Could Medicaid Expansion Decrease Diabetes-Related Major Amputation?

A recent study published in the JAMA Network Open found relative improvement in major amputations in racial and ethnic minority adults after Medicaid expanded benefits under the Patient Protection and Affordable Care Act (ACA). Researchers aimed to explore this association, specifically with regard to outcomes for diabetic foot ulcers (DFUs). They looked at hospitalizations for DFU among patients 20 to 64 years old and identifying among multiple racial and ethnic groups including African American, Asian and Pacific Islander, American Indian or Alaska Native, and Hispanic. The authors queried state inpatient databases over a nearly 3-year time frame for 19 states. After collecting the data, they categorized the states as either early adopters of the Medicaid expansion (using January 2014 as the cut-off date) or nonadopters.

In total, the authors looked at over 115,000 hospitalizations for DFUs among racial and ethnic minority patients. Most patients (64 percent) were 50 to 64 years old and male (65 percent). African American patients comprised 61 percent of the cohort, Hispanic 25 percent and 14 percent identified as another racial or ethnic minority group. Of these hospitalizations, nearly one-third were for Medicaid beneficiaries and 9 percent were for uninsured individuals.

After analyzing the data, early adopter states showed a 3 percent increase in hospitalizations after expansion, but nonadopter states saw an 8 percent increase. Early adopter states did not exhibit any change overall in major amputation rate after expansion, however, nonadopter states had a 9 percent increase in this same time frame. Uninsured adults saw a nearly one-third decrease in amputations in early adopter states, but in nonadopter states, the amputation rate did not change for these same patients. Medicaid beneficiaries did not note any changes in amputation rates regardless of the state type after the expansion. The authors content that this relative improvement could be due to at-risk uninsured patients becoming insured by Medicaid in the first two years of the implementation of the ACA.

Tze-Woei Tan, MD, MPH, FACS, lead author on the study says some of the contributing factors that can lead to elevated risk of diabetes-related amputation among racial and ethnic minority adults and those with low incomes are barriers to medical care due to lack of health insurance.

“Racial and ethnic minorities also have the highest uninsured rates compared to the average US population,” he explains. “We speculate that the positive effects might be related to the shifting of at-risk, insured patients into the Medicaid program.”

Dr. Tan feels that the findings of this study can impact providers by gaining an understanding of how expanding insurance coverage can improve the care and outcomes of traditionally underserved populations.

He feels there is still work to be done on this topic and that this study is just one step in that process.

“(The next step would be) to evaluate the long-term association of Medicaid expansion with DFU care and outcomes, including amputation,” says Dr. Tan, an Associate Professor in the Division of Vascular Surgery at the University of Arizona. 

References

1. Tan T-W, Calhoun EA, Knapp SM, et al. Rates of diabetes-related major amputations among racial and ethnic minority adults following Medicaid expansion under the patient protection and affordable care act. JAMA Netw Open. 2022;5(3):e223991.