Medicaid Expansion and Healthcare Workers; Cardiac Rehabilitation

TTHealthWatch is a weekly podcast from Texas Tech. In it, Elizabeth Tracey, director of electronic media for Johns Hopkins Medicine in Baltimore, and Rick Lange, MD, president of the Texas Tech University Health Sciences Center in El Paso, look at the top medical stories of the week.

This week’s topics include Medicaid expansion and healthcare workers, brain impact of long COVID, a drug for severe food allergies, and cardiac rehabilitation.

Program notes:

0:41 Cognition and memory after COVID

1:41 More severe disease leads to greater deficits

2:41 Severity related to strain of virus

3:26 Cardiac rehabilitation

4:26 The earlier the better

5:26 Automatic referral and navigator

6:30 Medicaid expansion and healthcare workers

7:30 Lower-income workers on Medicaid

8:31 Bigger safety net

9:31 Trickle down is not a good strategy

10:00 Antibody to IgE

11:00 Children and adolescents with food allergy

12:00 Study participants admired

12:41 End

Transcript:

Elizabeth: Does Medicaid expansion help healthcare workers?

Rick: A single treatment for multiple food allergies.

Elizabeth: Another look at what is the impact of long COVID.

Rick: And a review of cardiac rehabilitation.

Elizabeth: That’s what we’re talking about this week on TT HealthWatch, your weekly look at the medical headlines from Texas Tech University Health Sciences Center in El Paso. I’m Elizabeth Tracey, a Baltimore-based medical journalist.

Rick: I’m Rick Lange, president of Texas Tech University Health Sciences Center in El Paso, where I’m also dean of the Paul L. Foster School of Medicine.

Elizabeth: Rick, in keeping with our longstanding practice — and that’s almost 4 years to date of the practice of talking about COVID material first — let’s go to the New England Journal of Medicine.

This study is entitled “Cognition and Memory after COVID-19 in a Large Community Sample,” and it is a large sample. This was done in the U.K. where 800,000 adults were invited to complete an online assessment of cognitive function. They produced a global cognition score across eight tasks. They netted 112,000+, almost 113,000 people who had had COVID and multiple categories of COVID if you will: those who self-reported that they had had it, those who had been confirmed to have had it, those who had been hospitalized, and then people who said I’ve never had it. What does your cognitive function look like across these eight tasks? There was what I’m going to call a dose response, and that is the more severe your COVID was, the larger your deficits were. If you reported long COVID symptoms greater than 12 weeks duration, sure enough you had higher impact on your cognitive abilities. I wasn’t terribly surprised by this. Were you?

Rick: No, Elizabeth. I wasn’t either. They did delve a little bit into it. What they discovered was that the memory, the reasoning, and the executive function were the most sensitive to COVID-19-related cognitive differences.

Elizabeth: The other thing that they do note here is that among their sample they were more likely to be women, to be white, and slightly less likely to be from the youngest age groups. And here is an important caveat: or from areas with greater levels of multiple deprivation. I’m interested in, well, among that cohort, what is the rate of cognitive dysfunction subsequent to COVID infection?

Rick: Your point is well taken, Elizabeth, in that this particular study can’t absolutely say that there was a change in cognitive function because they didn’t have before and after data.

Elizabeth: The other thing that they note, of course, is that severity seemed to have been related to what strain of the virus one was infected with so that the earlier strains, when it first emerged, were associated with much more severe cognitive dysfunction.

Rick: Elizabeth, that may be a function of the different variants of COVID-19 or it could be that people later on were more likely to have been vaccinated. But you’re right, there was a difference between the early COVID period and the later COVID periods as well.

Elizabeth: Well, they end up by saying that the outlook is good, that they feel that most of this is going to resolve over time for the majority of people.

Rick: The changes were relatively small or modest, but, again, you could measure them.

Elizabeth: OK. Which of your two would you like to go to now?

Rick: Speaking about measuring things, let’s talk about cardiac rehab for a while. This is our first time that I can remember us reporting it in almost two decades doing the podcast. It’s a review article that I think summarizes what we know about cardiac rehab. In the U.S., there are about a million people that have some type of a cardiac event each year. Even though cardiac rehab is recommended in almost all of these individuals, only about a fourth of patients actually participate.

Let’s take a step back and say, what is cardiac rehab? The aim is to achieve the best cardiovascular health after that event. It’s oftentimes a whole team that does this. Physicians, nurses, exercise physiologists, dietitians, social workers, psychologists as well. Studies show pretty convincingly, the randomized trials, there is a benefit. These individuals who participated have better functional capacity, psychological health, and are more likely to adhere to treatment. They are more likely to control their risk factors, and it does reduce subsequent heart attacks and hospital readmissions. The last thing I should say is once someone’s had a cardiac event, the earlier one gets enrolled in cardiac rehab — we’re talking about 1 or 2 weeks after the event — the more likely they are to receive the benefits from it and the more likely they are to complete the program

Elizabeth: In view of the fact that this is such a comprehensive approach, talk to me about availability of high-quality programs across the country.

Rick: Yeah. You know what? That’s part of the issue. We don’t have enough capacity. If we look at existing cardiac rehab programs in the U.S., the estimated capacity is sufficient to only accommodate about 37% of the eligible patients. We certainly have excess capacity right now compared to those that actually participate and we know that those that are less likely to participate are women, older patients, racial or ethnic minority, patients in lower-socioeconomic status groups.

Elizabeth: It sounds like some kind of an approach that would utilize some online resources might be helpful here.

Rick: There are now in-home programs that you can do, but the initial step is actually getting people in and they show that you can just about double the utilization if you have automatic referral and a navigator that helps get people into the programs. In-home cardiac rehab programs are just as successful as those in which you have to go to a clinic.

Elizabeth: Is there any relationship between the severity of the cardiac event and someone’s propensity to enroll in a rehab program?

Rick: You would think that people that are most at risk would be more likely to get cardiac rehab, but those are the individuals that are less likely to get it. But Elizabeth, I think you’re right. Those that have had the more severe event are more motivated to complete the program.

Elizabeth: It reminds me of a patient I had who said to me when we were talking about barriers to care that he didn’t believe that he had had a heart attack. That’s something that your team really needs to understand and help you to understand that you really did have one, and that you really need to deal with the sequelae of that.

Rick: A lot of this isn’t just presenting the information, but it’s dealing with the psychological situations that occur around it as well to help motivate individuals to maintain their cardiovascular health.

Elizabeth: Let’s turn to JAMA. That last one was again in the New England Journal and we’re going to go back there for your final one. In JAMA, this is a study that’s entitled “Changes in Health Care Workers’ Economic Outcomes Following Medicaid Expansion.”

In this study, their sample included 1.3 million+ healthcare workers from 2010 to 2019. They looked at Medicaid expansion under the Affordable Care Act and they looked at states that did it and states that did not. They found that the expansion in the states that adopted it was associated with a 2.16 increase in annual incomes. However, this was driven by higher incomes among the two highest-earning quintiles of the healthcare workforce, including registered nurses, physicians, and executives. Those in the lower-earning quintiles did not experience any significant changes. Medicaid expansion was associated with a 3.15 percentage point increase in the likelihood that a healthcare worker received Medicaid benefits, so those at that lowest level. They also saw significant decreases in employer-sponsored health insurance and increases in SNAP [Supplemental Nutrition Assistance Program]. Their conclusion is that Medicaid expansion actually increased economic inequality among healthcare workers.

Rick: Medicaid expansion is supposed to bring more money to the healthcare organizations like hospitals and clinics. As a result, they say, well who benefits? I guess I would argue a little bit differently. I think everybody benefited some: janitors, medical assistance, and support personnel. Their income didn’t go up, but they were more likely to have insurance, albeit it was Medicaid. The higher-income workers were more likely to have a very modest increase. Whether you can call that inequality worsening, I say that may be a little bit of a reach.

You might argue they lost their private insurance and now they are on Medicaid, therefore it’s somewhat more restrictive. What happens with Medicaid is it’s a little bit more flexible and there is a bigger safety net. What they didn’t do was determine did people go from the employer-sponsored insurance to Medicaid because it was a benefit to them or was it because they couldn’t afford the health insurance anymore. We just don’t know that.

Elizabeth: Yeah. I have a lot of concerns about this cohort of people who work in the hospital and this is one of the reasons I chose this study. In one of the units where I spend a lot of time, we have people who are in EVS (Environmental Services) who have to have second jobs in spite of the fact that they’re fully employed. This is troubling to me because I have borne witness to the amazing service that they provide, not just in keeping the place clean, but frequently in interacting with patients and loved ones. I feel that the editorialists’ final comment on this that says improving financial outcomes for low-income workers may require interventions that directly target these outcomes versus hoping that Medicaid expansion is going to trickle down.

Rick: Elizabeth, that’s the tact we took at our university. We said they are essential workers. You and I have talked before about how we have a severe shortage of nurses and doctors. We’re doing everything that we can to try to recruit and retain them. Now everybody is essential in the organization, but what this study shows is the way to do that probably isn’t through Medicaid expansion as you mentioned.

Elizabeth: We can’t let that get lost.

Rick: Yeah. To think that by expanding Medicaid it trickles down to them, that’s not necessarily the case, so we just have to be intentional about it.

Elizabeth: Exactly. Back to NEJM.

Rick: This is therapy that’s already around. It’s an antibody to antibodies. The IgE [anti-immunoglobulin E] antibody, that’s what is really responsible for most of the allergic reactions. You’re exposed to some protein that looks to be foreign. The IgE antibody attaches to it and elicits a common allergic response. For some people with food allergies, it’s a very serious allergic response. We’ve talked before about peanut allergies, mostly manifesting in kids 1 to 2 years of age. They oftentimes outgrown them, but not always. During that time, they have to be very careful about avoiding foods that they’re sensitized to or oftentimes they don’t know they’re even in a particular food that they’re eating. To date, there is only one FDA-approved oral immunotherapy product for peanut allergy, but we do have a monoclonal antibody to IgE that’s already available to treat allergic asthma in children. It was noticed that those children, especially if combined with other medications, had reduced food allergies.

They picked about 180 children and adolescents, ages 1 to 17 years of age. They randomized them to receive either placebo or this omalizumab [Xolair], kids that had allergies to peanuts and to other foods. They were so allergic that if they had as little as one fourth of a peanut they would have an allergic reaction. They were randomized to receive this injection or placebo every 2 to 4 weeks for about 16 to 20 weeks and then they rechallenged them to six times the dose of peanuts that they were allergic to. It was about 70% effective in reducing allergic reactions, so they could take as much as six or 10 times what they were allergic to and not have any allergic reaction.

Elizabeth: Let’s talk about, though, its utility because this requires subcutaneous injection every 2 to 4 weeks for 16 to 20 weeks and that’s not inconsiderable for kids.

Rick: No it’s not, Elizabeth. For kids that have severe anaphylaxis and they have multiple food allergies, it is promising.

Elizabeth: It would be nice if we had something that was more than 70% effective, of course. Also, I have to admire the participants of this study because I would think that for somebody with severe anaphylactic reactions it would be scary to undergo the challenge.

Rick: It is scary to undergo the challenge. It’s scarier to not know when you might be exposed again.

Elizabeth: Then good news, something for these folks with this severe allergy. On that note then, that’s a look at this week’s medical headlines from Texas Tech. I’m Elizabeth Tracey.

Rick: I’m Rick Lange. Y’all listen up and make healthy choices.