Medicaid Expansion Under ACA May Have Reduced Rate of Major Diabetes-Related Amputations

Data from a new study are providing clinicians with insight into the effects of the Medicaid Expansion Under the Patient Protection and Affordable Care Act (ACA) on rates of diabetes-related major amputations among racial and ethnic minority adults with diabetes.

Results of the study, which leveraged data from more than 115,000 hospitalizations of adults with diabetic foot ulcers, suggests early ACA implementation was associated with a decreased rate of lower extremity amputation among racial and ethnic minority adults with diabetic foot ulcers, with this decreased rate most apparent among uninsured patients, which investigators suggest demonstrates a redistribution of at-risk uninsured African American adults, Hispanic adults, and adults in the other category into the Medicaid program.

“This study highlights the potential benefit of the ACA for populations at disproportionately elevated risks of diabetes-related amputation,” wrote investigators.

The effects of the implementation of Medicaid expansion under the ACA have been the subject of speculation since the legislation was enacted in March 2010. With this in mind, investigators from multiple US-based institutions sought to explore whether ACA implementation influenced the rate of diabetes-related major amputations among racial and ethnic minority adults.

Using data from State Inpatient Databases for 19 states and Washington DC for 2013 throughout the third quarter of 2015, investigators identified 115,071 hospitalizations among racial and ethnic minority adults with diabetic foot ulcers for inclusion in their analyses. For the purpose of analysis, states were categorized as early-adopter sets and nonadopter states.

The primary outcomes of interest were hospitalizations and major amputations for diabetic foot ulcers. Investigators noted this included both above-knee and below-knee amputations. Investigators noted hospitalization with missing values for race and ethnicity, gender, or insurance were excluded from their analyses.

Of the 115,071 hospitalizations, 61% occurred in African Americans, 25% occurred in Hispanic adults, and 14% occurred among adults classified into the other category. A total of 36,829 hospitalizations were among Medicaid beneficiaries and 10,500 were among uninsured individuals. A total of 152,986 hospitalizations for White adults with diabetic foot ulcers were identified during the same time period. This included 32,564 Medicaid beneficiaries and 11,562 uninsured individuals.

During the study period, hospitalization increased by 3% (95% CI, 1 to 5) in early-adopter states and increase by 8% (95% CI, 6 to 10), which investigators noted was a significant difference (P for interaction <.001). No change in amputation rate was observed among early-adopter states after expansion, but a 9% (95% CI, 3 to 16) increase was observed in nonadopter states, which also represented a significant change (P=.04).

Further analysis suggested the amputation rate among uninsured adults decreased by 33% (95% CI, 10 to 50) in early-adopter states and no change was observed in nonadopter states after expansion (12%; 95% CI, -10 to 38), which investigators noted was a significant difference (P=.006). Investigators also noted there was n difference in the change of amputation rate among Medicaid beneficiaries based on whether or not a state was an early-adopter or a nonadopter.

“The current study found that African American, Hispanic, and other racial and ethnic minority adults experienced relatively improved outcomes in states that adopted Medicaid expansion after ACA implementation,” investigators added. “The major amputation rates for racial and ethnic minority adults with DFUs significantly blunted in early-adopter states compared with nonadopter states after Medicaid expansion. This finding could be because of the recruitment of uninsured adults into the Medicaid program.”

This study, “Rates of Diabetes-Related Major Amputations Among Racial and Ethnic Minority Adults Following Medicaid Expansion Under the Patient Protection and Affordable Care Act,” was published in JAMA Network Open.