Washington DC - Capping a year of rancorous debate in the US over health insurance coverage, a new study suggests that patients with government-sponsored insurance (ie, Medicare and Medicaid) as well as patients with no insurance have worse cardiovascular outcomes than patients with private insurance one year after PCI. The study, published early online, will appear in the January issue of the American Journal of Cardiology.
The results, from a retrospective review of almost 13 600 patients, imply that the provision of health insurance alone might not have a dramatic effect on cardiovascular outcomes after PCI. "Insurance is only one piece of the puzzle to fixing disparities in both access to care and health care in general," lead author Dr Michael Gaglia, Jr (Washington Hospital Center, Washington, DC) told heartwire.
"There's no way to prove this, of course, but just because you give someone insurance doesn't mean that their health outcomes will automatically improve. Socioeconomic context is just as important as access to care and health insurance," Gaglia said.
Who has whatGaglia and his team analyzed data from patients who underwent PCI at their institution from June 2000 to June 2009. Of the 13 573 patients, 6653 (49.0%) had private insurance, 6150 (45.3%) had Medicare, 486 (3.6%) had Medicaid, and 284 (2.1%) were uninsured.
Medicare, Medicaid, and uninsured patients all had a lower median household income compared with patients with private insurance (p<0.001 for the trend). Medicare patients had more comorbidities, and current smoking and diabetes mellitus were more common in Medicaid patients. The overall procedural success rate was 98% and did not differ according to insurance type. Patients with Medicaid, Medicare, or no insurance were more likely to die in hospital (p<0.001 for the trend) and at one year than patients with private insurance. They were also more likely to have had major adverse cardiac events (a composite of death, Q-wave MI, and target vessel revascularization) at one year, but only if they were younger than 65 years. In patients age 65 and older, only Medicaid remained significantly associated with MACE at one year (HR 3.07, 95% CI 1.09-8.61). Medicare was not associated with MACE and there were too few uninsured patients in the >65 population for meaningful analysis, Gaglia said.
Gaglia acknowledged that some readers might interpret his findings to mean that having health insurance does not make any difference in terms of health outcomes. "That's not what we were going after," he explained. "We merely wanted to point out that insurance doesn't solve the problem of health disparities. There's more involved."
Cultural and behavioral complexities
Dr Christie Ballantyne (Methodist DeBakey Heart and Vascular Center and Baylor College of Medicine, Houston, TX) agrees with this view. "We've seen this a bit in the state of Texas, where they made vaccinations for children free and they still weren't being vaccinated in some communities," he told heartwire. "I see a lot of people who are overweight and don't exercise or who have high cholesterol and won't take medication. There can be a lot of denial. So I think just because you have insurance available doesn't mean everyone is going to do the preventive things. There might be other, cultural and behavioral complexities that are coming into play, and not just the availability of insurance."
Ballantyne said he found it very reassuring that Medicare patients over the age of 65, who make up the majority of Medicare patients, fared as well as private insurance patients. "This implies that it really didn't make much difference if you had government insurance or private insurance if you're over 65."
Also asked for his opinion, Dr Jeffrey Borer (Downstate Medical Center, Brooklyn, NY) noted that the reasons for the disparity in outcomes are not clear from the data. He notes that the poor outcomes in patients less than 65 who were on Medicare could be due to the predominance of severe renal disease in this subpopulation, and this fact complicates interpretation of the data because of the marked impact of renal disease on risk of coronary events. Likewise, the overwhelming predominance of Medicare in those age 65 and older limits conclusions about this sub-population as well, he said.
Borer suggests that differences in income and education, neither of which were evaluable from the database used in this study, may have impacted the search for medical help by Medicaid patients. "The drugs and devices used for therapy generally differed in patients with private and government insurance, possibly because of lack of insurance coverage sufficient to support use of the more expensive drug-eluting angioplasty stents and certain anti-thrombotic drugs under current government formulas," he said.
Also, the authors did not assess the frequency and adequacy of follow-up care, "or, perhaps more importantly, of pre-procedure preventive care, both probably affected by insurance type, probably differing among the groups and certainly impacting on outcomes. The fact that patients with Medicaid were more severely ill on presentation than those with private insurance suggests that pre-procedure care was more intensive and effective in patients with private insurance. Moreover, it is noteworthy that, from these data, the uninsured fared no less well than those on Medicaid."
Borer added that strict attention must be paid to the details of any government determined insurance that might result from efforts to increase the availability of health insurance for uninsured segments of the population, "to assure that insured care truly results in outcomes better than currently may be expected in the absence of insurance and optimally, that insured care truly equals best care."
Dr Mauricio Cohen (University of Miami Miller School of Medicine, FL) applauded the authors for their "noble endeavor" in looking at how insurance status affects cardiovascular outcomes, but he does not agree with their conclusion.
"It is interesting that they didn't show any difference in people older than 65 between private insurance and Medicare. And if you are less than 65 and qualify for Medicare, then there must be a special reason. The conclusion is not supported by the data. There are many apples and oranges in the same basket in this study. The analysis is limited by the retrospective nature and by the stark differences in the groups that you may not be able to adjust for. I'm sure there are multiple hidden variables that were not captured in their database."
Cohen added that his personal belief is that universal health coverage "would help narrow the gap between the different socioeconomic groups and different types of insurance."
