domingo, 12 de julio de 2015

Impact of Health Insurance Expansions on Nonelderly Adults With Hypertension

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Impact of Health Insurance Expansions on Nonelderly Adults With Hypertension

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Impact of Health Insurance Expansions on Nonelderly Adults With Hypertension

Suhui Li, PhD; Brian K. Bruen, MS; Paula M. Lantz, PhD; David Mendez, PhD

Suggested citation for this article: Li S, Bruen BK, Lantz PM, Mendez D. Impact of Health Insurance Expansions on Nonelderly Adults With Hypertension. Prev Chronic Dis 2015;12:150111. DOI:


Hypertension is a risk factor for cardiovascular disease (CVD), the leading cause of death in the United States. The treatment and control of hypertension is inadequate, especially among patients without health insurance coverage. The Affordable Care Act offered an opportunity to improve hypertension management by increasing the number of people covered by insurance. This study predicts the long-term effects of improved hypertension treatment rates due to insurance expansions on the prevalence and mortality rates of CVD of nonelderly Americans with hypertension.
We developed a state-transition model to simulate the lifetime health events of the population aged 25 to 64 years. We modeled the effects of insurance coverage expansions on the basis of published findings on the relationship between insurance coverage, use of antihypertensive medications, and CVD-related events and deaths.
The model projected that currently anticipated health insurance expansions would lead to a 5.1% increase in treatment rate among hypertensive patients. Such an increase in treatment rate is estimated to lead to 111,000 fewer new coronary heart disease events, 63,000 fewer stroke events, and 95,000 fewer CVD-related deaths by 2050. The estimated benefits were slightly greater for men than for women and were greater among nonwhite populations.
Federal and state efforts to expand insurance coverage among nonelderly adults could yield significant health benefits in terms of CVD prevalence and mortality rates and narrow the racial/ethnic disparities in health outcomes for patients with hypertension.


In the United States, approximately 78 million people — or 1 in 3 adults — have hypertension, defined as systolic blood pressure of 140 mm Hg or higher or diastolic blood pressure of 90 mm Hg or higher (1). Hypertension is a risk factor for cardiovascular disease (CVD), contributing to 35% of myocardial infarctions (MIs) and strokes, and 49% of heart failures (2). It is estimated that a 5 mm Hg reduction of systolic blood pressure in the population would lead to a 9% to 14% reduction in CVD-related mortality rates (3). Thus, prevention of elevated blood pressure can avert many CVD-related deaths.
Despite the low cost of antihypertensive medications, there is inadequate management of blood pressure at the population level. National surveys conducted during 2011–2012 show that only 72% of people with hypertension were taking antihypertensive drugs, and 53% of hypertensive patients had their blood pressure under control (4). Lack of insurance coverage is a critical barrier to better treatment of hypertension. Compared with insured people with hypertension, uninsured people with hypertension are 4.4 times more likely to have an unmet need for medical care and prescription drugs (5) and have lower treatment and control rates (6).
Health insurance expansions under the Affordable Care Act (ACA) offered an opportunity to improve hypertension management by increasing the number of people receiving clinical preventive services (such as routine blood pressure checks) without cost sharing and by lowering patients’ out-of-pocket costs of antihypertensive medications. The Congressional Budget Office estimated that by 2024, Medicaid expansions and federal subsidies to buy insurance in the Health Insurance Marketplaces would help 25 million uninsured people get insurance coverage (7). However, little research has been done to understand the extent to which such expansion in coverage is likely to improve the health status of hypertensive patients in the long term. We aimed to project the long-term effects of health insurance expansions on hypertension treatment, CVD incidence rates, and disease-related mortality rates, using a state-transition (Markov process) model that simulates the lifetime health events among cohorts of the nonelderly hypertensive population.


This study was supported by the American Heart Association. The conclusions and opinions expressed herein are solely those of the authors and do not necessarily reflect the opinions of the American Heart Association or the authors’ affiliations.

Author Information

Corresponding Author: Suhui Li, PhD, Milken Institute School of Public Health, Department of Health Policy and Management, The George Washington University, 950 New Hampshire Ave, NW, Washington, DC 20052. Telephone: 202-994-3120. Email:
Author Affiliations: Brian K. Bruen, Paula M. Lantz, Department of Health Policy and Management, The George Washington University, Washington, DC; David Mendez, Department of Health Management and Policy, The University of Michigan, Ann Arbor, Michigan.


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