Health Status of Uninsured Adults with Potential Medicaid Eligibility under ACA

In states that choose to expand Medicaid under provisions in the Patient Protection and Affordable Care Act (ACA), the program’s focus will shift from low-income pregnant women and children, very–low-income parents, and severely disabled to new population groups. These new groups will include childless adults and parents whose incomes are too high to qualify for Medicaid under current state eligibility criteria.

The change will affect the type of Medicaid patients seen by physicians in states that implement Medicaid expansion. Predictions about the new enrollees vary from the likelihood that they will be primarily nondisabled healthy adults to the assumption that they will have high levels of disability and multiple comorbidities.

The predictions are based on either self-reported data on health status and medical problems or on Medicaid claims data for adults covered under current, more narrow state Medicaid expansions.

To document the healthcare needs and health of currently uninsured adults who could become eligible for Medicaid under the ACA, researchers recently examined data from self-reports, physical examinations, and laboratory tests from a nationally representative sample of low-income uninsured adults. The prevalence of diseases found in the low-income population was compared with that found in adults with current Medicaid coverage. Results of the analysis were reported online in JAMA [doi:10.1001/jama.2013.7106].

The researchers analyzed data from the National Health and Nutrition Examination Survey, 2007-2010, to assess health conditions among 1042 uninsured adults 19 through 64 years of age with income ≤138% of the federal poverty level, compared with 471 low-income adult Medicaid beneficiaries.

The primary outcomes and measures were prevalence and control of diabetes, hypertension, and hypercholesterolemia based on examinations and laboratory tests, measures of self-reported health status including 9 specific medical conditions, and risk factors such as measured obesity status.

Compared with the Medicaid cohort, the uninsured adults were similar in age, birthplace, and marital status, but were more likely to be non-Hispanic white, male, and have a college degree and less likely to be non-Hispanic black. The uninsured adults were also in better health compared with the Medicaid enrollees and had lower levels of some risk factors. They were less likely to be obese and sedentary than the Medicaid cohort, but more likely to engage in binge drinking behavior.

In addition, the uninsured adults reported better health and fewer functional limitations. With the exception of depression, they were less likely to have any of the 9 specific medical conditions.

They were also much less likely (by 15.1 percentage points; 95% confidence interval [CI], 9.2%-20.9%; P<.001) to have multiple health conditions. For example, 30.1% of uninsured adults had hypertension, hypercholesterolemia, or diabetes, compared with 38.6% of Medicaid enrollees (P=.02).

However, if uninsured adults had any of the specified conditions, they were less likely to be aware of them and to have them controlled compared with Medicaid enrollees. For example, 80.1% of uninsured adults with at least 1 of the 3 conditions had at least 1 uncontrolled condition, compared with 63.4% of adults in the Medicaid population.

In summary, the researchers said: “Compared with adults currently enrolled in Medicaid, uninsured low-income adults potentially eligible to enroll in Medicaid under the ACA had a lower prevalence of many chronic conditions. A substantial proportion of currently uninsured adults with chronic conditions did not have good disease control; projections based on sample weighting suggest this may represent 3.5 million persons (95% CI, 2.9 million-4.2 million). These adults may need initial intensive medical care following Medicaid enrollment.”