People with health insurance coverage are healthier, more likely to receive care when they need it, and less likely to die compared to people without it. This reality was the driving force behind the Affordable Care Act (ACA), which has led to more than 20 million previously uninsured Americans gaining insurance coverage—including those who gained coverage through the expanded income limit for Medicaid eligibility. 

There was hope that the Medicaid eligibility expansion could improve cardiovascular health among low-income people, who have a relatively higher prevalence of cardiovascular disease. A 2019 JAMA Cardiology study by LDI Senior Fellows Sameed Ahmed M. Khatana, Ashwin Nathan, and Peter Groeneveld confirmed that potential, finding a link between expanded Medicaid eligibility and lower cardiovascular mortality among middle-aged adults. 

But how exactly does having health insurance coverage improve cardiovascular health?

To learn more, the researchers conducted a follow-up study that compared rates of cardiovascular care use among adult Medicaid beneficiaries under the age of 65. 

The study focused on four states—New Jersey and Minnesota, which expanded Medicaid eligibility, and Georgia and Tennessee, which did not—and found a clear association between expanded Medicaid eligibility and increased cardiovascular care use among low-income nonelderly adults, including visits to cardiovascular-related specialists. Compared to the states that did not expand Medicaid eligibility, the expansion states had a 38% greater increase in the rate of beneficiaries with outpatient visits for cardiovascular disease management and a 43% greater rise in the prescription rate for drugs to manage cardiovascular disease. 

The investigators chose these four states because each had detailed Medicaid administrative claims data on utilization rates and they also used the same data collection and reporting system during the 2012-2015 study period, covering two years before and after the ACA-led expansion took effect. 

The decision to use Medicaid administrative claims allowed for a more detailed analysis on health care use among low-income people than national surveys, said lead author Khatana. When the researchers probed subgroup data, for instance, they discovered the utilization of cardiovascular care services rose among all age, gender, race, and ethnicity subgroups in the expansion states, and the increase was greater among non-Hispanic white adults compared to non-Hispanic Black adults. 

“Since other studies have documented a greater relative increase in insurance coverage among non-white adults compared to white adults, this was a somewhat surprising finding that could be particular to the states we studied,” he said. Noninsurance issues, such as transportation and availability of providers, also may serve as barriers to care access for some individuals.

What the Findings Mean for American Health Care  

Khatana noted that during their study period, most of the increase in insurance coverage among lower-income individuals in the US was due to Medicaid. So the trends they found are likely generalizable to the broader low-income nonelderly adult population.

The findings highlight how health insurance coverage increases access to care for chronic conditions like cardiovascular disease. In doing so, Medicaid eligibility expansion could help reduce socioeconomic disparities in access to cardiovascular preventive care, Khatana said. 

But the impact of the ACA is still less than universal. While designed to expand Medicaid coverage to nearly all adults with incomes up to 138% of the federal poverty level ($20,120 for an individual in 2023), only 40 states plus Washington, D.C. have adopted the Medicaid expansion to date. Meanwhile, 10 states, including heavily populated Texas and Florida, have declined to do so. 

Should these remaining states decide to adopt the ACA’s Medicaid expansion, Khatana said, millions more Americans would benefit from increased access to cardiovascular care that could improve quality of life, reduce cardiovascular emergencies, and save many lives. 

The study, “Medicaid Expansion and Outpatient Cardiovascular Care Use Among Low-Income Nonelderly Adults, 2012-15,” was published in November 2023 in Health Affairs. Authors include Sameed Ahmed M. Khatana, Lin Yang, Lauren A. Eberly, Ashwin S. Nathan, Ravi Gupta, Scott A. Lorch, and Peter W. Groeneveld.


Jen Fisher Wilson

Research Writer, Editor

More on Health Care Access & Coverage