How strongly does coverage affect access?

With the expansion of Medicaid under the Affordable Care Act extending coverage to citizens with income less than 138% of the federal poverty level (FPL), it was hoped that the newly insured would have greater access to healthcare, thereby improving health outcomes. show that this is not necessarily the case. This study presents a mixed picture.

The authors of this study investigated whether patients with chronic conditions (diabetes, high blood pressure, high cholesterol, and obesity) had better outcomes when compared to uninsured patients for non-elderly adults below the federal poverty level.

At baseline, a higher percentage of Medicaid patients had a chronic medical condition compared to the uninsured (55.7% vs. 33.2%). Of the uninsured, 38.4% had not been seen in the outpatient setting the previous year, compared with only 8.2% of those with Medicaid. When parsing out those with chronic disease, 19.6% of the uninsured had not seen a provider, compared to only 4.5% of those with Medicaid. The data suggest that Medicaid patients are 5 times as likely to have had an annual outpatient visit compared to the uninsured.

There was no significant difference in control of diabetes or cholesterol levels between the uninsured and those with Medicaid, but Medicaid patients had 1.83 greater odds of previously being diagnosed with hypertension and 1.69 greater odds of having their blood pressure controlled. Overweight individuals with Medicaid also had greater odds of previous diagnosis.

than the uninsured and thereby likely have increased ‘opportunity’ to receive a diagnosis of a chronic medical condition. It must be remembered that those who are ill may also be more likely to seek out Medicaid coverage. Additionally, while differences in control of hypertension were found, it is interesting that similar decreases were not seen in the control of other chronic conditions.

Chronic disease management is multidimensional and factors related to genetics, diet, exercise, and environment all play a role.  Prescription medication and counseling from healthcare providers are just two of many factors.  Increasing access to care is no doubt important, but we must also focus on improving health education and the social determinants of health if we are to make sustainable gains in the battle over chronic disease.

commentary by Vidya Eswaran

Abstract

Objectives. We sought to determine the association between Medicaid coverage and the receipt of appropriate clinical care.

Methods. Using the 1999 to 2012 National Health and Nutritional Examination Surveys, we identified adults aged 18 to 64 years with incomes below the federal poverty level, and compared outpatient visit frequency, awareness, and control of chronic diseases between the uninsured (n=2975) and those who had Medicaid (n=1485).

Results. Respondents with Medicaid were more likely than the uninsured to have at least 1 outpatient physician visit annually, after we controlled for patient characteristics (odds ratio [OR]=5.0; 95% confidence interval [CI]=3.8, 6.6). Among poor persons with evidence of hypertension, Medicaid coverage was associated with greater awareness (OR=1.83; 95% CI=1.26, 2.66) and control (OR = 1.69; 95% CI = 1.32, 2.27) of their condition. Medicaid coverage was also associated with awareness of being overweight (OR = 1.30; 95% CI = 1.02, 1.67), but not with awareness or control of diabetes or hypercholesterolemia.

Conclusions. Among poor adults nationally, Medicaid coverage appears to facilitate outpatient physician care and to improve blood pressure control.

PMID: 26562119

Christopher, AS, et al. Am J Public Health. 2015; 12: e1-e7.