Medicaid Expansion Positive For Minorities With Diabetic Foot Ulcerations

Tze-Woei Tan, MBBS, MPH, FACS

New research findings demonstrate substantial positive effects of the Affordable Care Act’s Medicaid Expansion for the care of racial and ethnic minorities with diabetic foot ulcerations.

The findings, presented at the American Diabetes Association’s (ADA’s) 80th Virtual Scientific Sessions, demonstrated a 17% decrease in the risks of amputation among patients who lived in states that adopted Medicaid Expansion in 2014.

“These results might suggest patients with (diabetic foot ulcerations) living in states that chose to expand Medicaid coverage might be seeking care earlier and were able to prevent major leg amputation,” Tze-Woei Tan, MBBS, MPH, FACS, said in a statement.

More than half of patients with diabetes-related lower-extremity amputation die within 5 years, which is a rate higher than most cancer-related deaths. Up to 33% of those with diabetes develop a foot ulcer, the most common reason for infection and leg amputation.

Racial and ethnic minorities have significantly higher risks of developing diabetic foot ulcers and leg amputation than non-Hispanic Whites. Among patients with diabetes and peripheral artery disease—a major risk factor for leg amputation—lack of insurance is also known to be a significant factor.

Congress passed the Patient Protection and Affordable Care Act in 2010 to reduce the number of uninsured Americans. Individual states made the decision of whether to expand Medicaid coverage.

Tan and a team of colleagues analyzed 19 state inpatient databases from 2013-2015 to identify people with diabetic foot ulcerations who were uninsured or who had Medicaid coverage. The investigative team categorized patients into early-adopter states and non-adopter states. Early-adopter states implemented the Affordable Care Act by January 2014. Logistic regression was used to examine the effects of state type (early vs non-adopter), time (pre- vs post-Affordable Care Act), and their interaction on the proportion of amputation.

Overall, 25,493 non-white Medicaid beneficiaries and 9863 uninsured minority patients aged 20-64 years old who had diabetic foot ulcerations were included in the analysis. Among early-adopter states, the number of inpatient admissions to treat diabetic foot ulcerations for Medicaid beneficiaries increased by 180.7%. The number of admissions of uninsured patients decreased by 21.5%. In non-adopter states, the number of admissions of uninsured patients increased by 78.2%.

For major amputations, the odds among non-white Medicaid beneficiaries decreased by 17.3% in early-adopter states and increased 1% in non-adopter states (P=.045). Odds of a minor amputation increased 14% in early-adopter states and decreased 8% in non-adopter states (P=.003).

“African Americans, Hispanics, and those without health insurance have disproportionately higher risks of lower extremity amputation, so access to care for patients with foot ulcers is vital,” Tan said. “The broadening of the (Affordable Care Act) may reduce disparities in diabetes-related amputations.”

The study, “The Affordable Care Act Medicaid Expansion Correlated with Reduction in Lower Extremity Amputation among Minorities with Diabetic Foot Ulcerations,” was presented at ADA 2020.