Heart failure deaths are rising in the US, especially in states that reject Medicaid expansion

Heart failure (HF) mortality is on the rise in the United States, according to a new analysis in the Journal of the American Heart Association. The impact of this trend appears to be hitting some areas much worse than others, suggesting that an escalation in local prevention efforts and the implementation of certain state-level policies could make a significant difference.

“While HF mortality rates are increasing nationally, there is significant regional variation in HF prevalence, HF hospitalization rates, and outcomes after HF hospitalization,” wrote lead author Peter A. Glynn, MD, of Northwestern University Feinberg School of Medicine in Chicago, and colleagues. “It is therefore essential to understand how the burden of HF mortality is borne at regional and state levels, as well as the underpinnings of any observed variation.”

Glynn et al. examined CDC data from 1999 to 2017, tracking both cardiovascular health (CVH) and age-adjusted mortality rates (AAMRs) for HF per 100,000 people. Overall, HF AAMR was on the decline from 1999 to 2011 before it increased consistently from 2011 to 2017. This trend held true for the entire country, the group observed, not just one specific region.

Increases in HF AAMR were the most prevalent in the South and Midwest. Mississippi had the highest HF AAMR for all three years the authors investigated: 1999, 2011 and 2017. Other states consistently near the top of the rankings included Arkansas, Oklahoma, Alabama, Indiana, Georgia, West Virginia and Kentucky.

The authors also noted that Black men and women consistently had a higher HF AAMR than white men and women in all regions of the country. Interventions on a local level can help combat this trend, but Glynn and colleagues also pointed out that state-level insurance policies appear to be a primary reason that Black men and women are falling so far behind other Americans when it comes to CVH.

For instance, the group explained, dozens of states implemented an expansion of Medicaid after the Affordable Care Act went into effect. When looking at what states have not expanded Medicaid, it becomes clear that this might directly be leading to poorer health outcomes.

“Subsequent research has demonstrated that implementation of the Affordable Care Act not only increased the overall rate of insurance coverage in the United States, but it also reduced race and ethnicity related disparities in health insurance,” the authors wrote. “Coverage gains and disparity improvements were greater in states that implemented Medicaid expansion compared with states that did not expand Medicaid. Unfortunately, ≈46% of Black working‐aged adults live in non‐expansion states and have thus been disproportionately impacted by non‐expansion. The states that have not expanded are clustered predominantly in the South and Midwest where rates of HF mortality are also highest.”

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