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Mary K. Caffrey
The findings in Diabetes Care served as early confirmation of what some had feared: a bifurcated Medicaid system will lead to an American of haves and have-nots in healthcare.

While many studies were released in conjunction with the 5-year anniver-sary of the Affordable Care Act (ACA), the results published March 22, 2015, in Diabetes Care hit like a thunderclap. An analysis of data from a national laboratory testing company showed a 23% rise in type 2 diabetes mellitus (T2DM) diagnoses among Medicaid enrollees in states that expanded the program in the law’s first year. In states that did not expand Medicaid, the number of new diagnoses among enrollees barely budged (up 0.4%).1

This divide appeared even though the states that did not expand Medicaid include many with high existing rates of T2DM; many are in the Deep South, across a region recognized by CDC as the “diabetes belt.” (See FIGURES 1 and 2.) There was really only 1 conclusion, the authors wrote. “I cannot think of any other explanation except these people have now got health insurance,” said co-author Vivian Fonseca, MD, professor of medicine at Tulane University.2


RESULTS OF THE STUDY

When the ACA passed in 2010, its supporters sought to expand Medicaid to all households with incomes up to 138% of the federal poverty line. But the US Supreme Court ruled otherwise in 2012; because the healthcare program for the poor is jointly funded by states and the federal government, the justices chose to let states decide on their own whether to extend benefits to the next income tier. 

By January 2014, when the first ACA policies took effect, 26 states and the District of Columbia had expanded Medicaid, while 24 had not. This allowed researchers to directly compare the effect of expansion on the number of new T2DM diagnoses that would appear among Medicaid enrollees aged 19 to 64 years, by using laboratory records from Quest Diagnostics.1

In an interview with Evidence-Based Diabetes Management, Fonseca said the study itself was straightforward: “What is the impact going to be on diabetes as more and more people get insurance?” For all the debate about the ACA, Fonseca said he was strictly interested in the changes in patterns surrounding the disease. “My interest is scientific. It has nothing to do with politics,” he said.

Researchers stripped away identification information from lab results. Then they identified new cases of diabetes by the presence of either an International Classification of Diseases, Ninth Revision diagnosis code for the disease or a glycated hemoglobin test result of >6.4%. These results would have to have occurred within the first 6 months of 2014, and been absent during the preceding year, to count as a new T2DM diagnosis. Through this method, researchers identified 215,398 patients who were newly diagnosed with T2DM during 2013 the control period and 218,890 who met the definition in 2014, the study period. Overall, this was a 1.6% increase.1


Then, researchers identified 26,237 Medicaid patients with new T2DM di-agnoses in 2013, compared with 29,673 in 2014, for an increase of 13% in the Medicaid population. The number of Medicaid patients with new diagnoses increased by 23% in the 26 states plus the District of Columbia that expanded Medicaid. In these states, the difference was 14,625 diagnoses in 2013, compared with 18,020 diagnoses in 2014. In the other 24 states, the difference was 11,612 in 2013 vs 11,653 patients in 2014, for a rate of 0.4%.1 “In some ways, the differences are probably higher than what we anticipated,” Fonseca told EBDM.

FROM THEORY TO REALITY

The Diabetes Care results add weight to concerns that some experts expressed last year in interviews with EBDM: the ability of the working poor to access treatment for diabetes will vary depend-ing on where they live, due to state-level decisions on Medicaid expansion.

Krista Maier, associate director of public policy for the American Diabetes Association (ADA), told EBDM in May 2014 that states that did not extend Medicaid to those in the next tier above 100% of the poverty line were effectively locking this group out of health coverage. Because the ACA assumed all states would expand Medicaid, there was no provision for financial assistance for consumers if their states opted against expansion, she explained.3 According to the Kaiser Family Foundation, an estimated 3.7 million adults were in this “coverage gap” as of March 2015.4

The irony, Maier noted in 2014, is that states that refuse to expand Medicaid are required to support those with dia-betes who become disabled due to am-putations, blindness, or other complica-tions. “When you can’t afford the care to manage your disease, you scale back the care. Without adequate care, you increase risk of complications,’’ she said. “The states that don’t expand Medicaid are, essentially, waiting for the person to become so sick they are disabled to be eligible. If they expanded eligibility these people could receive care before they are disabled.’’3

Maier’s observations are noteworthy in light of the Diabetes Care findings that 35.4% of the new T2DM diagnoses in ex-pansion states were among those aged 19 to 49 years. If persons with T2DM in this age group can achieve better glyce-mic control and avoid long-term com-plications, there would be opportuni-ties for medical savings and avoidance of lost productivity. In 2013, the ADA determined that these 2 items cost the United States $245 billion a year.5

Before results like those published in Diabetes Care, however, any discussion about whether failure to expand Medi- caid could be linked to health outcomes was strictly theoretical. Now, that is no longer the case. Larry Levitt, senior vice president of the Kaiser Family Foundation, told The Washington Post that “People can really start to assess what the law means in tangible terms, like how many people have gotten insurance, and what that coverage means for their finances and their health.”2


“MISSED OPPORTUNITY”

Robert Ratner, MD, chief medical officer for the ADA, was among those who pointed out the irony of the find-ings: the states that have not expanded Medicaid are those that have the largest populations with the disease, and thus may have the largest numbers of people living with T2DM who don’t know it. Catching the disease early creates the opportunity to reduce long-term medical costs, he said.6

When the results were released, Ratner told National Public Radio, “Those states that did not expand Medicaid missed that opportunity and they still have large percentages of people, perhaps as large as 20%, living with the disease.”6


An accompanying editorial in Diabetes Care, co-authored by the journal's editor-in-chief, William T. Cefalu, MD, called on policy leaders to set aside politics and make healthcare decisions based on facts. “The data demonstrate the benefits of Medicaid expansion, yet nearly half of our states have chosen not to expand this benefit to their citizens. The real-world benefits and costs of Medicaid expansion merit additional research and civil debate. And perhaps most important, their results should be used to guide health policy to address the growing burden of chronic diseases.”7 

References

1. Kaufman HW, Chen Z, Fonseca VA, McPhaul MJ. Surge in newly identified diabetes among Medicaid patients in 2014 within Medicaid expan-sion states under Affordable Care Act [published online March 22, 2015]. Diabetes Care. pii: dc142334.

2. Sun LE. How does Obamacare help low-income diabetes patients? first, it finds them. The Wash-ington Post. http://www.washingtonpost.com/ national/health-science/how-does-obamacare-help-low-income-diabetes-patients-first-it-finds-them/2015/03/22/98d1b122-cf20-11e4-8a46-b1dc9be5a8ff_story.html. Published March 23, 2015. Accessed April 13, 2015.

3. Page P. Medicaid expansion choices mean different care for poor diabetics, depending on where they live. Am J Manag Care. 2014;20(SP8) SP239-240.

4. Artiga S, Stephens J, Damico A. The impact of the coverage gap in states not expanding Medicaid by race and ethnicity. Kaiser Family Foundation website. http://kff.org/disparities-policy/issue-brief/the-impact-of-the-coverage-gap-in-states-not-expanding-medicaid-by-race-and-ethnicity/. Published April 3, 2015. Accessed April 13, 2015.

5. American Diabetes Association. Economic costs of diabetes in the United States. Diabetes Care. 2013;36:1033-1046.

6. Kelto A. States that expand Medicaid detect more cases of diabetes. National Public Radio website. http://www.npr.org/blogs/ health/2015/03/23/394836516/states-that-expand-medicaid-detect-more-cases-of-diabetes. Published March 23, 2015. Accessed April 15, 2015.

7. Herman WH, Cefalu WT. Healthy policy and diabetes care: is it time to put politics aside [pub-lished online March 22, 2015]? Diabetes Care. pii: dc1503838.

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