Study Links Medicaid Expansion to Fewer Cardiovascular Deaths

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More than 5 years after the full implementation of the Affordable Care Act, outcomes data on the effects of Medicaid expansion are starting to emerge.

In the 5 years since the Affordable Care Act (ACA) took full effect, Medicaid expansion has been linked to more people learning they had diabetes, closing the racial gap in cancer care, and now, fewer cardiovascular deaths.

The latest study, appearing in JAMA Cardiology, comes from the Perelman School of Medicine at the University of Pennsylvania, where researchers used county-level data to compare mortality rates between areas that had expanded Medicaid by 2016 and those that had not.

Researchers led by Sameed Ahmed M. Khatana, MD, a fellow in cardiovascular disease at the University of Pennsylvania, found that even after accounting for demographic, clinical, and economic differences between the states, counties in the expansion areas had 4.3 fewer deaths per 100,000 residents per year (95% CI, 1.8-6.9) from cardiovascular causes after Medicaid expansion than if they had followed the same trends in nonexpansion areas.

During the study period, 29 states and Washington, DC, had extended insurance coverage to those earning up to 138% of the federal poverty line; the number now stands at 37 states with expansion and 14 that have not. The holdouts include some of the poorest states, such as Mississippi and Alabama, and 2 of the most populous—Texas and Florida.

The researchers note they cannot state a cause-and-effect relationship between expansion and fewer deaths based on reviewing the data. But in an interview with The American Journal of Managed Care® (AJMC®), Khatana said that data are starting to emerge that show links between expansion and better health outcomes—he cited the study presented last week during the annual meeting of the American Society of Clinical Oncology that found a reduction in racial disparities in cancer care, which followed earlier data that showed the ACA had reduced the gap in early diagnosis of cancer.


Differences between the expansion and nonexpansion states in healthcare utilization and diagnostics emerged early on after the start of Medicaid expansion in 2014. One of the first major findings came in 2015, when a study by Quest Diagnostics, published in Diabetes Care, found a 23% jump in the number of Medicaid beneficiaries diagnosed with diabetes in expansion states, compared with just a 0.4% increase in the nonexpansion states.

Data on health outcomes have, necessarily, taken longer to emerge. The JAMA Cardiology study cites other evidence that points to the link between expansion and better outcomes, including better diabetes control and higher rates of patients receiving cardiovascular medication. In the interview, Khatana said more data will appear now that Medicaid expansion has been in effect for several years.

“It’s taken a few years for the outcomes data to trickle out, to show what the association is—positive, negative, or nothing at all,” he said. “More targeted analyses will be done.”

For example, Khatana’s group at Penn is working on a study to examine the effect of Medicaid expansion on the ability of patients with failing hearts to receive a ventricular assist device, which he said cannot be obtained without insurance.

It’s possible that Medicaid expansion produced both direct and indirect benefits that improve health, the authors say in the JAMA Cardiology article. Besides the obvious benefit—better access to care through coverage—they note ACA may have created “spillover effects,” including the cash infusions to safety net hospitals and community health clinics that care for at-risk patients.

What went unsaid is that states without Medicaid expansion have had more than their share of rural hospital closings; longer travel times have been linked to worse outcomes and higher mortality for certain conditions, such as those receiving a coronary bypass graft. The ACA envisioned that patients would be covered by Medicaid and, in turn, withdrew funds for uncompensated care; in states where expansion never materialized, hospitals are squeezed more than ever.

AJMC® asked Khatana whether policy makers should start looking for the effects of Medicaid expansion—and differences in population health between states—as cohorts of 65-year-olds become eligible for Medicare.

“That’s a very interesting point,” he said. There have been policy discussions about what happens when uninsured 64-year-olds move into Medicare, Khatana said. But now, many people who, in the past, might have spent years without coverage will reach Medicare eligibility after several years with Medicaid coverage.

“Whether a healthier population is coming into the Medicare pool from the expansion states is a really interesting question,” he said.


Khatana SAM, Bhatla A, Nathan AS, et al. Association of Medicaid expansion with cardiovascular mortality [published online June 5, 2019]. JAMA Cardiol. doi: 10.1001/jamacardio.2019.1651.