Medicaid Enrollment and Service Use Among Adults With Down Syndrome

Doubly Marginalized: The Interplay of Racism and Disability in Outcomes for Minoritized People With Down Syndrome

BACKGROUND

Intersectionality, or the multidimensional influence of social identity and systems of power, may drive increased morbidity and mortality for adults of color with Down syndrome. We documented racial and ethnic differences in death and hospitalizations among Medicaid-enrolled adults with Down syndrome and assessed the interaction of racial-ethnic group and Down syndrome.

METHODS

Our sample consisted of 119,325 adults with Down syndrome and >3.2 million adults without intellectual disability enrolled in Medicare at any point from 2011 to 2019. We calculated age-adjusted mortality and hospitalization rates by racial-ethnic group among those with Down syndrome. We examined the additive interaction between Down syndrome and racial and ethnic group on mortality and hospitalization rates.

RESULTS

Among those with Down syndrome, age-adjusted mortality rate did not differ between Black and White racial groups (rate ratio: 0.96, 95% confidence interval [CI] = 0.92, 1.01), while the mortality rate was lower for Pacific Islanders (0.80), Asian (0.71), Native (0.77), and mixed-race groups (0.50). Hospitalization rates were higher for all marginalized groups compared to the White group. When assessing the interaction between racial-ethnic group and Down syndrome, Black, Native Americans, and mixed-race groups exhibited a negative additive interaction for mortality rate, and all groups except Native Americans exhibited positive additive interaction for hospitalization.

CONCLUSIONS

Increased hospitalization rates for adults with Down syndrome from marginalized racial and ethnic groups suggest worse health and healthcare. Similar mortality rates across racial and ethnic groups may result from an increased infant mortality rate in marginalized groups with Down syndrome, leading to reduced mortality among those surviving to adulthood.

Through the Looking Glass: A Data Lens on Health of People With Intellectual and Developmental Disabilities

Population level data on health of people with intellectual and developmental disabilities (IDD) are sorely needed to identify their health status, health disparities, and health needs. Key considerations to inform programs and policies need to address prevalence, problem identification, and progress assessment. Recent advances have been made in health data about people with disabilities generally that identify strategies for improving health data for people with IDD, including critical need for a standardized operational definition and survey identifiers of IDD. Past and current actions by federal agencies' to improve health data for health equity are summarized. Emerging developments in IDD health data are identified, including increasing use of self-report, data linking and harmonizing, intersectionality, and recognition of ableism.

Employment of people with Down syndrome: A scoping review

Down syndrome is the most prevalent genetic condition contributing to intellectual disability. Advancements in medical care have significantly increased the life expectancy of people with this condition, making employment a vital component for independent living and quality of life. The aim of this study was to examine the current literature on the employability and employment experiences of individuals with Down syndrome, focusing on the evolution of the employment rate and factors influencing employment such as cognitive and personal factors, societal attitudes, challenges, and effective support systems. Using Arksey and O'Malley's methodology, a scoping review of relevant qualitative and quantitative articles from PubMed, Scopus, Web of Science (WoS), CINAHL, and Medline was conducted. The search focused on the keywords found in the title and abstract of articles from 1980 to 2023. The search strategy utilized medical subject headings (MeSH), including "work", "Down syndrome", and "employment". All articles employing qualitative, quantitative, and mixed methods that were published in English were included. Of an initial 4,296 articles, 32 full-text articles were evaluated, and nine met the inclusion criteria. The data indicated improved employment rates for people with Down syndrome, with a recent employment rate of 53%. However, jobs are often limited to sectors like food service and are underutilizing their skills. Key factors associated with employment status include cognitive abilities, family support, and social attitudes. Despite positive perceptions, significant barriers such as systemic bias persist. Effective support systems are crucial but are often hindered by limited opportunities. In conclusion, employment opportunities for people with Down syndrome have improved, but challenges such as limited job diversity and systemic barriers remain. Comprehensive policies are recommended to promote inclusive employment practices and tailored support systems.

Occurrence of mosaic Down syndrome and prevalence of co-occurring conditions in Medicaid enrolled adults, 2016-2019

BACKGROUND

Mosaic Down syndrome is a triplication of chromosome 21 in some but not all cells. Little is known about the epidemiology of mosaic Down syndrome. We described prevalence of mosaic Down syndrome and the co-occurrence of common chronic conditions in 94,533 Medicaid enrolled adults with any Down syndrome enrolled from 2016 to 2019.

METHODS

We identified mosaic Down syndrome using the International Classification of Diseases and Related Health Problems, tenth edition code for mosaic Down syndrome and compared to those with nonmosaic Down syndrome codes. We identified chronic conditions using established algorithms and compared prevalence by mosaicism.

RESULTS

In total, 1966 (2.08%) had claims for mosaic Down syndrome. Mosaicism did not differ by sex or race/ethnicity with similar age distributions. Individuals with mosaicism were more likely to present with autism (13.9% vs. 9.6%) and attention deficit hyperactivity disorder (17.7% vs. 14.0%) compared to individuals without mosaicism. In total, 22.3% of those with mosaic Down syndrome and 21.5% of those without mosaicism had claims for Alzheimer's dementia (Prevalence difference: 0.8; 95% Confidence interval: -1.0, 2.8). The mosaic group had 1.19 times the hazard of Alzheimer's dementia compared to the nonmosaic group (95% CI: 1.0, 1.3).

DISCUSSION

Mosaicism may be associated with a higher susceptibility to certain neurodevelopmental and neurodegenerative conditions, including Alzheimer's dementia. Our findings challenge previous assumptions about its protective effects in Down syndrome. Further research is necessary to explore these associations in greater depth.

Alzheimer Dementia Among Individuals With Down Syndrome

Importance

With the advancement in administrative data as a research tool and the reliance on public health insurance for individuals with Down syndrome, population-level trends in Alzheimer dementia in this population are beginning to be understood.

Objective

To comprehensively describe the epidemiology of Alzheimer dementia in adults with Down syndrome in a full US Medicare and Medicaid sample.

Design, Setting, and Participants

This cohort study included 132 720 adults aged 18 years or older with Medicaid and/or Medicare claims data with an International Statistical Classification of Diseases and Related Health Problems code for Down syndrome. Data were collected from January 1, 2011, to December 31, 2019, and analyzed from August 2023 to May 2024.

Main Outcomes and Measures

The main outcome was prevalence of Alzheimer dementia in each calendar year and during the 9-year period. Alzheimer dementia incidence rates by calendar year and age and stratified for race or ethnicity as well as time to death after Alzheimer dementia diagnosis were also assessed.

Results

There were 132 720 unique adults with Down syndrome from 2011 to 2019: 79 578 (53.2%) were male, 17 090 (11.7%) were non-Hispanic Black, 20 777 (15.7%) were Hispanic, 101 120 (68.8%) were non-Hispanic White, and 47 692 (23.3%) had ever had an Alzheimer dementia diagnosis. Incidence was 22.4 cases per 1000 person-years. The probability of an incident Alzheimer dementia diagnosis over 8 years was 0.63 (95% CI, 0.62-0.64) for those entering the study between ages 55 to 64 years. Mean (SD) age at incident diagnosis was 54.5 (7.4) years and median (IQR) age was 54.6 (9.3) years. Mean (SD) age at death among those with Alzheimer dementia was 59.2 (6.9) years (median [IQR], 59.0 [8.0] years). The mean (SD) age at onset for the Hispanic group was 54.2 (9.2) years, 52.4 (7.8) years for the American Indian or Alaska Native group, and 52.8 (8.2) years for the mixed race groups compared with 55.0 (7.8) years for the White non-Hispanic group. For age at death, there were no differences by sex. The mean (SD) age at death was later for the White non-Hispanic group (59.3 [6.8] years) compared with the Hispanic group (58.5 [7.8] years), Native American group (57.8 [7.1] years), and mixed race group (58.2 [7.0] years).

Conclusions and Relevance

In this cohort study of adults with Down syndrome who were enrolled in Medicaid and Medicare, Alzheimer dementia occurred at high rates. Consistency with clinical studies of dementia in Down syndrome supports the use of administrative data in Down syndrome-Alzheimer dementia research.

Autism Among Adults with Down Syndrome: Prevalence, Medicaid Usage, and Co-Occurring Conditions

Our objective was to examine occurrence of both conditions in Medicaid; and compare Medicaid service use and cost, and chronic conditions among adults with Down syndrome and autism to those with Down syndrome alone and those with autism alone. We used ICD9 and ICD10 codes in Medicaid claims and encounters from 2011 to 2019 to identify autism and Down syndrome in adults > 18 years. We then calculated costs, claims, hospitalizations, long term care days, and chronic conditions, and compared by group- autism alone, Down syndrome alone, Down syndrome + autism. Between 2011 and 2019, there were 519,450 adult Medicaid enrollees who met our criteria for autism (N = 396,426), Down syndrome (N = 116,422), or both Down syndrome and autism (N = 6,602). In 2011, 4.1% of enrollees with Down syndrome had co-occurring autism; by 2011 it was 6.6%. The autism group had the fewest claims and inpatient hospitalizations, followed by the Down syndrome group, then the Down syndrome + autism group. After age adjustment, those with Down syndrome alone and Down syndrome + autism had elevated prevalence of atrial fibrillation, dementia, heart failure, kidney disease, and obesity compared to the autism alone group. Both groups also had decreased occurrence of depression and hypertension compared to the autism alone group. Prevalence of autism is higher among people with Down syndrome than in peers. The increased costs and service use for those with both conditions highlight the extent to which this population need health care and signal the need for more effective preventative care and therapies.

Medicare, Medicaid, and dual enrollment for adults with intellectual and developmental disabilities

OBJECTIVE

Given high rates of un- and underemployment among disabled people, adults with intellectual and developmental disabilities rely on Medicaid, Medicare, or both to pay for healthcare. Many disabled adults are Medicare eligible before the age of 65 but little is known as to why some receive Medicare services while others do not. We described the duration of Medicare enrollment for adults with intellectual and developmental disabilities in 2019 and then compared demographics by enrollment type (Medicare-only, Medicaid-only, dual-enrolled). Additionally, we examined the percent in each enrollment type by state, and differences in enrollment type for those with Down syndrome.

DATA SOURCES AND STUDY SETTING

2019 Medicare and Medicaid claims data for all adults (≥18 years) in the US with claim codes for intellectual disability, Down syndrome, or autism at any time between 2011 and 2019.

STUDY DESIGN

Administrative claims cohort.

DATA COLLECTION AND ABSTRACTION METHODS

Data were from the Transformed Medicaid Statistical Information System Analytic Files and Medicare Beneficiary Summary files.

PRINCIPLE FINDINGS

In 2019, Medicare insured 582,868 adults with identified intellectual disability, autism, or Down syndrome. Of 582,868 Medicare beneficiaries, 149,172 were Medicare only and 433,396 were dual-enrolled. Most Medicare enrollees were enrolled as child dependents (61.5%) Medicaid-only enrollees (N = 819,256) were less likely to be white non-Hispanic (58.5% white non-Hispanic vs. 72.9% white non-Hispanic in dual-enrolled), more likely to be Hispanic (19.6% Hispanic vs. 9.2% Hispanic in dual-enrolled) and were younger (mean 34.2 years vs. 50.5 years dual-enrolled).

CONCLUSION

There is heterogeneity in public insurance enrollment which is associated with state and disability type. Action is needed to ensure all are insured in the program that works for their healthcare needs.