Introduction:
Uninsurance is a known contributor to racial/ethnic minority health inequities. Insurance is needed for prescription medications and follow-up visits with specialists. Among racial/ethnic minority patients hospitalized with heart failure (HF), it is not well studied whether the Affordable Care Act (ACA) Medicaid Expansion was associated with increased receipt of guideline-directed medical treatment (GDMT) on discharge from HF hospitalization.
Methods:
Using Get With The Guidelines-HF registry, logistic regression models were used to assess the odds of receiving GDMT [angiotensin converting enzyme inhibitor(ACE)/ angiotensin receptor blocker (ARB)/ angiotensin receptor-neprilysin inhibitor(ARNI); beta blocker; aldosterone antagonist; hydralazine/nitrate; HF education; HF follow-up appointment] in early adopter versus non-adopter states in the periods before (2012-2013) and after ACA Medicaid Expansion (2014-2019) within each race/ethnicity. Models were adjusted for patient-level covariates and generalized estimating equations addressed within-hospital clustering. The interaction (p-int) between adopter state status and timing of ACA Medicaid Expansion (2014) was evaluated.
Results:
Among 271,606 patients (57.5% early adopter, 42.5% non-adopter states), 65.5% were White, 22.8% were African-American, 8.9% were Hispanic, and 2.9% were Asian. In fully adjusted analyses, ACA Medicaid Expansion was associated with significant likelihood of receipt of ACE/ARB/ARNI at discharge in Hispanics [before ACA: OR 0.40 (95% CI: 0.13, 1.23); after ACA: OR 2.46 (95% CI 1.10, 5.51); p-int <0.01]. Asians were more likely to receive a HF follow-up appointment [before ACA: OR 0.64 (0.20, 2.06); after ACA: OR 1.44 (0.50, 4.15); p-int 0.03]. No significant differences were found in receipt of GDMT at the time of ACA Medicaid Expansion for other racial/ethnic groups. Independent of timing of ACA, Hispanics were more likely to receive all GDMT if they resided in an early adopter state compared to non-adopter state (p<0.01). Individual evidence-based treatments varied by state group independent of ACA timing for other racial/ethnic groups. With the exception of ACE/ARB/ARNI, beta blockers, and HF follow-up, <60% of patients in both state groups received other forms of GDMT despite eligibility.
Conclusions:
Among patients hospitalized with HF at centers voluntarily participating in a national quality improvement program, the ACA Medicaid Expansion was associated with increased receipt of ACE/ARB/ARNI in Hispanics, and increased receipt of follow-up appointments in Asians. Independent of the ACA, Hispanics residing in early adopter states were more likely to receive GDMT than Hispanics in non-adopter states. Futher expansion of ACA may reduce racial/ethnic disparities in HF; however, additional steps must be taken to overcome barriers to prescribing GDMT to all.
Medicaid Expansion and Racial and Ethnic Disparities in Access to Health Care: Applying the National Academy of Medicine Definition of Health Care Disparities
