3160 The Medicaid Coverage Gap and IBD Care

Abstract

INTRODUCTION: Medicaid expansion is a key provision of the 2010 Affordable Care Act (ACA) that bolsters healthcare access for Inflammatory Bowel Disease (IBD) patients. Prior to the ACA, Medicaid was guaranteed only to specific patient populations whose income falls within certain limits of the federal poverty level (FPL). Medicaid expansion ensures eligibility for all adults aged 18-65 years with incomes up to 138% of the FPL regardless of age, family, or health status. 17 states, including Missouri, have not expanded Medicaid which has created a coverage gap for low-income adults who do not qualify for Medicaid nor the ACA's Marketplace subsidies. We present a case of a young Missourian within the Medicaid coverage gap who was unable to gain healthcare access for severe fistulizing Crohn's disease until his incarceration. CASE DESCRIPTION/METHODS: A 27-year-old man with Crohn's disease presented from a correctional facility with enterocutaneous fistulae and abdominal wall abscesses. He was uninsured with limited healthcare access and unable to afford the recommended biologic therapy. Once incarcerated, he qualified for Department of Corrections healthcare coverage and sought care. Surgery with temporary colostomy was recommended due to his advanced disease. The patient did not want to have an ostomy in prison so instead opted for treatment with infliximab, complete bowel rest, and total parenteral nutrition. His hospital course was complicated by drug-induced liver injury from infliximab which extended his admission to 107 days. The correctional facility eventually enacted a compassionate release which paradoxically terminated his healthcare coverage and jeopardized further access to care. The patient was enrolled in Missouri Medicaid due to disability and underwent surgery but not before suffering significant morbidity from preventable complications of Crohn's disease. DISCUSSION: The Medicaid coverage gap in non-expansion states limits healthcare access for non-disabled, low-income IBD patients. Our patient's case exemplifies challenges to providing healthcare to IBD patients within the Medicaid coverage gap in non-expansion states. Healthcare costs for IBD patients are more expensive than for those without IBD, increasing the importance of maximizing healthcare coverage for this patient population. Policy change in non-expansion states would improve access to healthcare coverage which may reduce hospitalizations and improve outcomes for low-income IBD patients.