By Pauline
Bartolone August 6, 2018
Low-income
people with diabetes are better able to afford their medications and manage
their disease in states that expanded Medicaid under the Affordable Care Act, a
new study suggests.
The Health Affairs study,
released Monday afternoon, found a roughly 40 percent increase in the number of
prescriptions filled for diabetes drugs in Medicaid programs of the 30 states
(including Washington, D.C.) that expanded eligibility in 2014 and 2015,
compared with prior years.
By
contrast, states that didn’t embrace the Medicaid expansion saw no notable
increase.
“Gaining
Medicaid insurance would have significantly reduced out-of-pocket spending for
insulin for previously uninsured patients, thereby facilitating uptake of the
medication,” the Health Affairs study said.
Diabetes,
characterized by abnormally high blood sugar, is a chronic disease that
requires expensive and ongoing medical care. More than 114 million adults in
the U.S. have diabetes or prediabetes, making the disease one of the country’s
most formidable health challenges.
“In the
long run, preventing diabetic complications not only saves lives, but it
improves public health and saves public money,” said Dr. Michael Bush, an
endocrinologist in Beverly Hills, Calif., and president of the California
chapter of the American Association of Clinical Endocrinologists.
Bush
and other experts said the Health Affairs study shows that the Medicaid
expansion can help patients manage their health and also limit unnecessary
spending. An analysis by the Centers for Disease Control and Prevention cited
by the study shows that each diabetic patient who is treated for the condition
can lead to a $6,394 reduction in health care costs (in 2017 dollars) because
of fewer hospital admissions.
In
California, roughly 3.9 million people gained coverage when the state expanded
eligibility for Medi-Cal, the state’s version of the federal Medicaid program.
In all, about 13.5 million people — more than one-third of Californians — are
enrolled in Medi-Cal.
By
2016, about 12 million people
had enrolled in Medicaid nationwide as a result of the expansion, according to
the Kaiser Family Foundation. The foundation estimates that more than 2 million people who
live in non-participating states would have qualified for Medicaid had their
states chosen to expand. (Kaiser Health News, which produces California
Healthline, is an editorially independent program of the foundation.)
“It’s
not particularly surprising that extending Medicaid opened up this door for
lots of other people to be able to fill prescriptions and be able to take
advantage of managing a chronic disease like diabetes,” said Flojaune Cofer,
director of state policy and research at Public Health Advocates, a nonprofit
organization based in Davis, Calif., that seeks to eliminate health
inequalities in California.
But
Michael Cannon, director of health policy studies at the libertarian Cato
Institute, said the Medicaid expansion may not mean good news for everyone.
Medicaid
pays a fraction of a drug’s list price, which leads pharmaceutical
companies to hike prices for everyone,
he said. That, in turn, could drive up everyone’s premium costs or lead those
with private insurance to pay more out-of-pocket.
“You
have to look at not just the immediate effects of a policy, but all of the
effects of a policy,” Cannon said. “As prices rise, fewer people will be able
to afford diabetic medications.”
Last
year, nearly 900,000 Californians with Medi-Cal were known to have diabetes,
according to state figures.
One of
them is James Warden, 62, a retired rancher near Fresno, Calif., who said he
was forced to stop working because of a back injury several years ago.
Warden
enrolled in Medi-Cal in 2016 and was diagnosed with diabetes last year after a
urinary condition landed him in the hospital, he said. Without the coverage, he
said, he wouldn’t have the insulin his body needs.
“Medi-Cal
saved me,” he said. “I wouldn’t have the money to be able to pay, or go to the
doctor or anything.”
The
researchers found that people in groups with a higher prevalence of diabetes
before the ACA became law, such as those ages 55–59, showed larger increases in
filling their diabetes prescriptions after the Medicaid expansions.
The
price of insulin, a staple medication for many diabetes patients, rose almost
200 percent from 2002 to 2013, according to the study.
And
nearly 40 percent of insulin users who responded to the American Diabetes
Association’s 2018 insulin affordability survey reported
that they had faced a price increase in the past year. As a result of the price
hikes, many said, they took less of the medication, missed doses or switched to
a cheaper drug.
In
states that didn’t expand Medicaid after 2014, such as Texas and Florida, the
number of diabetes prescriptions filled remained relatively flat, the study
found. In these states, low-income and uninsured diabetics must rely on a
“patchwork of options” to get insulin and other medications to treat their
disease, according to the American Diabetes Association. Patients may need to
seek help through drug company patient assistance programs or charities, the
group said.
The
study also showed a surge in filled prescriptions for newer, pricier diabetes
drugs that have fewer side effects and control diabetes more effectively. And
there was an increase in prescriptions for metformin, a generic drug that is
often used as a first line of treatment for new Type 2 diabetes patients.
The
rise in metformin prescriptions suggests the federal health law also led to
more people being diagnosed with the disease, the authors said.
The
study, conducted by University of Southern California pharmaceutical and health
economists, was based on an analysis of filled prescriptions before and after
the state Medicaid expansions began in 2014. The number of states that expanded
Medicaid has since grown to 33 states and Washington, D.C.
The
prescriptions analyzed cover the period from 2008 to 2015. About 15 percent of
retail pharmacies did not share their information, and the data did not include
prescriptions filled by health clinics or via mail-order, which could have led
to underestimates of the total effect, the authors said.
Bush,
the Beverly Hills endocrinologist, acknowledged that providing diabetes drugs
to Medicaid patients is costly to taxpayers. But he said it’s money well spent.
“This
is clearly a disease where if you take care of it now, you can prevent complications
that occur later,” he said.
[Clarification:
This story was updated at 2 p.m. PT on Aug. 8 to clarify Michael Cannon’s views
on the behavior of pharmaceutical companies in the Medicaid market.]
Pauline
Bartolone: pbartolone@kff.org,
@pbartolone
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