5 Key Facts About Medicaid Coverage for Adults with Chronic Conditions
Note: This brief was updated on April 14, 2025 to clarify the sources of data, which include data on both self-reported and diagnosed chronic conditions.
Chronic conditions (also referred to as chronic disease or illness) have drawn increased attention in recent months, partly due to the focus on chronic conditions under HHS secretary Robert F. Kennedy’s “Make America Healthy Again,” (MAHA) initiative. Among working age adults enrolled in Medicaid, approximately three quarters have one or more chronic conditions, and nearly one-third have three or more. Medicaid coverage facilitates access to care for this population.
To achieve the federal savings required by the House budget resolution, Congress would need to cut federal Medicaid spending by hundreds of billions of dollars, leaving states with significant budget shortfalls. Federal funding cuts of that magnitude would force states to make difficult choices—such as reducing Medicaid eligibility, scaling back benefits, lowering provider reimbursement rates, raising taxes, or cutting spending on other programs such as education. Because state Medicaid programs differ considerably, their policy responses would likely vary. Amid this evolving landscape, this issue brief examines Medicaid’s coverage of adults with chronic conditions using data from the National Health Interview Survey (NHIS) and Medicaid administrative data (see Methods).
1. Three in four adults enrolled in Medicaid report one or more chronic conditions.
Chronic conditions are conditions that last at least one year and require ongoing medical care or limit daily activities (e.g. heart disease, diabetes, cancer, mental illness, etc.). Medicaid-enrolled adults (ages 19-64) report higher chronic condition rates than privately insured adults (75% vs. 66%), and nearly one-third report three or more chronic conditions (Figure 1). Higher rates among Medicaid enrollees partly reflect program eligibility criteria because states are generally required to cover people with disabilities who receive Supplemental Security Income, and all states choose to provide additional optional coverage for other adults with disabilities or high medical spending. Uninsured adults report lower chronic condition rates, which may reflect less incentive to obtain coverage because they don’t feel it’s needed or a lack of awareness of their health conditions because of limited health care access. Other KFF work shows that less than half of those without insurance had a doctor’s visit in the past year versus about 85% of insured adults.
2. Medicaid facilitates access to care for people with chronic conditions.
Nine in ten (91%) of Medicaid-enrolled adults with chronic conditions reported having a healthcare visit in the last year, which is just higher than privately insured adults (86%), and significantly higher than uninsured adults (63%) (data not shown). In addition to health care visits, many chronic conditions require routine access to prescription medications and when that access is limited, the risk of health complications, including those that are life-threatening, rises. Over three-quarters of Medicaid-enrolled adults with one or more chronic conditions filled a prescription medication in the past year, rising to 95% among those with three or more conditions (data not shown). Low or no out-of-pocket costs for prescription medications in the Medicaid program help adults with chronic conditions avoid cost-related rationing or delays in prescription access. Uninsured adults were 2.5 times more likely than Medicaid-enrolled or privately insured adults to report skipping or delaying prescription medications due to cost (28%, 11%, and 8%, respectively, Figure 2).
3. The most common chronic conditions diagnosed among adult Medicaid enrollees are physical conditions, followed by behavioral health.
The most common chronic conditions are physical, with 13.9 million adult Medicaid enrollees having a diagnosed physical health condition in 2021. High blood pressure, high cholesterol, and obesity were the most frequently diagnosed physical health conditions and can act as risk factors for other chronic conditions, such as heart disease. More than 10.1 million nonelderly Medicaid-enrolled adults have a diagnosed behavioral health condition, including mental health and substance use conditions. A separate KFF analysis shows that among those with any mental illness, approximately 2.3 million have a diagnosed serious mental illness. Cognitive impairment conditions, including dementia and intellectual and developmental disabilities (IDD), affect over 700,000 nonelderly Medicaid adults and often cause functional limitations that require long-term care (Figure 3). The number of enrollees diagnosed with behavioral, physical, or cognitive impairment conditions varies by state, but in all states, at least 1,000 Medicaid enrollees have each type of chronic condition (Appendix Table 1).
Unlike earlier exhibits, this analysis uses Medicaid claims data from 2021, the latest available to KFF. Claims data reflect only diagnoses recorded during medical visits in 2021 and do not measure overall prevalence. Prevalence rates from surveys are generally higher than claims-based estimates because not everyone is screened, treated, or has a recorded diagnosis for their chronic conditions in claims data in any given year. Additionally, during the pandemic, certain types of health care utilization declined even as Medicaid enrollment increased. While the direction of change for utilization rates is more clear (a decline), it is uncertain how these changes impacted the total number of people with recorded diagnoses in 2021 claims data. The numbers exclude Medicaid enrollees who also have Medicare (since Medicare is the primary payer for outpatient and acute care services), as well as enrollees ages 65 and older, nearly all of whom also have Medicare coverage (see Methods).
4. Rates of diagnosed physical conditions among adult Medicaid enrollees increase with age.
Unlike behavioral health and cognitive impairment conditions, rates of diagnosed physical health conditions among adult Medicaid enrollees increase with age. Seventeen percent of Medicaid enrollees ages 19 to 26 have one or more diagnosed physical health conditions in a year, rising to 32% of enrollees ages 27 to 49 and 61% of enrollees ages 50 to 64. In contrast, rates of diagnosed behavioral health conditions remain relatively stable across age groups, ranging from 20% among those ages 19 to 26 to 27% among the older age groups. Cognitive impairments are less prevalent among adults under age 65, affecting only 3% of Medicaid enrollees ages 19-26 and 1% of enrollees ages 27-64 (Figure 4).
5. Medicaid spending doubles for adult enrollees diagnosed with one or two chronic conditions and increases fourfold for those with three or more conditions.
Medicaid spends an average of $5,000 for adult enrollees without chronic conditions compared with $10,000 for those with one or two diagnosed conditions in a year, and nearly $20,000 for those with three or more conditions (Figure 5). The higher spending reflects increased health care needs, which result in in more health care visits, greater use of acute care, and an increased likelihood of using long-term care. Adult enrollees with chronic conditions account for 69% of all spending for adult enrollees (data not shown).
Methods |
| National Health Information Survey (NHIS): The NHIS is a nationally representative survey that collects data on chronic conditions, among other topics, from respondents. This analysis includes 24 chronic conditions: coronary heart disease, high cholesterol, angina, myocardial infarction, stroke, hypertension, diabetes, chronic obstructive pulmonary disease, asthma, arthritis, psoriasis, Crohn’s disease, ulcerative colitis, hepatitis, epilepsy, dementia, depression/anxiety, glaucoma, cataracts, diabetic retinopathy, macular degeneration, cancer, obesity, and chronic fatigue syndrome. Anxiety and depression are combined into a single mental health flag. The total number of chronic conditions reported by respondents was categorized as none, 1-2, or 3 or more. Most chronic conditions are self-reported, and for conditions where NHIS differentiates lifetime from current prevalence (cholesterol, hypertension, chronic fatigue, asthma), only current conditions were included. National survey estimates presented in Figures 1 and 2 use the most recent NHIS data (2023) and include respondents ages 19-64. Health insurance coverage is self-reported and includes respondents who report any Medicaid.
Medicaid Claims Data: This analysis used the 2021 T-MSIS Research Identifiable Files including the inpatient (IP), long-term care (LT), other services (OT), and pharmacy (RX) claims files merged with the demographic-eligibility (DE) files from the Chronic Condition Warehouse (CCW). Defining Chronic Conditions: This analysis used the CCW algorithm for identifying chronic conditions (updated in 2020). This analysis also included in its definition of chronic conditions substance use disorder, mental health, obesity, HIV, hepatitis C, and intellectual and developmental disabilities. In total, 35 chronic conditions were included and were further grouped into 3 broad categories: behavioral health, physical health, and cognitive impairment conditions. Specific conditions within these groupings include:
Enrollee Inclusion Criteria: Enrollees were included if they were ages 19-64, had full Medicaid or CHIP coverage for at least one month, and were not dually eligible for Medicare. State Inclusion Criteria: To assess the usability of states’ data, the analysis examined quality assessments from the DQ Atlas for OT claims volume and OT managed care encounters and compared the share of adults diagnosed with any mental illness (AMI) in each states’ Medicaid data to estimates for adult Medicaid enrollees from the 2021-2022 restricted National Survey on Drug Use and Health (NSDUH). States were excluded if: (1) they received a “High Concern/ Unusable” rating on the relevant DQ Atlas assessment measure, and (2) their Medicaid estimate of AMI differed from the NSDUH estimate by more than 15.1 percentage points (the 75th percentile of all differences). If at least 70% of a state’s Medicaid enrollees were covered by either managed care or by fee for service, only the corresponding DQ Atlas indicator was considered (i.e. managed care encounters volume or claims volume (FFS)). For states with more mixed delivery systems, both sets of indicators were considered; in these cases; a “High Concern/Unusable” rating on either measure, combined with a difference above 15.1 percentage points, led to exclusion. Based on these criteria, Mississippi was excluded, leaving 49 states and D.C. in the data presented in Figures 3 and 4. The DQ Atlas was used to assess the usability of state Medicaid spending data. Due to “unusable” 2021 spending data according to the DQ Atlas, West Virginia and Mississippi were excluded from Figure 5. |