Source/Disclosures
Disclosures: Khatana reports he received funding from the NHLBI. Please see the study for all other authors’ relevant financial disclosures.
September 30, 2020
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Medicaid expansion may improve availability of VADs for low-income patients

Source/Disclosures
Disclosures: Khatana reports he received funding from the NHLBI. Please see the study for all other authors’ relevant financial disclosures.
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Increased frequency of ventricular assist device implantation occurred in states that expanded Medicaid eligibility criteria from 2013 to 2015, researchers reported.

The same did not occur in states that did not expand Medicaid.

Medicaid expansion
Source: Adobe Stock.

According to a research letter published in the Journal of the American College of Cardiology, VAD implantation increased for men in states that expanded Medicaid compared with nonexpansion states. Researchers observed no increase in VAD implantation among women, regardless of expansion.

Sameed Khatana

“The major implications of this study are that there was potentially an unmet need for life-saving VAD therapy among low-income patients who were previously uninsured and then gained health insurance coverage through expansion of Medicaid under the Affordable Care Act in 2014,” Sameed Khatana, MD, MPH, instructor of cardiovascular medicine in the Perelman School of Medicine at the University of Pennsylvania, told Healio. “Given the higher burden of CVD in lower-income populations, increasing health insurance coverage in this population led to a significant overall increase in VAD implantations in the states that expanded Medicaid in 2014, but not in the states that did not expand Medicaid. Additionally, since Black patients have both a higher burden of heart disease and lower rates of insurance coverage, in states that expanded Medicaid, there was a narrowing in the gap between Black and white patients in terms of rates of VAD implantations.”

Using the data from INTERMACS, investigators identified patients in the U.S. who underwent VAD implantation from 2013 to 2015 and stratified them according to whether they lived in a state that expanded Medicaid. The goal was to determine whether Medicaid expansion was associated with increased VAD implantations.

VAD implantation in Medicaid expanded states

Researchers observed that the quarterly VAD implantation rate in expansion states increased from 0.23 implants per 100,000 residents in 2013 to 0.33 implants per 100,000 residents in 2015 (P = .001). The rate of VAD implantation in nonexpansion states remained unchanged, at 0.28 implants per 100,000 residents (P = .15).

After states expanded Medicaid eligibility criteria, the VAD implantation rate increased by 0.011 per 100,000 residents more per quarter compared with nonexpansion states (95% CI, 0.002-0.019; P = .015).

“Given the ongoing debate about the Affordable Care Act, studies such as ours are important to consider as policymakers decide whether to expand Medicaid further or impose restrictions on the program,” Khatana said in an interview.

Effects of expansion by race

Among men, VAD implantation rates increased more in expansion states compared with nonexpansion states for both Black and white individuals (RR for Black men = 0.052; 95% CI, 0.015-0.089; RR for white men = 0.023; 95% CI, 0.008-0.038). Investigators observed no increase among Black or white women in expansion compared with nonexpansion states (RR for Black women = –0.011; 95% CI, –0.037 to 0.016; RR for white women = –0.001; 95% CI, –0.007 to 0.005).

Moreover, VAD implantation after expansion was more prevalent among Black patients compared with white patients (RR for implantation per 100,000 more residents per quarter = 0.019; 95% CI, 0.003-0.035). This trend was not observed in nonexpansion states (RR for implantation per 100,000 more residents per quarter = 0.009; 95% CI, –0.011 to 0.029).

“Although this is not a clinical study, the findings point out the fact that lower-income individuals tend to have a disproportionate burden of CVD,” Khatana told Healio. “Policies to improve access in this group have the potential to improve the CV health of a large number of patients.

“Future research that examines how these newly enrolled Medicaid beneficiaries do after receiving a VAD will further help physicians and health systems in devising clinical programs that maximize the health outcomes of this population,” Khatana said in an interview.

For more information:

Sameed Khatana, MD, MPH, can be reached at sameed.khatana@pennmedicine.upenn.edu; Twitter: @sameedkhatana.