ACA improves coverage and access for cardiovascular patients in Medicaid expansion states

Affordable Care Act
More patients are seeking medical treatment for cardiovascular symptoms post-ACA. (Getty/zimmytws)

Implementation of the Affordable Care Act (ACA) improved access to healthcare for cardiovascular patients, according to a new study conducted by Harvard Medical School.

The study, conducted with researchers from Massachusetts General Hospital, Boston Healthcare System and the Boston University School of Medicine, looked at data across racial and ethnic lines for adults with both atherosclerotic cardiovascular disease (CVD) or cardiovascular risk factors (CVRFs). They were examining the patients' data to determine the rate of access to care both before and after the ACA.

Following the implementation of the ACA, insurance coverage increased 6.9 percentage points for those in the study, and the rate of not missing a physician visit increased by 3.6 percentage points. Finally, having a regular checkup increased for this demographic by 2.1 percentage points and having a relationship with a personal physician increased by 1 percentage point. And of all those surveyed, the changes were doubled for those patients with incomes under $35,000 a year.

“What we did not know is for people with serious medical conditions such as cardiovascular disease—the number one killer in United States—how much the ACA helped in terms of coverage and access to care,” Danny McCormick, M.D., associate professor of medicine at Harvard Medical School and co-author, told FierceHealthcare. “We thought it was possible that the ACA would not have helped as much because we thought many of these people with their high health needs would have already been insured, and thus the ACA may not have had as big an impact. What we found is that, in this population, the ACA actually made a substantial difference, covering nearly 10 million people with existing cardiovascular disease or risk factors.”

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Comparing expansion versus nonexpansion states, residents of expansion states had higher levels of coverage and access in the pre-ACA period and experienced larger increases than did residents of nonexpansion states in the post-ACA period. Specifically, residents of Medicaid expansion states increased 1.7 percentage points over those of nonexpansion states for insurance coverage and 1.3 percentage points more for ability to afford a physician visit. Medicaid expansion states had another 1.3-percentage-point advantage for having more annual checkups and a 2.8 percentage point advantage for having a personal physician.

Health insurance coverage increased in all states, but there was a large variance by state. The proportion of the population of people with CVD/CVRF but without insurance in the post-ACA era was lowest in Massachusetts, 6.1%, and as high as 27% in Texas.

Disparities were vast by race and ethnicity as well. While there was a 2.7-percentage-point increase in coverage among blacks versus whites and a 5.7-percentage-point increase among Hispanics relative to whites post-ACA, the study found that the ability to afford a physician was only narrowed slightly, 1 percentage point and 1.5 percentage points, respectively. For example, among Hispanic people with CVD/CVRFs in nonexpansion states post-ACA, 42% continued to lack insurance coverage, 25% could not afford a physician visit, 40% did not have a checkup in the last year, and 48% did not have a personal physician.

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“We found that disparities were narrowed for people with cardiovascular disease. However, perhaps even more striking is the remaining racial and ethnic gaps in coverage: the figure in our table shows that after the ACA, 20% of black and 42% of Hispanic people with cardiovascular disease remain uninsured in Medicaid nonexpansion states. I think this is pretty shocking,“ McCormick said.

Prior to the study, access to treatment for management of CVD and CVRFs was highly tied to the rate at which adults had healthcare for screenings.

The study concludes that the benefits of Medicaid expansion observed in previous studies extend to people with CVD/CVRFs and are substantial. But in spite of some overall improvements, the proportion of adults with CVD/CVRFs who lack coverage and experience barriers to care in the post-ACA era remains substantial, particularly among residents of Medicaid nonexpansion states and among racial and ethnic minorities. These findings are significant in that people with CVD are at higher risk for mortality and have higher health needs.

So why are there still so many gaps in insurance coverage since the ACA?

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The study says there are multiple reasons why the ACA did not close these gaps more than it did, including states’ decisions to not expand Medicaid, the ineligibility of millions of Hispanic persons due to their immigration status, perceived unaffordability of plans offered through marketplaces, and high out-of-pocket expenses.

McCormick concludes that the study makes three important points:

  • First, the ACA covered a substantial number of people with cardiovascular disease/risk factors, particularly minorities. If the ACA were to be repealed without as comprehensive a replacement, many people who need care the most would lose coverage and suffer progression of their disease and higher death rates.
  • Second, states that expanded Medicaid saw greater gains in coverage and access for people with CVD than nonexpansion states. Therefore, one way to substantially further improve coverage for CVD patients would be for states that have not yet expanded Medicaid to do so now. It also turns out that the states that have not yet expanded are also among those with the highest rates of CVD and risk factors.
  • Finally, the ACA only provided coverage and access to one-third of the uninsured population with CVD/risk factors and thus is really inadequate in terms of getting access to care for this population. In order for that to happen, much more comprehensive health reform would be needed—one that provides universal coverage.