How Has the Medicaid Expansion Affected Patients Hospitalized With Acute MI?

ACS, STEMI, acute coronary syndrome
ACS, STEMI, acute coronary syndrome
While recent Medicaid expansion has reduced uninsured rates among patients with AMI, it has not improved quality of care or patient outcomes.

The recent expansion of Medicaid has been linked to a significant reduction in rates of uninsurance among patients hospitalized with acute myocardial infarction (AMI), according to research published in JAMA Cardiology. However, the Medicaid expansion did not improve either quality of care or patient outcomes when compared with nonexpansion states.

Karen E. Joynt Maddox, MD, MPH, of the Washington University School of Medicine in St. Louis, Missouri, and colleagues conducted a retrospective cohort study using data pulled from hospitals participating in the National Cardiovascular Data Registry Acute Coronary Treatment and Intervention Outcomes Network Registry (n=325,343). Patients were 65 years or younger, and had been hospitalized for AMI between January 1, 2012 and December 31, 2016.

The primary outcome of the study was an assessment of the rates of uninsured and Medicaid-insured AMI hospitalizations in states that participated in the 2014 state Medicaid expansion. Researchers analyzed in-hospital care quality, procedure use, and mortality in the years before and after the expansion.

Dr Joynt Maddox and colleagues found that in expansion states, uninsured AMI hospitalizations declined from 18% to 8.4%); in nonexpansion states, the reduction was more modest (25.6% to 21.1%), with an increase in Medicaid coverage from 7.5% to 14.4% and 6.2% to 6.9% in expansion and nonexpansion states, respectively.

In a cohort of low-income patients (n=55,737), the “odds of receipt of defect-free care” increased (76.3% vs 75.9%; adjusted odds ratio [aOR], 1.11; 95% CI, 1.02-1.21), and there was no change in the use of most procedures, including diagnostic cardiac catheterization, percutaneous coronary intervention for non–ST-segment elevation myocardial infarction, or coronary artery bypass graft.

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In-hospital mortality rates were similar during the pre- and postexpansion periods (3.2% vs 2.8%; aOR, 0.93; 95% CI, 0.77-1.12), and there was only a slight decline in in-hospital death noted (3.3% vs 3%, aOR, 0.85; 95% CI, 0.73-0.99).

Researchers concluded that their findings “[have] important implications regarding the financial protection and security, through insurance, of vulnerable patients. Among low-income adults hospitalized for AMI, Medicaid expansion was not associated with improved quality of care or better outcomes.”

They concluded, “These findings suggest that current care systems for urgent, time-sensitive conditions may be less sensitive to insurance than has been recognized in the past.”

Disclosures: Drs Wadhera, Bhatt, Yeh, and Joynt Maddox report a number of disclosures. For a complete list, please see the original study referenced.  


Wadhera RK, Bhatt DL, Wang TY, et al. Association of state Medicaid expansion with quality of care and outcomes for low-income patients hospitalized with acute myocardial infarction [published online January 16, 2019]. JAMA Cardiol. doi:10.1001/jamacardio.2018.4577