Prevalence of Complex Medical Conditions Among Teens and Young Adults in Medicaid: National and State Estimates

Purpose: An increasing number of children with complex medical conditions (CMCs) survive into adulthood. Medicaid is a key payer for this population, yet enrollment in Medicaid for adolescents with CMCs through the transition to adulthood is not well-described. Our objective is to measure the prevalence of CMCs among older adolescents and young adults in Medicaid, overall and within states. Methods: We used enrollment and medical claims data from the Transformed Medicaid Statistical Information System Analytic Files to analyze a cross-sectional census of individuals aged 15–25 enrolled 11+ months in comprehensive Medicaid in 2016 from 47 states and the District of Columbia. Individuals with CMCs were identified by applying a validated claims-based algorithm (Pediatric Medical Complexity Algorithm). We compared the prevalence of CMCs by age, type of diagnosis, and geography. Results: About 9.3 million Americans between 15 and 25 years (21% of individuals in this age bracket) met our eligibility criteria. Of these enrollees, 3.8 percent (352,710 people) had a CMC. The prevalence of individuals with CMCs was higher among enrollees at the age of 19 and above (3.6%–5.4%) compared with enrollees 15–18 (3.1%). Mental health diagnoses, progressive disorders, and neurological diagnoses were the most common components of a CMC. States varied substantially in the percent of this age group enrolled in Medicaid and the percent of enrollees with CMCs. Discussion: These results can be used as foundational information for national and state policymakers to allocate resources and by researchers to calibrate public program expectations and benchmark future research.