Has the Affordable Care Act Influenced Cardiology Disease Rates in the San Joaquin Valley?

Purpose: The study provides a summary of Cardio Vascular Disease (CVD) in the San Joaquin Valley (SJV) and the burden held on residents despite the increased number of insured under the Affordable Care Act (ACA). Methods: Patient Discharge Data were collected from the Office of Statewide Planning and Development (OSHPD) from 2010-2017. With a range of Age 40 to 64. Patients all reside in the San Joaquin Valley (Fresno, Kern, Kings, Madera, Merced, San Joaquin, Stanislaus, and Tulare). The American Community Survey (ACS) was used for population estimates. Regression was used to model the effects of the ACA on severity diagnosis and length of stay. Results: From the result, CVD patients from the age of 40-64 declined. Many individuals appeared in 2013 with county indigent or self-pay and changed in 2015 to Medi-Cal. Overall, rates of hospitalization decreased. However, regression analysis suggested an increase in severity diagnoses and an increase in the length of stay after the ACA was implemented. Conclusion: The study provides a summary of Cardio Vascular Disease (CVD) in the San Joaquin Valley (SJV) and the burden held on residents despite the increased number of insured under the Affordable Care Act (ACA). The evaluation of discharge data demonstrates the positive impact the ACA has for those suffering from CVD in SJV.


Introduction
Health care reform under the Affordable Care Act is driving healthcare workers to make swift changes.
Currently, 14 million people in California are estimated to have at least one chronic condition and over half of this group have multiple chronic diseases (Affordable Care Act Impact, n.d.). Despite improvements for treatment, prevention, and access to care, cardiovascular disease is the number one condition that claims more California lives than any other. At least one out of three individuals are diagnosed with a common form of CVD, such as heart failure, stroke, and high blood pressure. The American Heart Association indicated that by the year 2035, the number of Americans with CVD is projected to rise to 131.2 million -45 percent of the total U.S. population (AHA, 2017). Residents living in the San Joaquin Valley are not immune to this catastrophic episode either. Despite the immediate changes made to healthcare under the ACA, annual costs for CVD is estimated to cost $37 billion annually or 16% of all health care costs in California (Economic Burden of Chronic Disease in California, 2015). More than any other chronic disease in the state of California. In 2010, CVD cost the SJV approximately $613 million dollars.
With the decline of mortality from CVD in California, disparities still persist. Individuals with lower levels of income and education are more likely to have one form of CVD than any other persons. The SJV attributes to some of the highest poverty rates and poor socioeconomic conditions when compared to the rest of California. In all parts of the region, poverty is deeply rooted. The area is dominated by low-wage farm and service jobs and has average employment income behind the rest of the state. There are over 28 million chronic conditions in California in general, with CVDs being the most common (36.4 %) (Brown et al., 2014). The San Joaquin Valley Counties include: Fresno, Kern, Kings, Madera, Merced, San Joaquin, Stanislaus, and Tulare. United States Census Bureau issued a report entitled the American Community Survey in 2017, which found that six San Joaquin Valley counties had the highest percentage of residents living below the federal poverty line of any counties in California. The report also found that the same six counties are among the 52 with the highest poverty rate in the US.
The median income for a household in the valley is $46,713. The poverty rate for individuals below the poverty level is 23.7%. According to the United States Census Bureau, the SJV had a total population at the time of the 2011-2015 of 4,080,509. While the eight counties in the SJV differ widely in the prevalence of diseases and health status, almost all diseases and health threats have a greater prevalence in the region.
According to Wolf and Maddox (2019), the ACA has affected heart failure patients by coverage expansion, delivery health reform, and insurance regulation. However, there is a gap in the literature that fails to include regions that are challenged with multiple disparities. The high levels of poverty in the region mean fewer have access to health care. Environmental risks, low education levels, and a high number of agricultural workers all contribute to the region's considerable at-risk population. The Affordable Care Act has offered a chance to address these challenges. As more people are covered by some kind of health insurance, preventive services, in particular for vulnerable populations can be www.scholink.org/ojs/index.php/rhs Research in Health Science Vol. 5, No. 3, 2020 85

Population
The study focused on those with a primary diagnosis of a cardiovascular-related event including hypertension, heart failure, and stroke. The study population was limited to individuals who were 40 to Medi-Cal (Medicaid in California), Private, worker's compensation, county indigent programs, or other public insurance as their primary source of payment were included in the analysis. Patient records were excluded if they were missing data on gender, age, race/ethnicity, payer, and county of residence.

Statistical Analysis
SPSS 26 statistical software was used to conduct the analysis. Descriptive statistics including frequency, percentage, mean, and standard deviation for the study population are presented in Table 1. In Table 2, we display the frequency of hospitalizations, the estimated populations in the San Joaquin Valley, and the rate of hospitalizations per 10,000 in the population by year. In Figure 1, we illustrate the percentage of cardiovascular-related hospitalizations by insurance coverage and year. We used Chi-squared tests to examine and compare the distribution of patient diagnosis severity by insurance coverage prior to and after ACA implementation and can be found in Table 3. Logistic and ordinary least squares regression were used to examine the outcomes of patient severity and length of stay, respectively. Regression results are displayed in Table 4.

Trends in Utilization of Hospital Services by Insurance Coverage
In Figure 1, we illustrated the percentage of hospital admissions by insurance coverage and year. We

ACA Implementation, Insurance Coverage, and Severity of Diagnosis
In Table 3, we show the percentage of patients pre-and post-ACA implementation by insurance coverage and severity of diagnosis. We found a significant effect of ACA implementation on the relationship between insurance coverage and severity of diagnosis. Among individuals on Medi-Cal, Pre-ACA implementation, 40% of patients were admitted with a comorbidity or a major comorbidity.
Post-ACA implementation, we found that this percentage increased to 53% among individuals on Medi-Cal. Across all insurance coverage groups, after the ACA was implemented we observed an increase in the percentage of patients with a comorbidity or major comorbidity in comparison to years before the ACA was implemented.  X^2 test significant at p < .05.
In Table 4, we show results of a two multivariate analyses. We show exponentiated log odds from a logistic regression on severity and we show beta weights from an ordinary least squares regression on the length of stay in day.

ACA Implementation and Severity of Diagnosis
Adjusting for all other covariates in the model, we found that implementation of the ACA increased the odds of a comorbidity or major comorbidity diagnosis by 82%. In Table 4, we show the OR 1.824 (p<.001) for ACA implementation. Pre-ACA implementation is considered from 2010-2013 and post-ACA implementation is from 2014-2017.

Insurance Coverage and Severity of Diagnosis
Adjusting for all other variables in the model, the odds of having a hospitalization with a sever diagnosis were 43% less for patients on Medi-Cal, 67% for patients on private insurance, 64% for patients on county indigent, other government, or other indigent, and 59% for patients on self-pay or other payer coverage. The ACA implementation demonstrated the largest effect in the model. The odds of a severe diagnosis was 82% greater post-ACA implementation in comparison to pre-ACA implementation. We found an interaction between the implementation of the ACA and Medi-Cal coverage on the odds of a severity diagnosis.

Interaction Effects of Insurance Coverage and ACA Implementation on Severity of Diagnosis
We found an interaction where ACA implementation moderated the effect of Medi-Cal coverage on the odds of a severity diagnosis, OR 0.939 (p<.05). The main effect of ACA increased the odds ratio of a severity diagnosis, OR 1.824 (p<.05), but this effect was not as large among those on Medi-Cal, OR 0.939 (p<.05) compared to all others.

Length of Stay
In Table 4, we show the results of a multivariate ordinary least squares model on the length of stay in the hospital. We found that patients on types of insurance coverage had significantly shorter stays in the hospital compared to those on Medicare, adjusting for all covariates. We found that a significant and positive effect of the ACA implementation on length of stay, beta 0.105 (p<.001). The implementation of the ACA had significant interaction effects with Private and Workers' Compensation, beta 0.215 (p<.001) as well as with County Indigent, Other Government, and Other Indigent insurance coverage, beta -0.271 (p<.001).

Discussion
This study found that people who were hospitalized after the implementation of the ACA tended to have more major comorbidities and longer lengths of stay in comparison to people hospitalized prior to the implementation of the ACA. To the best of our knowledge, this is the first study to illustrate this effect.
The survey results suggested that payer mix distribution in hospitals has been impacted by the ACA and that utilization of other public coverage programs has decreased with an increase of Medi-Cal coverage.
Additionally Association predicts that by the year 2030, the total direct cost of CVD will jump to $918 billion. In the state for California, CVD is a reflection of the nations. CVD accounts for one in three of all deaths in the state. Additionally, in the SJV there is growing evidence that the rate of death caused by cardiac illnesses is greatly affected by income inequality, access to economic opportunities and education. The Medicaid Expansion and ACA has given SJV substantial economic relief. The healthcare expansion of the ACA has allowed many SJV providers and hospitals to provide care to those who are newly covered. and preventative primary care rates, is needed to determine the potential impact of the ACA to CVD.
Expansion of medical coverage is just one factor that can improve cardiovascular health and reduce the likelihood of developing CVD. The American Heart Association has identified seven key components of cardiovascular health that all Americans should strive to achieve: normal blood pressure, normal cholesterol, normal blood sugar levels, not smoking, maintaining a normal weight, eating a healthy diet, and meeting recommendations for physical activity. Additionally, it is essential to train and educate individuals who are knowledgeable about health disparities in the socioeconomic and cultural contexts of the region and to develop the future generation of researchers who will begin to find solutions to these disparities that contribute to CVD.

Study Limitations
These data sets do not show how many individuals acquired Medi-Cal or private insurance through the exchange. With today's healthcare industry, Primary care is a key component. Unfortunately, within this report, Primary care utilization data is not available. Migration effects can also be a limitation due to the distribution on population of place can be irregular. Beerli (2004) states, the indirect population parameters depend on the degree of the migration rate from the unknown populations. Hence, the more immigrants from unknown population, the population size can fluctuate.

Conclusion
The evidence produced in this study indicates the positive impact the ACA has on the SJV for those suffering from CVD. The evidence also demonstrated that the ACA is essential when trying to conquer cardiovascular disease in the San Joaquin Valley. Any changes made to the ACA could be detrimental to the existing state of CVD in the SJV. Thus, causing more economic burden to the state of California.
Many challenges remain ahead for healthcare policy. If this research could be reproduced in other states that serve individuals with poor socioeconomic conditions and disparities, it would be beneficial to health care policy makers. Proving that there is a need to keep access to health care for all, despite the inability to pay or access coverage is essential. For instance, health care policy leaders need to be risk takers and exhibit better concepts that are unconventional. Along these same lines, health care leaders', hospitals, and clinics need to form organizational procedures and customs that exhibit a new value system to include access to all for healthcare coverage. This is to say, by setting the expectation that