The ACA is helping Americans with CVD—but not enough

The Affordable Care Act increased access to healthcare and health insurance for millions of Americans after it was first implemented five years ago. But for CVD patients in particular, some experts argue the law is falling short.

Since the ACA took full effect in January of 2014, U.S. citizens living with heart disease and CV risk factors have seen wider access to medical care, Ameen Barghi, of Harvard Medical School, and colleagues wrote in the Journal of General Internal Medicine. But certain corners of the country remain untouched by the ACA and, even with Medicaid expansion, some 20.6 million CV patients remained uninsured in 2015-2016.

“Patients with existing cardiovascular conditions require regular medical care and daily medications to prevent another heart attack or stroke,” Barghi said in a statement from Physicians for a National Health Program. “The good news is that the medications for cardiovascular disease are very effective, and millions of Americans gained some coverage under the ACA. Unfortunately, despite these gains, millions of Americans with these conditions remain uncovered, and many of those will likely suffer serious complications and even death because they cannot get the care they need.”

Barghi and his team analyzed a nationally representative dataset of 1,014,450 adults with CVD or at least two established CV risk factors, comparing their health data from 2012-2013 (pre-ACA) to data logged in 2015-2016 (post-ACA).

The researchers found that after ACA implementation, insurance coverage among heart patients in the U.S. increased by nearly 7%. More patients—3.6% more—were able to afford a doctor’s visit, 2.1% more could afford a check-up and 1% more had a personal physician. Changes were approximately doubled for people with incomes of less than $35,000 per year.

Barghi et al. said the ACA seemed to reduce previous disparities in coverage for ethnic and racial minorities, if just by a narrow margin. Minorities saw gains in some outcomes, but 13% of black and 29% of Hispanic adults with CVD or CV risk factors remained uninsured in 2015-2016 and nearly a quarter of low-income Americans with the conditions—more than 20 million people—still lacked coverage.

Access to healthcare varied depending on where a person lived, the authors wrote. Insurance coverage increased the most in states that expanded Medicaid, from 81% to 89%, while in non-expansion states coverage increased from 76% to 81%. Post-ACA, the percentage of chronically ill people with health insurance ranged from a high of 94% in Massachusetts to a low of 73% in Texas.

Racial disparities were glaring in non-expansion states, Barghi and colleagues reported. Of Hispanic people with CVD or CV risk factors in non-Medicaid expansion states, 42% lacked insurance in 2015-2016, 25% couldn’t afford a doctor’s visit, 40% hadn’t had a checkup in the past year and 48% didn’t have a personal physician.

The authors argued that if more states expanded Medicaid, more CVD patients would be covered, especially those with low incomes and people of color. They said their findings should be considered in light of the Trump administration’s recent efforts to obliterate the ACA and replace it with a more “market-based” system.

“Repealing or weakening the ACA would strip coverage from millions of Americans with cardiovascular disease or cardiovascular risk factors, spelling disaster for many of them,” Danny McCormick, the study’s senior author and a physician at Cambridge Health Alliance, said in the PNHP statement. 

“However, today’s piecemeal approaches to coverage, including the ACA, will not get all these patients covered. Only a comprehensive Medicare-for-All plan could provide both coverage and good access to care for everyone with a cardiovascular disease or risk factor. Polls show that such reform is popular with the American people, and increasingly on the agenda of many elected officials.”