Medicaid eligibles for 2014 healthier than expected

Washington Patients who might be gaining Medicaid coverage starting in 2014 on the whole will be healthier than the program beneficiaries physicians previously have treated, but in numerous cases these new patients will need immediate attention for chronic illnesses that have gotten out of control.

A study in the June 26 issue of The Journal of the American Medical Association compared a national sample of more than 1,000 uninsured nonelderly adults with 471 adults enrolled in Medicaid. Their goals were to determine what the health conditions and risk factors might be for individuals that potentially are eligible for Medicaid under the Affordable Care Act.

The uninsured sample population in the study corresponded to a weighted estimate of the 14.7 million adults who might qualify for the program and whose incomes didn't exceed 138% of poverty. This is the adjusted threshold states were given to expand their programs under the ACA. The Medicaid-enrolled group represented an estimated 5.9 million people already in the program.

According to the article, authored by Sandra L. Decker, PhD, an economist at the National Center for Health Statistics and co-authored by several other researchers, expansion means shifting Medicaid's focus to new populations, such as parents and childless adults whose incomes currently are too high to qualify for the program. “This is likely to affect the type of Medicaid patients seen by physicians in states choosing to expand Medicaid,” the article stated. The study's uninsured sample also included individuals who currently are eligible but have never signed up for the program.

Decker presented the results of the study at the AcademyHealth annual research meeting in Baltimore on June 23.

The study observed that uninsured individuals eligible for Medicaid on the whole had fewer functional limitations, were more active and were less likely to be obese than Medicaid participants. They also reported fewer chronic problems such as hypertension and diabetes than their enrolled counterparts. While similarities existed between the two groups in terms of marital status, age and birthplace, the researchers found that the uninsured were more likely to be male, non-Hispanic whites who were college graduates.

Several factors could explain the healthier status for this group of uninsured, said Genevieve Kenney, PhD, a senior fellow at the Urban Institute and a co-author of the report. In its current form, Medicaid explicitly targets the disabled and the lowest-income adults. “In addition, we know from prior research that among those who are currently eligible, take-up of Medicaid tends to be higher among those in worse health,” Kenney said.

Women also are more likely to access the health care system as primary caretakers of children, so it's not surprising to see a higher proportion of men in the Medicaid-eligible uninsured population, said Melinda Dutton, a partner at Manatt Health Solutions, a law and consulting firm working with states, health professionals and others on health system reform implementation.

Some of these uninsured are not yet eligible for Medicaid, and others haven't sought coverage previously because of the absence of pressing health care needs. These people are saying to themselves: “I'm a low-income person, I have a lot of other competing demands in my life, and I'm not necessarily thinking about going after that Medicaid coverage,” Dutton said.

Health risks of the uninsured

Binge drinking was more prevalent among the uninsured who are eligible for Medicaid in 2014. Also, those with chronic diseases did not always manage them appropriately.

The study found that 80% of the uninsured individuals studied who had diabetes, hypertension or hypercholesterolemia had at least one uncontrolled chronic condition. The uninsured group was less likely than the enrolled Medicaid patients to have a steady source of care. More than a third hadn't seen a doctor or other type of health care practitioner in the past year, in comparison to just 8% of the individuals on Medicaid fitting into that category.

What physicians might see in 2014 is a slightly healthier group of new Medicaid patients, Dutton said. “But when they first come through the door … there's going to be some identifying of populations who hadn't been getting health care before” and discovering they have chronic problems that need immediate treatment, she said.

Many of these patients could be unaware that they have health issues, said Reid B. Blackwelder, MD, president-elect of the American Academy of Family Physicians. At least a third of diabetics don't know they're afflicted, because they're not experiencing significant health issues. Another example is hypertension, which often doesn't show its devastating effects until the person has a stroke or a heart attack, he said.

The key is to catch these diseases in the early stages before they do permanent damage, Dr. Blackwelder said. But “there are a number of folks who don't know how sick they are,” and many of them don't seek care until they're very sick or have developed complications that force them into emergency departments or hospitals, he said.

Even those on Medicaid can end up in the ED because of the access problems and low payments associated with the program. “You have patients on Medicaid who can't find a physician,” Dr. Blackwelder said.

In discussing the results, the study's authors noted the limitations in their research. “Although we have compared the health status and risk factors of uninsured adults who could be eligible for Medicaid with current enrollees for the nation as a whole, the health care needs of adults who will be eligible for Medicaid will depend on which states expand eligibility, what those states' previous eligibility limits were and the specific health profiles of those areas,” the study stated.