Needs Likely to Be Great When Uninsured Get Medicaid

By Nancy Walsh, Staff Writer, MedPage Today

Published: June 23, 2013

Reviewed by Robert Jasmer, MD; Associate Clinical Professor of Medicine, University of California, San Francisco

Action Points

·         Many currently uninsured adults will soon be eligible for Medicaid under the Affordable Care Act, some of whom will likely need care promptly to deal with undiagnosed and uncontrolled conditions.

·         Note that fewer uninsured adults had high blood pressure, high cholesterol, or diabetes compared with those receiving Medicaid but among uninsured adults who did have one of those conditions, at least one of the diseases was uncontrolled in 80.1%.

Many currently uninsured adults will soon be eligible for Medicaid under the Affordable Care Act, and while these individuals tend to be healthier overall than patients already enrolled in Medicaid, they will likely need care promptly to deal with undiagnosed and uncontrolled conditions, a national study suggested.

Fewer uninsured adults had high blood pressure, high cholesterol, or diabetes compared with those receiving Medicaid (30.1% versus 38.6%, P=0.02) according to Sandra L. Decker, PhD, of the CDC's National Center for Health Statistics in Hyattsville, Md., and colleagues.

But among uninsured adults who did have one of those conditions, at least one of the diseases was uncontrolled in 80.1% compared with 63.4% of Medicaid recipients who had uncontrolled conditions, the researchers reported online in the Journal of the American Medical Association.

Various predictions about the effects of Medicaid expansion have ranged from the possibility that most new participants will be healthy adults to the likelihood that many will have numerous untreated chronic conditions.

To provide estimates of the actual effects and needs, Decker and colleagues analyzed data from the National Health and Nutrition Examination Survey of 2007-2010, focusing on low income adults ages 19 through 64.

To be included in the analysis, individuals had to have income below 138% of the poverty level and be U.S. citizens.

Factors considered in the analysis included demographic characteristics, risk behaviors such as smoking and drug use, obesity, general health, and functional limitations.

Rates of hypertension, dyslipidemia, and diabetes also were considered, as was healthcare utilization in the previous year and use of an emergency department.

The uninsured sample included 1,042 participants and the 471 were on Medicaid.

Those numbers corresponded to national estimates of 14.7 million and 5.9 million, respectively.

The uninsured were more often white, male, and had graduated from college.

They also tended to report better health in general and to have no functional limitations. The number with multiple comorbidities was 15 percentage points lower than among the Medicaid patients (P<0.001).

A third of the uninsured had not seen a healthcare professional within the previous year, compared with fewer than 10% of Medicaid patients.

A total of 46.1% of the uninsured had no usual source for healthcare, compared with only 11% of Medicaid patients (P<0.001), and twice as many of those without insurance relied on the emergency department for care (10.9% versus 5.2%, P=0.01).

Almost one-third of uninsured hypertensive adults hadn't had the condition diagnosed (30.5%), compared with 17.6% of those with Medicaid (P=0.02).

And in a full two-thirds of hypertensive adults (67.4%) without insurance, the disease wasn't controlled, compared with 40.1% of patients with hypertension receiving Medicaid.

Similarly, 78% of uninsured adults with high cholesterol were not controlled, compared with 52.5% (P=0.002) of Medicaid recipients.

"We found that approximately one-quarter of uninsured adults (or a weighted estimate of approximately 3.5 million) who may be eligible for Medicaid had at least one of the three [chronic] conditions. This can have significant health implications for these uninsured individuals, because uncontrolled diabetes, hypertension, and hypercholesterolemia have been associated with significantly increased risk of premature mortality," the researchers noted.

And while many of the uninsured individuals included in this analysis self-reported good health and limited risks, one-third were obese, half were smokers, and one-quarter indicated that their health was no better than fair or poor -- "all factors that could require attention from clinicians," they added.

The need for healthcare among the currently uninsured is likely to be "substantial" in states that expand their Medicaid eligibility requirements, the researchers concluded.

Limitations included the possibility that there may have been unmeasured factors, such as differences in healthcare seeking, in uninsured and Medicaid patients, and the self-report of risk behaviors such as alcohol and drug use.

The authors reported no conflicts of interest.

Primary source: Journal of the American Medical Association
Source reference:
Decker S, et al "Health status, risk factors, and medical conditions among persons enrolled in Medicaid vs uninsured low-income adults potentially eligible for Medicaid under the Affordable Care Act" JAMA 2013; DOI: 10.1001/jama.2013.7106.

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