PROJECT SUMMARY/ABSTRACT Cardiovascular morbidity and mortality disproportionately impact lower income individuals and racial minorities. These groups are also significantly less likely to have health insurance coverage in the United States. There is growing evidence that expansion of health insurance coverage in low-income populations can lead to improvements in health outcomes. In a recently published analysis by Dr. Khatana and colleagues, that serves as the preliminary analysis for the proposed research, expansion of insurance coverage through Medicaid was associated with fewer deaths from cardiovascular disease. A possible mechanism by which this occurred is improved access to cardiovascular care, however, this has not been previously studied. This proposed research plan aims to understand whether expansion of insurance coverage impacts access to inpatient and outpatient care for cardiovascular disease, and whether it narrows disparities in care access for racial minorities. Aim 1 seeks to examine whether expansion of insurance coverage through Medicaid under the Affordable Care Act led to an increase in access to inpatient care in the setting of acute myocardial infarction or stroke, and whether this varied between non-Hispanic Black and non-Hispanic White individuals. Aim 2 will investigate whether access to outpatient care for chronic cardiovascular disease is associated with changes in insurance coverage and whether insurance expansion narrows racial disparities in outpatient access. These two aims will utilize different large administrative claims databases. Aim 3 will augment these analyses by employing qualitative research methods to interview low-income patients discharged after a cardiovascular hospitalization. Patients in the post-discharge period are especially vulnerable to adverse outcomes such as readmission or death. Therefore, uninsured and insured patients will be interviewed to understand whether insurance status is associated with differences in health seeking behaviors, adherence to medical advice and therapies, health status and outcomes. These aims will lead to a future multi-site cohort study of low-income individuals with cardiovascular disease, which will be used to prospectively investigate how changes in health insurance coverage impact cardiovascular outcomes. Dr. Khatana, an early career investigator and a fellow in cardiovascular medicine, has a long-term goal of becoming an independently funded cardiovascular health policy and outcomes researcher with a focus on how health policies impact the cardiovascular health of low- income individuals using both large administrative databases as well as qualitative methods at the individual level. These research aims are part of a comprehensive training plan and will be supervised by a mentorship and advisory team consisting of national leaders in health outcomes and policy research, and advanced statistical and qualitative methodologies, and will guide his transition to an independently funded research career.

PROJECT NARRATIVE Low-income individuals, especially those who are racial minorities, in the US have a disproportionately higher burden of cardiovascular disease, and also have lower rates of health insurance coverage. This study aims to understand whether health insurance coverage for low-income individuals is associated with improvements in access to inpatient and outpatient cardiovascular care, improvements in racial disparities in care access, as well as care after discharge from a cardiovascular hospitalization. The findings of this study will help understand the mechanisms by which recent expansion of Medicaid under the Affordable Care Act was associated with improved cardiovascular mortality, as well as inform future health policies seeking to improve cardiovascular outcomes.