Association of Medicaid Expansion With Cardiovascular Mortality.
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ABSTRACT:
SUBMITTER: Khatana SAM
PROVIDER: S-EPMC6552110 | biostudies-literature | 2019 Jul
REPOSITORIES: biostudies-literature
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Association of Medicaid Expansion With Cardiovascular Mortality.
Khatana Sameed Ahmed M SAM Bhatla Anjali A Nathan Ashwin S AS Giri Jay J Shen Changyu C Kazi Dhruv S DS Yeh Robert W RW Groeneveld Peter W PW
JAMA cardiology 20190701 7
<h4>Importance</h4>Medicaid expansion under the Patient Protection and Affordable Care Act led to one of the largest gains in health insurance coverage for nonelderly adults in the United States. However, its association with cardiovascular mortality is unclear.<h4>Objective</h4>To investigate the association of Medicaid expansion with cardiovascular mortality rates in middle-aged adults.<h4>Design, setting, and participants</h4>This study used a longitudinal, observational design, using a diffe ...[more]
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Project description:Importance:The Patient Protection and Affordable Care Act (ACA) permits states to expand Medicaid coverage for most low-income adults to 138% of the federal poverty level and requires the provision of mental health and substance use disorder services on parity with other medical and surgical services. Uptake of substance use disorder services with medications for opioid use disorder has increased more in Medicaid expansion states than in nonexpansion states, but whether ACA-related Medicaid expansion is associated with county-level opioid overdose mortality has not been examined. Objective:To examine whether Medicaid expansion is associated with county?×?year counts of opioid overdose deaths overall and by class of opioid. Design, Setting, and Participants:This serial cross-sectional study used data from 3109 counties within 49 states and the District of Columbia from January 1, 2001, to December 31, 2017 (N?=?3109 counties ×?17 years?=?52?853 county-years). Overdose deaths were modeled using hierarchical Bayesian Poisson models. Analyses were performed from April 1, 2018, to July 31, 2019. Exposures:The primary exposure was state adoption of Medicaid expansion under the ACA, measured as the proportion of each calendar year during which a given state had Medicaid expansion in effect. By the end of study observation in 2017, a total of 32 states and the District of Columbia had expanded Medicaid eligibility. Main Outcomes and Measures:The outcomes of interest were annual county-level mortality from overdoses involving any opioid, natural and semisynthetic opioids, methadone, heroin, and synthetic opioids other than methadone, derived from the National Vital Statistics System multiple-cause-of-death files. A secondary analysis examined fatal overdoses involving all drugs. Results:There were 383?091 opioid overdose fatalities across observed US counties during the study period, with a mean (SD) of 7.25 (27.45) deaths per county (range, 0-1145 deaths per county). Adoption of Medicaid expansion was associated with a 6% lower rate of total opioid overdose deaths compared with the rate in nonexpansion states (relative rate [RR], 0.94; 95% credible interval [CrI], 0.91-0.98). Counties in expansion states had an 11% lower rate of death involving heroin (RR, 0.89; 95% CrI, 0.84-0.94) and a 10% lower rate of death involving synthetic opioids other than methadone (RR, 0.90; 95% CrI, 0.84-0.96) compared with counties in nonexpansion states. An 11% increase was observed in methadone-related overdose mortality in expansion states (RR, 1.11; 95% CrI, 1.04-1.19). An association between Medicaid expansion and deaths involving natural and semisynthetic opioids was not well supported (RR, 1.03; 95% CrI, 0.98-1.08). Conclusions and Relevance:Medicaid expansion was associated with reductions in total opioid overdose deaths, particularly deaths involving heroin and synthetic opioids other than methadone, but increases in methadone-related mortality. As states invest more resources in addressing the opioid overdose epidemic, attention should be paid to the role that Medicaid expansion may play in reducing opioid overdose mortality, in part through greater access to medications for opioid use disorder.
| S-EPMC6991255 | biostudies-literature
Project description:Importance:The Affordable Care Act Medicaid expansion may be associated with reduced mortality, but evidence to date is limited. Patients with end-stage renal disease (ESRD) are a high-risk group that may be particularly affected by Medicaid expansion. Objective:To examine the association of Medicaid expansion with 1-year mortality among nonelderly patients with ESRD initiating dialysis. Design, Setting, and Participants:Difference-in-differences analysis of nonelderly patients initiating dialysis in Medicaid expansion and nonexpansion states from January 2011 to March 2017. Exposure:Living in a Medicaid expansion state. Main Outcomes and Measures:The primary outcome was 1-year mortality. Secondary outcomes were insurance, predialysis nephrology care, and type of vascular access for hemodialysis. Results:A total of 142?724 patients in expansion states (mean age, 50.2 years; 40.2% women) and 93?522 patients in nonexpansion states (mean age, 49.7; 42.4% women) were included. In Medicaid expansion states, 1-year mortality following dialysis initiation declined from 6.9% in the preexpansion period to 6.1% after expansion (change, -0.8 percentage points; 95% CI, -1.1 to -0.5). In nonexpansion states, mortality rates were 7.0% before expansion and 6.8% after expansion (change, -0.2 percentage points; 95% CI, -0.5 to 0.2), yielding an adjusted absolute reduction in mortality in expansion states of -0.6 percentage points (95% CI, -1.0 to -0.2). Mortality reductions were largest for black patients (-1.4 percentage points; 95% CI, -2.2, -0.7; P=.04 for interaction) and patients aged 19 to 44 years (-1.1 percentage points; 95% CI, -2.1 to -0.3; P=.01 for interaction). Expansion was associated with a 10.5-percentage-point (95% CI, 7.7-13.2) increase in Medicaid coverage at dialysis initiation, a -4.2-percentage-point (95% CI, -6.0 to -2.3) decrease in being uninsured, and a 2.3-percentage-point (95% CI, 0.6-4.1) increase in the presence of an arteriovenous fistula or graft. Changes in predialysis nephrology care were not significant. Conclusions and Relevance:Among patients with ESRD initiating dialysis, living in a state that expanded Medicaid under the Affordable Care Act was associated with lower 1-year mortality. If this association is causal, further research is needed to understand what factors may have contributed to this finding.
| S-EPMC6417808 | biostudies-literature
Project description:ImportanceCardiovascular 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.ObjectiveTo 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 participantsFor 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.ExposureState Medicaid expansion as of January 1, 2014.Main outcomes and measuresComparison 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).ResultsOf 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; 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 relevanceStates 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.
| S-EPMC6324285 | biostudies-literature
Project description:Importance:In the United States, nonprofit hospitals receive tax-exempt status with the expectation that they provide a high level of benefit to local communities. Prior work has shown that Medicaid expansion reduced hospital spending on uncompensated care. Objective:To measure the association of tax-exempt hospital spending with community benefit and changes in uncompensated care after Medicaid expansion. Design, Setting, and Participants:This cohort study was performed using a difference-in-differences analysis (ie, a pre-post treatment-control design) to estimate changes in reported charitable categories associated with Medicaid expansion. Data from Internal Revenue Service form 990, Schedule H, tax filings for 2253 tax-exempt hospitals in the United States from 2012 to 2016 were used. Data were analyzed from June to November 2019. Exposure:The proportion of the hospital's tax filing that spanned the period after Medicaid expansion. Main Outcomes and Measures:Hospital-reported spending on uncompensated care, unreimbursed Medicaid expenses, and other community benefit spending categories. Results:Across 2253 hospitals, mean (SD) uncompensated care costs between 2012 and 2016 were $4.20 million ($8.80 million) and unreimbursed Medicaid expenses were $7.60 million ($18.62 million). Compared with tax-exempt hospitals in states that did not expand Medicaid, those in states that did expand Medicaid reported mean reductions in their provision of uncompensated care of $1.11 million (95% CI, $0.35 million to $1.87 million; P?<?.001), representing a mean change of -2% (95% CI, -6% to 2%; P?<?.001). These reductions have been offset by mean reported increases in the provision of unreimbursed Medicaid expenses of $1.63 million (95% CI, $0.31 million to $2.94 million; P?=?.02), representing a mean increase of 2% (95% CI, 1% to 4%; P?=?.01). Tax-exempt hospitals in states that expanded Medicaid reported no statistically significant mean increase in spending on other community benefit activities. Conclusions and Relevance:In this study, large decreases in uncompensated care among tax-exempt hospitals associated with Medicaid expansion were not accompanied by increases in other reportable categories of community health benefit spending. Instead, they were accompanied by increased spending on unreimbursed Medicaid expenses.
| S-EPMC7137680 | biostudies-literature
Project description:BackgroundCurrently, little is known about the effect of the Patient Protection and Affordable Care Act's Medicaid expansion on care delivery and outcomes in cervical cancer.AimWe evaluated whether Medicaid expansion was associated with changes in insurance status, stage at diagnosis, timely treatment, and survival outcomes in cervical cancer.Methods and resultsUsing the National Cancer Database, we performed a difference-in-differences (DID) cross-sectional analysis to compare insurance status, stage at diagnosis, timely treatment, and survival outcomes among cervical cancer patients residing in Medicaid expansion and nonexpansion states before (2011-2013) and after (2014-2015) Medicaid expansion. January 1, 2014 was used as the timepoint for Medicaid expansion. The primary outcomes of interest were insurance status, stage at diagnosis, treatment within 30 and 90 days of diagnosis, and overall survival. Fifteen thousand two hundred sixty-five patients (median age 50) were included: 42% from Medicaid expansion and 58% from nonexpansion states. Medicaid expansion was significantly associated with increased Medicaid coverage (adjusted DID = 11.0%, 95%CI = 8.2, 13.8, p < .01) and decreased rates of uninsured (adjusted DID = -3.0%, 95%CI = -5.2, -0.8, p < .01) among patients in expansion states compared with non-expansion states. However, Medicaid expansion was not associated with any significant changes in cancer stage at diagnosis or timely treatment. There was no significant change in survival from the pre- to post-expansion period in either expansion or nonexpansion states, and no significant differences between the two (DID-HR = 0.95, 95%CI = 0.83, 1.09, p = .48).ConclusionAlthough Medicaid expansion was associated with an increase in Medicaid coverage and decrease in uninsured among patients with cervical cancer, the effects of increased coverage on diagnosis and treatment outcomes may have yet to unfold. Future studies, including longer follow-up are necessary to understand the effects of Medicaid expansion.
| S-EPMC8714536 | biostudies-literature
Project description:ObjectiveTo determine the association between Medicaid expansion and infant mortality rate (IMR) in the United States.Data sourcesState-level aggregate data on US IMR, race, and sex were abstracted from the US Center for Disease Control and Prevention's Wide-ranging Online Data for Epidemiologic Research.Study designThe association between Medicaid expansion and IMR adjusted for race and sex was assessed with multiple linear regression models using difference-in-differences estimation and Huber-White robust standard errors.Principal findingsDifference-in-differences regression found no association between Medicaid expansion status and change in national IMR from 2010 to 2017 (Coef. = 0.04; 95% CI: -0.39, 0.46). However, among Hispanics, the program was found to be associated with reduction in IMR (Diff-in-Diff Coef. = -0.53; 95% CI: -1.02, -0.03).ConclusionsOverall, the Affordable Care Act-induced Medicaid expansion was not associated with IMR reduction in expansion states relative to nonexpansion states. However, the program was associated with a significant IMR decline among Hispanics.
| S-EPMC7240769 | biostudies-literature
Project description:IntroductionThe purpose of this study is to determine the association between Medicaid expansion in Louisiana and cancer mortality by race and sex.MethodsData from the National Vital Statistics System mortality files were used to quantify deaths from cancer between 2010 and 2019 for Louisiana and a sample of states that had yet to adopt the Affordable Care Act's Medicaid expansion as of December 2019. A series of population-weighted comparative interrupted time series models were estimated to determine whether Louisiana's Medicaid expansion was associated with reduced cancer mortality. Analyses were conducted in May 2021-August 2021.ResultsMedicaid expansion was associated with an average of 3.3 (95% CI= -6.4, -0.1; p=0.045) fewer quarterly cancer deaths per 100,000 Black female Louisiana residents and an average of 5.8 (95% CI= -10.4, -1.1; p=0.015) fewer quarterly cancer deaths per 100,000 Black male residents. There were no statistically significant changes in cancer mortality for White people in Louisiana associated with Medicaid expansion. Following expansion, the Black-White mortality gap in cancer deaths declined by approximately 57% for female individuals (4.6-2.0) and 49% for male individuals (10.1-5.2).ConclusionsMedicaid expansion in Louisiana was associated with a reduction in cancer mortality for Black female and male adults. Estimates of the association between Medicaid expansion and cancer mortality in Louisiana directly relate to the potential impacts for states that have yet to adopt Medicaid expansion under the Affordable Care Act, which are primarily located in the Southern U.S.
| S-EPMC8940617 | biostudies-literature
Project description:Importance:Medicaid expansion was widely expected to alleviate the financial stresses faced by hospitals by providing additional revenue in the form of Medicaid reimbursements from patients previously receiving uncompensated care. Among nonprofit hospitals, which receive tax-exempt status in part because of their provision of uncompensated care, Medicaid expansion could have released hospital funds toward other community benefit activities. Objective:To examine changes in nonprofit hospital spending on community benefit activities after Medicaid expansion. Design, Setting, and Participants:This cohort study used difference-in-differences analysis of 1666 US nonprofit hospitals that filed Internal Revenue Service Form 990 Schedule H detailing their community benefit expenditures between 2011 and 2017. The analysis was conducted from February to September 2019. Exposures:State Medicaid expansion between 2011 and 2017. Main Outcomes and Measures:Percentage of hospital operating expenditures attributable to charity care and subsidized care, bad debt (ie, unreimbursed spending for care of patients who did not apply for charity care), unreimbursed Medicaid spending, noncare direct community spending, and total community benefit spending. Results:Of 1478 hospitals in the sample in 2011, nearly half (653 [44.2%]) were small hospitals with fewer than 100 beds, and nearly 70% of hospitals (1023 [69.2%]) were in urban areas. Among the 1666 nonprofit hospitals, Medicaid expansion was associated with a decrease in spending on charity care and subsidized care (-0.68 [95% CI, -0.99 to -0.37] percentage points from a baseline mean [SD] of 3.6% [4.0%] of total hospital expenditures; P?<?.001) and in bad debt (-0.17 [95% CI, -0.32 to -0.01] percentage points). There was an increase in unreimbursed spending attributable to caring for Medicaid patients (0.85 [95% CI, 0.60 to 1.10] percentage points; P?=?.04), which canceled out uncompensated care savings from the expansion. Noncare direct community expenditures decreased overall (-0.24 [95% CI, -0.48 to 0.00] percentage points; P?=?.049). Direct community expenditures remained more stable in small hospitals (-0.07 [95% CI, -0.20 to 0.05] percentage points; P?=.26) compared with large hospitals (-0.37 [95% CI, -0.86 to 0.12] percentage points; P?=?.14) and in nonurban hospitals (0.02 [95% CI, -0.09 to 0.14] percentage points; P?=?.70) compared with urban hospitals (-0.36 [95% CI, -0.73 to 0.01] percentage points; P?=?.06). Conclusions and Relevance:In this study, Medicaid expansion was associated with a decrease in nonprofit hospitals' burden of providing uncompensated care, but this financial relief was not redirected toward spending on other community benefits.
| S-EPMC7260619 | biostudies-literature
Project description:ObjectiveTo test whether Medicaid expansion is associated with (a) a greater number of naloxone prescriptions dispensed and (b) a higher proportion of naloxone prescriptions paid by Medicaid.Data sources/study settingWe used the IQVIA National Prescription Audit to obtain data on per state per quarter naloxone prescription dispensing for the period 2011-16.Study designIn this quasi-experimental design study, the impact of Medicaid expansion on naloxone prescription dispensing was examined using difference-in-difference estimation models. State-level covariates including pharmacy-based naloxone laws (standing/protocol orders and direct authority to dispense naloxone), third-party prescribing laws, opioid analgesic prescribing rates, opioid-involved overdose death rates, and population size were controlled for in the analysis.Principal findingsMedicaid expansion was associated with 38 additional naloxone prescriptions dispensed per state per quarter compared to nonexpansion controls, on average (P = .030). Also, Medicaid expansion resulted in an average increase of 9.86 percent in the share of naloxone prescriptions paid by Medicaid per state per quarter (P < .001).ConclusionsOur study found that Medicaid expansion increased naloxone availability. This finding suggests that it will be important to consider naloxone access when making federal- and state-level decisions affecting Medicaid coverage.
| S-EPMC7080392 | biostudies-literature
Project description:Maternal mortality has been increasing in the United States over the past 3 decades, while decreasing in all other high-income countries during the same period. Cardiovascular conditions account for over one fourth of maternal deaths, with two thirds of deaths occurring in the postpartum period. There are also significant healthcare disparities that have been identified in women experiencing maternal morbidity and mortality, with Black women at 3 to 4 times the risk of death as their White counterparts and women in rural areas at heightened risk for cardiovascular morbidity and maternal morbidity. However, many maternal deaths have been shown to be preventable, and improving access to care may be a key solution to addressing maternal cardiovascular mortality. Medicaid currently finances almost half of all births in the United States and is mandated to provide coverage for women with incomes up to 138% of the federal poverty level, for up to 60 days postpartum. In states that have not expanded coverage, new mothers become uninsured after 60 days. Medicaid expansion has been shown to reduce maternal mortality, particularly benefiting racial and ethnic minorities, likely through reduced insurance churn, improved postpartum access to care, and improved interpregnancy care. However, even among states with Medicaid expansion, significant care gaps exist. An additional proposed intervention to improve access to care in these high-risk populations is extension of Medicaid coverage for 1 year after delivery, which would provide the most benefit to women in Medicaid nonexpanded states, but also improve care to women in Medicaid expanded states.
| S-EPMC8475675 | biostudies-literature