Insurance and Cardiovascular Health
Time for Evidence to Trump Politics
The United States is entrenched in a fierce debate over healthcare reform. The Affordable Care Act (ACA) strove to reduce the number of uninsured individuals, and after its implementation, 20 million Americans gained insurance coverage. Ongoing shifts in health policy imperil these gains. As options for repealing, replacing, or revising the ACA are debated, we aim to outline what is known about the relationship between insurance coverage and cardiovascular care, the impact of the ACA on cardiovascular care, and areas where gaps in our knowledge remain. Understanding these relationships may help clinical leaders and policymakers better craft future policy initiatives.
Insurance Coverage and Cardiovascular Care
Routine medical care is essential for appropriate risk factor screening and treatment. Insurance mediates access to health care, so it is not surprising that uninsured individuals are less likely to receive screening for hypertension, diabetes mellitus, and hypercholesterolemia. Even when diagnosed, treatment and control of cardiovascular risk factors is lower in the uninsured population.1 Perhaps, in part, because of these disparities, coronary artery disease is more prevalent in low-income populations, who are generally at greater risk of being uninsured. Furthermore, although rates of acute myocardial infarction decreased in the US population the decade before the ACA, the proportion of uninsured individuals hospitalized for acute myocardial infarction rose.
In populations with established cardiovascular conditions, lack of insurance has been associated with poorer care quality and worse short-term outcomes. Uninsured patients with coronary artery disease are less likely to receive appropriate evidence-based therapies in the outpatient setting.2 Patients with acute myocardial infarction without insurance have been shown to receive less aggressive care and fewer invasive cardiac procedures, and they also have higher in-hospital mortality rates than privately insured individuals.3 The narrative is no different for uninsured individuals hospitalized for heart failure, who are less likely to receive guideline directed therapy and also experience worse in-hospital outcomes.4 This pattern also pervades other cardiovascular conditions, such as stroke and peripheral artery disease. Lack of insurance clearly encumbers the delivery of optimal cardiovascular care.
Impact of the ACA on Cardiovascular Care
In 2010, 7.3 million Americans with cardiovascular disease were uninsured. Almost half of this population lacked coverage because of cost and collectively were less likely to have a usual place of health care or be able to afford prescription drugs. They also experienced higher out-of-pocket health costs compared with insured individuals. In the first year after the ACA’s implementation, 7 million individuals at risk of or with cardiovascular disease gained insurance coverage.
How did this shift in coverage impact healthcare utilization? Studies of insurance expansion in low-income populations, which primarily gained coverage through Medicaid enrollment, demonstrated improvements in access to primary care, specialty care, and prescription drugs. Outpatient utilization, preventative care, and self-reported care quality also improved after Medicaid and private insurance expansion, whereas reliance on emergency department services decreased. Simultaneously, catastrophic out-of-pocket medical costs also declined.5 In the ACA era, the acquisition of health insurance has addressed some gaps in access to care, improved healthcare utilization, and diminished financial strain.
Areas Where Gaps Remain
What is less well known but arguably as critical is whether and how acquiring health insurance actually translates into better long-term cardiovascular health. Although it seems intuitive that insurance coverage and health would be positively related, evidence for a longitudinal association between gaining coverage and experiencing sustained, long-term improvements in health is sparse (Figure). We need more concrete data that health insurance improves cardiovascular (and overall) health on individual and population levels, as well as a better understanding of the mechanisms by which this occurs. Recent large shifts in coverage, as part of the ACA, provide an opportunity to study such phenomena.
However, health insurance is not a panacea; to make real improvements in cardiovascular health, we as a healthcare community will need to recognize that many of the most important factors that influence health are outside hospital walls. Factors often linked with being uninsured, such as low socioeconomic status, limited educational attainment, and living in neighborhoods with high levels of deprivation, may impact health in significant ways that attenuate the long-term benefits of gaining coverage. Even with insurance, other barriers associated with race and ethnicity, citizenship status, disability, and geography may impede health advancement. However, acquiring insurance may mitigate the negative effects of some social determinants of health in meaningful ways, and this represents another key area for future research efforts.
Providing Evidence to Guide Policy
Repealing the ACA could threaten insurance coverage for >23 million Americans. Although healthcare providers often invoke the idea that health insurance coverage is a “moral imperative,” this perspective is not universally shared by national policymakers. Compelling evidence that insurance coverage improves long-term health, particularly for vulnerable populations, may push policymakers to spend more time debating how to, rather than whether to, expand insurance coverage.
Cardiologists have long advocated for a practice environment in which robust data are actively translated into clinical practice, and we should adopt a similar stance for health policy. In a time of great uncertainty around health reform, we should acknowledge that evidence convincingly demonstrates that uninsurance is associated with adverse clinical outcomes. Simultaneously, we should work to provide additional evidence on the long-term impact of broadening insurance coverage on cardiovascular disease epidemiology, care quality and outcomes, and population health. It is critical that cardiologists be equipped with the best evidence base to engage, inform, and guide policymakers during periods of discussion and debate regarding national health policy.
Sources of Funding
Dr Wadhera is partially supported by the Jerome H. Grossman, MD Fellowship in Healthcare Delivery Policy at the Harvard Kennedy School’s Healthcare Policy Program. Dr Joynt receives research support from the National Heart, Lung, and Blood Institute (K23HL109177-03) and is a former employee of the US Department of Health and Human Services, where she continues work on a limited basis as a contractor.
The opinions expressed in this article are not necessarily those of the editors or of the American Heart Association.
Circulation is available at http://circ.ahajournals.org.
- © 2017 American Heart Association, Inc.
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