Multiple chronic conditions and Medicaid expansions

In MMWR, Brian Ward and Lindsey Black of the National Center for Health Statistics report that 25.7% of US adults have been diagnosed with multiple chronic conditions (MCC). In their analysis of data from the 2014 National Health Interview Survey, they examined rates of diagnoses of arthritis, asthma, cancer, COPD, coronary heart disease, diabetes, hepatitis, hypertension, stroke, or weak/failing kidneys.

It's not surprising that MCC prevalence varied by age; just 7.3% of those aged 18-44 had multiple chronic conditions, compared to 32.1% of those aged 45-64 and 61.6% of those aged 65 and up. Those of us already familiar with geographic differences in health also won't be surprised to see that MCC prevalence varies substantially between states and regions. Ward and Black note that 10 states had MCC prevalence estimates above the national average: Kentucky, Alabama, West Virginia, Mississippi, Montana, New Mexico, Maine, Michigan, Ohio, and Pennsylvania (those are listed in descending order -- i.e., Kentucky has the greatest share of adults with MCC diagnoses).

At the regional level, the East South Central region (Alabama, Kentucky, Mississippi, Tennessee) has by far the greatest MCC prevalence: 34.5%. That's substantially higher than the second-highest prevalence of 28.4%, which is in East North Central (Illinois, Indiana, Michigan, Ohio, Wisconsin). Ward and Black write:

... a number of states with higher observed MCC prevalence estimates overlap geographically with states with high stroke mortality rates (the so-called “stroke belt,” which includes all of Mississippi and parts of Alabama, Arkansas, Florida, Georgia, Kentucky, Louisiana, North Carolina, Ohio, Pennsylvania, South Carolina, Tennessee, Texas, Virginia, and West Virginia), and the “diabetes belt” (which also includes all of Mississippi and parts of Alabama, Arkansas, Florida, Georgia, Kentucky, Louisiana, North Carolina, Ohio, Pennsylvania, South Carolina, Tennessee, Texas, Virginia, and West Virginia), where past research has noted high diabetes prevalence estimates.

The authors note that they're presenting crude estimates that don't account for different age distributions. This is probably why the MCC prevalence estimate for women is so much higher than that for men (27.2% vs 21.4%). Women make up 56% of the 65+ population (my calculation using 2012 Census Bureau statistics), the age group most likely to have been diagnoses with multiple chronic conditions. Ward and Black explain that reporting the crude rates "might be useful in targeting service delivery and projecting resources."

Chronic conditions and Medicaid expansions

Although insurance coverage doesn't automatically translate to services and resources to care for adults with multiple chronic conditions, it's worth noting that three of the states with above-average MCC prevalence estimates -- Alabama, Maine, and Mississippi -- haven't accepted the ACA's Medicaid expansion. (If you want to know more about the Medicaid expansion, check out the posts listed below.) In these states, thousands of adults fall into the "coverage gap," with household incomes too high to qualify them for traditional Medicaid and too low to qualify for subsidized marketplace insurance. In a recent Kaiser Family Foundation analysis, Rachel Garfield and Anthony Damico calculated that Alabama has 139,000 uninsured nonelderly adults in the coverage gap, while Maine and Mississippi have 28,000 and 108,000, respectively. It's likely that many of these adults have multiple chronic conditions, and the lack of insurance isn't helping them access care that could help them mange these diseases.

As for the state with the highest MCC prevalence, Kentucky's previous governor, Steve Beshear, accepted the Medicaid expansion. As M. Gabriela Alcalde points out at the Health Affairs Blog, a recent increase in chronic disease prevalence in that state might actually be due to more people gaining access to healthcare -- i.e., it's not that more people suddenly have diabetes or COPD, it's that more people are able to see providers who can diagnose these diseases.

Kentucky's new governor, Matt Bevin, has proposed dramatically altering the state's Medicaid program, by requiring low-income, non-disabled adults to pay premiums and work in order to qualify for coverage, and making vision and dental benefits contingent on health activities or volunteer work. But, Kaiser Health News's Phil Galewitz reports, that may not fly:

Bevin’s alternative hinges on approval from the Centers for Medicare & Medicaid Services. By Aug. 1, the governor is expected to apply to CMS for a waiver from Medicaid’s rules — challenging the administration’s policy against linking Medicaid coverage to a work requirement.

Stakes are high. Bevin has threatened to undo Kentucky’s Medicaid expansion altogether if CMS rejects his plan.

Kentucky Voices for Health, a coalition of more than 200 consumer advocacy groups, healthcare organizations, and individuals, opposes Governor Bevin's proposal:

Governor Bevin's proposed Medicaid waiver puts Kentucky's successful Medicaid expansion and the coverage of nearly HALF A MILLION Kentuckians at risk. It will mean less coverage and more barriers for the most vulnerable Kentuckians, including veterans, people with disabilities, formally resettled refugees fleeing persecution, low-income workers and families. This plan threatens to undermine the health and economic gains we have made in the past two years as a result of Medicaid expansion. It would be a giant step backward for Kentucky.  ... [The proposed plan] will:

• Eliminate coverage for an estimated 86,000 eligible Kentuckians and potentially many more who will be unable to meet the new requirements or understand complex system changes.

• Penalize hard-working, low-income Kentuckians and their families.

• Put more burden on our most vulnerable citizens.

• Create significant financial and administrative barriers to care.

• Reduce access to medically necessary services.

• Expand bureaucracy with increased administrative cost and red tape.

States with high prevalence estimates for multiple chronic conditions should be especially interested in assuring their residents have access to high-quality healthcare. I hope we don't see Kentucky take a step backwards.

Some of our past posts on the Medicaid expansion

Supreme Court decision is great for public health – but fate of 16 million poorest uninsured is still unclear (June 2012)
What happens to the poorest residents in states declining the Medicaid expansion? (April 2013)
Medicaid opt-out resulting in enormous losses for community health centers (May 2014)
ACA predicted to have positive impact on insurance disparities; Medicaid expansion key to widening access for black Americans (December 2014)
Report: Expanding Medicaid programs a win for both residents and state budgets (March 2016)