Insurance Expansion Means Boom in Chronic Illness Diagnoses

Marcia Frellick

September 09, 2015

Insured people are significantly more likely — by 14 percentage points — than similar uninsured people to be diagnosed with diabetes and high cholesterol, a new study indicates. The probability of being diagnosed with high blood pressure was 9 points higher among the insured.

Daniel R. Hogan, a technical officer at the World Health Organization in Geneva, Switzerland, and coauthors found that among those already diagnosed, having insurance was linked with significantly healthier levels of blood sugar, total cholesterol, and systolic blood pressure. The results were published in the September issue of Health Affairs.

Given these results, expansion of insurance coverage from the Affordable Care Act (ACA) could mean 1.5 million more people diagnosed with at least one of these diseases and 659,000 fewer individuals with uncontrolled cases.

That has clear implications for policy makers, the authors say.

"These people will need regular access to health care providers, and policy makers need to rethink their strategy for ensuring that newly insured patients can get the care they need," they write. "For example, this may require relaxing scope-of-practice rules in some places, to allow nurse practitioners and others to care more independently for these patients."

"Era of Teamwork"

Wayne Riley, MD, MPH, president of the American College of Physicians, said the college agrees with the authors.

"As a primary care physician, this validates anecdotally what many of us have felt along, that there's a lot of undiagnosed, untreated chronic disease among the uninsured," he told Medscape Medical News.

"The good news out of this is that we're going to catch these chronic diseases before they get out of hand, and as a primary care physician, that's music to my ears."

He said he also agrees with the need for providers other than physicians to help treat the new numbers of patients.

"The era of teamwork is here, and we have embraced models that include nurse physicians, physician extenders, etc, because they play a critical role in making sure we get to these patients with their new insurance and get them to a primary care physician or primary care provider," Dr Riley said.

Regarding the economics of the additional patients, he said models need to look at the costs over time, not just the initial costs of finding the patients and getting their diseases under control.

If 1.5 million more are diagnosed with these chronic diseases, he asked, "what is the putative cost if 25% of them don't have a heart attack?"

If diabetes is diagnosed early, Dr Riley points out, that may forestall retinopathy, amputations, and heart attack or stroke. Those cost savings need to be studied longitudinally in addition to this study, which uses survey data.

Hundreds of Thousands

Authors analyzed 1999 to 2012 data for 28,157 respondents to the National Health and Nutrition Examination Survey to evaluate relationships between health insurance and the diagnosis of three of the most common chronic conditions.

If the number of nonelderly Americans without insurance were cut by half, which is projected by the Congressional Budget Office as a result of the ACA, the authors estimate there would be 313,000 (95% confidence interval [CI], 108,000 - 545,000) fewer cases of undiagnosed diabetes, 811,000 (95% CI, 565,000 - 1,078,000) fewer cases of undiagnosed hypercholesterolemia, and 485,000 (95% CI, 302,000 - 681,000) fewer cases of undiagnosed hypertension.

This would occur among 1.5 million people, some of whom might have more than one condition, the study concludes. This would bump up the number of diagnoses for these three conditions by a total of about 20%.

The authors also estimate that there would be 162,000 (95% CI, −21,000 to 374,000) fewer cases of uncontrolled diabetes, 241,000 (95% CI, 25,000 - 475,000) fewer cases of uncontrolled high cholesterol, and 271,000 (95% CI, 82,000 - 476,000) fewer cases of uncontrolled hypertension among the 659,000 patients already diagnosed.

This work was supported by the National Institute of Diabetes and Digestive and Kidney Diseases. The authors have disclosed no relevant financial relationships. Dr Riley is a director of Hospital Corporation of America and a member of the National Academy of Medicine.

Health Aff. 2015;34:1554-1562. Abstract

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