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June 2025 (Volume 103)
Quarterly Article
Luke E. Barry
Sanjay Basu
May Wang
Roch A. Nianogo
Sep 23, 2026
Jun 29, 2026
Jun 12, 2026
Back to The Milbank Quarterly
Policy Points:
Context: Evidence suggests Medicaid expansion has improved cardiovascular disease (CVD) outcomes, especially among those of lower socioeconomic status. However, less is known about the cost-effectiveness of Medicaid in achieving these outcomes and reducing CVD disparities. We use distributional cost-effectiveness analysis methods to examine the efficiency and equitability of Medicaid expansion in reducing CVD outcomes.
Methods: A Monte Carlo Markov-chain microsimulation model was developed to examine lifetime changes in CVD outcomes and disparities as a result of expansion and the associated cost and quality-of-life impacts.
Findings: Medicaid expansion was associated with a reduction of 11 myocardial infarctions, eight strokes, and four CVD deaths per 100,000 person-years compared with no expansion. The largest reductions occurred for those with lower income and education, and those of Black and Hispanic race/ethnicity. We found that the benefits of expansion generally balanced out the costs while redistributing health from higher to lower income groups. In probabilistic sensitivity analysis, we found—using a health opportunity cost threshold of $150,000—that Medicaid expansion was cost-effective in reducing CVD outcomes 53% of the time and both cost-effective (efficient) and equity enhancing 26% to 29% of the time.
Conclusions: Medicaid expansion resulted in a reduction in CVD incidence, suggesting that it was both cost-effective and equity enhancing in reducing CVD outcomes but with a high degree of uncertainty.