A 28 year-old single man with type I diabetes mellitus presents to your busy Texas emergency department in diabetic ketoacidosis (DKA). This is his third hospitalization for DKA in 5 months. When you ask the patient about his current medication regimen, he admits that he frequently skips doses as a cost-savings measure. He shares that he works 45 hours a week at a small local grocery store, makes minimum wage ($15,660 pretax), and has no health insurance. His prescribed insulin regimen, consisting of Lantus at bedtime and Humalog with meals, costs approximately $600 a month. This cost estimate is based on 25 units of nightly Lantus and 25 total units of Humalog daily from GoodRx advertised list prices for the San Antonio area.

Question 1: If this patient is making only $15,660 a year, why does he not qualify for Medicaid?

The original intent of Medicaid was to provide healthcare to impoverished Americans who met certain eligibility criteria. Specifically, it applies to:

• Families with children
• Pregnant women
• Those with certain disabilities
• Elderly (≥65 years old)
• Nursing home residents whose income is below a state-defined threshold

What about childless adults?

Childless adults, such as this patient, have historically NOT been eligible, no matter how poor.¹ Exceptions have not been made for single adults suffering from severe acute or chronic illness such as type 1 diabetes, cancer, or trauma. Because Medicaid is operated at the state level with support of the federal government, there is great variation among Medicaid programs in terms of income eligibility requirements, coverage, and offered benefits.

With the passing of the Affordable Care Act (ACA) in 2012, States were permitted to expand Medicaid to provide healthcare coverage to childless adults. As of February 2019, 37 states adopted Medicaid expansion, including Utah, Nebraska, and Idaho where Medicaid expansion legislation was passed in November 2018. However 14 states, including Texas where this patient resides, have not adopted this policy (orange shaded states in Figure 1).

Question 2: If he is working full time, why does he not receive insurance through his employer?

Employer Sponsored Insurance and the Market Places

Under the ACA, companies with greater than 50 employees are now required to offer health benefits.⁴ This program is expensive for employers. To cover a single employee who needs family health coverage, the employer contributes on average about $14,000 a year.⁵ Unfortunately, your patient is employed in a 10-person company, and the employer does not offer employer sponsored insurance.

Those working for smaller companies who do not provide insurance and wish to obtain health care coverage can purchase health insurance via the ACA marketplaces or “short term health plans.” Your patient unfortunately did not enroll in either option.

• Insurance plans offered on the ACA marketplaces are required to cover the “10 essential health benefits” including inpatient admissions, maternity care, outpatient services, prescription drugs, and mental health.⁶ They also must cover pre-existing conditions. For various reasons such as the repeal of the individual mandate and implementation of short term insurance plans, premiums for these plans have, on average, been rising.⁷
• Short term insurance plans may be less expensive than ACA marketplace plans but cover much fewer services. For example, there are currently no short term health plans that cover maternity care and only 25% that cover prescription drugs.⁸ Generally, they do not cover pre-existing conditions.⁹

Question 3: What are the average out of pocket expenses for patients with type 1 diabetes?

This will depend on many factors, including a patient’s:

• Health insurance (or lack thereof)
• Geographic location
• Health status
• Co-morbidities

Listed below are the charges for some common medications and services likely to be incurred by patients with type 1 diabetes WITHOUT insurance coverage.

Summary

• Develop a better understanding of the barriers to care for our patients face in order to deliver effective, comprehensive care.
• Be a patient advocate and familiarize yourself with the health coverage landscape facing our patients.