.scopus.com/inward/record.url?scp=85062247363&partnerID=8YFLogxK
UR - http://www.scopus.com/inward/citedby.url?scp=85062247363&partnerID=8YFLogxK
U2 - 10.1001/jamanetworkopen.2018.1296
DO - 10.1001/jamanetworkopen.2018.1296
M3 - Article
C2 - 30646120
AN - SCOPUS:85062247363
SN - 2574-3805
VL - 1
JO - JAMA network open
JF - JAMA network open
IS - 4
M1 - e181296
ER -