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).
Did you know?
Overall, Texas has the highest percentage of uninsured people in the U.S.2 Approximately 21% of Texans, including 835,000 children, are uninsured.3
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
Listed below are the charges for some common medications and services likely to be incurred by patients with type 1 diabetes WITHOUT insurance coverage.
|Medication and Equipment||Cost to Patient Without Insurance|
|Insulin pump + syringes/batteries||$4,500-$6,500 10 + $1,500|
|Test strips||$0.30-1.00/each 11|
|Lantus (insulin glargine)||$430/month 12|
|Humalog (insulin lispro)||$530/month 12|
|Basaglar (“biosimilar” form of glargine)||$330/month 12|
|Hospital and Outpatient Charges and Fees||Amount|
|DKA with mean hospital stay (in 2014)||$26,566 13|
|Emergency Department critical care charge||$3,648 14|
|Intensive Care Unit room and bed||$1,977 15|
|Comprehensive metabolic panel + venipuncture||$82 16|
|Hepatic function panel||$201 14|
|Lactated Ringer’s solution||$100 16|
- 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.
1.Medicaid: A Primer. Kaiser Family Foundation. https://kaiserfamilyfoundation.files.wordpress.com/2010/06/7334-05.pdf. Published 2013. Accessed March 18, 2019.
2.KFF/EHF Poll: Texans’ Top State Health Priorities Include Lowering Out-of-Pocket Costs and Reducing Maternal Mortality. The Henry J. Kaiser Family Foundation. https://www.kff.org/health-reform/press-release/poll-texans-health-priorities-costs-maternal-mortality-medicaid/. Published June 14, 2018. Accessed March 7, 2019.
3.Alker J, Pham O. Nation’s Progress on Children’s Health Coverage Reverses Course. Center For Children and Families. https://ccf.georgetown.edu/2018/11/21/nations-progress-on-childrens-health-coverage-reverses-course/. Published November 21, 2018. Accessed March 7, 2019.
4.How the Affordable Care Act affects small businesses. Healthcare.gov. https://www.healthcare.gov/small-businesses/learn-more/how-aca-affects-businesses/. Accessed March 18, 2019.
5.2018 Employer Health Benefits Survey. The Henry J. Kaiser Family Foundation. https://www.kff.org/health-costs/report/2018-employer-health-benefits-survey/. Published October 3, 2018. Accessed March 7, 2019.
6.Essential Health Benefits. Healthcare.gov . https://www.healthcare.gov/glossary/essential-health-benefits/. Accessed March 7, 2019.
7.2019 Premiums for ACA Silver Plans Will Be 16 Percent Higher Than They Would Have Been Absent the Repeal of the Individual Mandate, Expansion of Short-Term Plans and Loss of Federal Cost-Sharing Payments, Analysis Finds. The Henry J. Kaiser Family Foundation. https://www.kff.org/health-reform/press-release/2019-premiums-for-aca-silver-plans-will-be-16-percent-higher-than-they-would-have-been-absent-the-repeal-of-the-individual-mandate-expansion-of-short-term-plans-and-loss-of-federal-cost-sharing-payme/. Published October 26, 2018. Accessed March 7, 2019.
8.Pollitz K, Long M, Semanskee A, Kamal R. Understanding Short-Term Limited Duration Health Insurance. The Henry J. Kaiser Family Foundation. https://www.kff.org/health-reform/issue-brief/understanding-short-term-limited-duration-health-insurance/). Published April 23, 2018. Accessed March 7, 2019.
9.Levitt L, Fehr R, Claxton G, Cox C, Pollitz K. Why Do Short-Term Health Insurance Plans Have Lower Premiums Than Plans That Comply with the ACA? The Henry J. Kaiser Family Foundation. https://www.kff.org/health-reform/issue-brief/why-do-short-term-health-insurance-plans-have-lower-premiums-than-plans-that-comply-with-the-aca/. Published October 31, 2018. Accessed March 18, 2019.
10.How Much Does an Insulin Pump Cost? CostHelper. https://health.costhelper.com/insulin-pump.html. Accessed March 7, 2019.
11.How Much Does a Glucose Meter Cost? CostHelper. https://health.costhelper.com/glucose-meter.html. Accessed March 18, 2019.
12.Insulins. GoodRx . https://www.goodrx.com/insulins. Accessed March 7, 2019.
13.Desai D, Mehta D, Mathias P, Menon G, Schubart UK. Health Care Utilization and Burden of Diabetic Ketoacidosis in the U.S. Over the Past Decade: A Nationwide Analysis. Dia Care. May 2018:1631-1638. doi:10.2337/dc17-1379
14.Patient Pricing Information & Billing Policies | UH Cleveland Medical Center | University Hospitals. University Hospitals. https://www.uhhospitals.org/locations/uh-cleveland-medical-center/patients-and-visitors/billing-insurance-and-medical-records/patient-pricing-information. Accessed March 7, 2019.
15.Hospital Charge Description Master. MedStar Franklin Square Medical Center. https://www.medstarfranklinsquare.org/for-patients/patients-and-visitors/billing-and-insurance/hospital-charge-description-master/. Accessed March 18, 2019.
16.Billing Information. University Medical Center New Orleans. https://www.umcno.org/patients-visitors/i-m-a-patient/billing/. Accessed March 7, 2019.