CV Risk Factor Management Remains Low Across Medicaid Expansion, Nonexpansion States

Rishi K. Wadhera, MD

New findings suggest that while working-age adults with low income in Medicaid non expansion states in the United States saw higher rates of uninsured individuals and worse access to care than expansion states, cardiovascular risk factor management was similar, as were low treatment rates.

However, within these non expansion states, data show uninsured adults had lower odds of receiving appropriate cardiovascular risk management compared with insured adults, according to investigators led by Rishi K. Wadhera, MD, Richard A. and Susan F. Smith Center for Outcomes Research in Cardiology, Beth Israel Deaconess Medical Center.

“In Medicaid non expansion states, more than 4 million uninsured individuals experienced markedly worse access to care and significantly lower rates of indicated monitoring and treatment of cardiovascular risk factors compared with their insured counterparts,” Wadhera wrote.

The team used data from the Centers for Disease Control and Prevention (CDC) Behavioral Risk Factor Surveillance System (BRFSS) from January - December 2019, with 3 questions in mind:

• How do rates of insurance coverage differ among working-age (18 - 64 years) compared with those that did expand Medicaid?
• How do health care access and cardiovascular risk factor management compare between these populations?
• Do measures of health care access and cardiovascular risk factor monitoring and treatment differ between working-age adults with low income who are insured vs insured in Medicaid non expansion states?

They used the estimated adjusted risk difference (RD) in outcomes to compare adults in Medicaid non expansion and expansion states. Ultimately, the weighted study population consisted of 28,028,451 working-age adults with low income. This included 10,094,994 (36.0%) adults in Medicaid non expansion states and 17,933,457 (64.0%) in expansion states.

Overall data show adults with low income living in Medicaid nonexpansion states had significantly higher uninsurance rates than those living in expansion states (42.4% [95% CI, 40.2% - 44.7%] vs 23.8% [95% CI, 22.8% - 24.8%]; P <.001).

Moreover, adults with low income in nonexpansion states had higher uninsurance rates (42.4% [95% CI, 40.2% - 44.7%] vs 23.8% [95% CI, 22.8% - 24.8%]) and were less likely to have a usual source of care (55.4% [95% CI, 53.1% - 57.6%] vs 65.4% [95% CI, 64.3% - 66.5%]; adjusted RD, -11.4% [95% CI, -13.9% to -8.8%]).

Investigators found no significant differences between expansion and expansion states regarding cardiovascular risk factor management.

However, data from non expansion states show uninsured adults were less likely to receive indicated monitoring of cholesterol (72.6% [95% CI, 67.7% - 77.4%] vs 93.7% [95% CI, 92.4% - 95.0%]; RD, -17.2% [95% CI, -21.8% to -12.6%]) and hemoglobin A1C levels (55.2% [95% CI, 40.0% - 72.5%] vs 88.5% [95% CI, 79.2% - 97.9%]; RD, -25.8% [95% CI, -47.6% to -4.1%]), compared with insured adults.

These findings remained for hypertension treatment in uninsured adults, compared to insured adults (49.4% [95% CI, 43.3% - 55.6%] vs 74.7% [95% CI, 71.5% - 78.0%]; RD, −16.3% [95% CI, −23.2% to −9.4%]). Investigators noted the patterns were found to be similar for uninsured adults versus insured adults in expansion states, as well.

“The findings suggest that policy strategies to expand insurance coverage and improve care delivery for chronic conditions (eg, hypertension, diabetes, and high cholesterol level) are needed to reduce cardiovascular health inequities in the US,” Wadhera concluded.

The study, “Health Care Access and Management of Cardiovascular Risk Factors Among Working-Age Adults With Low Income by State Medicaid Expansion Status,” was published in JAMA Cardiology.