Adverse Childhood Experiences and Cardiovascular Risk-Factors Among Low-Income Uninsured Adults: Will Medicaid Make a Difference?

Background:  Adverse Childhood Experiences (ACEs) have been linked to multiple poor adult health outcomes, including cardiovascular disease (CVD), the nation’s number one cause of death. Our clinical understanding of ACEs is limited to the general insured population; little is known about the prevalence and CVD health impact of ACEs in low-income uninsured populations. As millions of low-income adults gain coverage through  Affordable Care Act (ACA) Medicaid expansions, it is important to know more about ACEs in this understudied population. The objectives of this study are to estimate the prevalence of ACEs in a low-income, mostly-uninsured, adult population; determine the relationship between ACEs and risk factors for CVD; and to determine the causal impacts of Medicaid coverage as a moderator of risk.

Methods:  This study leverages the Oregon Health Insurance Experiment’s (OHIE) study population, who were randomly selected to apply for Medicaid, and key data, collected through in-person health screenings, including clinical measures of cardiovascular risk. Data on ACEs were collected via a follow-up mail survey with OHIE study participants who previously contributed biomarker data. A total of 12,229 low income non-elderly uninsured adults that signed up for Oregon’s 2008 Medicaid lottery and participated in the 2010 in-person health screenings that formed the sample for this ACEs study. 12,054 were sent the Oregon ACE survey with a response rate of 48%, n = 5,900.

We measured obesity (BMI ≥ 30), hypertension (≥140/90), high cholesterol (≥240mg/dL) and uncontrolled diabetes (A1c ≥6.5). Smoking, physical activity, and medical history were self-reported. The ACEs 10 item questionnaire covering neglect, abuse, and household dysfunction were the primary independent variables. We used Ordinary Least Squares (OLS) regression to examine relationships between ACEs and cardiovascular risk-factors. We leveraged the random assignment of access to limited spots in Oregon’s Medicaid program to identify the causal impact of insurance as a moderator of risk between ACEs and risk of cardiovascular disease using a standard instrumental variable (IV) approach where the lottery is an instrument for coverage.

Results:  ACEs were more prevalent in our low-income population when compared to previous published estimates in a general clinical population, with notably high rates of emotional abuse (37%), emotional neglect (32%), and significantly higher exposure to household dysfunction across all measures. ACEs were highly statistically associated with multiple cardiovascular risk factors. One of the most striking findings is that Medicaid almost eliminated hypertension among those without a history of childhood abuse (specifically sexual abuse), while it showed no impact among those with. Other moderating impacts were less notable.

Implications:  Low income adults have higher rates of ACEs than previously reported and were much more likely to experience household dysfunction, such as a parent incarcerated or mentally ill. Higher exposure in childhood put individuals at increased risk for poor cardiovascular health. With Medicaid coverage, hypertension was almost eliminated among those without a history of sexual abuse but persisted among those with. This suggests primary care might consider new trauma-focused approaches, including social work services, as more low-income adults gain access to care through Medicaid expansions.