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Diabetic Limb Amputation Rates Among Racial, Ethnic Minorities Improve Following Medicaid Expansion


New research found Medicaid expansion was associated with lower rates of diabetic limb amputations among racial minorities in the United States.

Data from states that enacted Medicaid expansion early on under the Affordable Care Act (ACA) revealed improvements in amputation rates for diabetic foot ulcerations (DFUs) among African American, Hispanic, and other racial and ethnic minority adults compared with rates seen in states that did not expand Medicaid, according to study findings published in JAMA Network Open.

The relative improvement could be due to recruitment of at-risk uninsured adults into the Medicaid program during the first 2 years of ACA implementation, the authors wrote.

DFU precedes over 80% of amputations and serves as the leading cause of limb loss among minority individuals with diabetes. These populations also experience a disproportionately elevated risk of extremity amputation, with research showing, “African American, Hispanic, and American Indian individuals with DFUs have a several-fold greater risk of amputation than their White counterparts.”

The ACA was enacted in March 2010, and in 2014, states began expanding their Medicaid programs to nonelderly adults with incomes up to 138% of the federal poverty level, the researchers explained. Currently, 39 states and Washington, DC, have expanded their programs while 12 states have not.

To better understand whether early implementation of this policy helped reduced rates of limb amputations due to DFUs, the investigators assessed data from State Inpatient Databases (SID) from 2013, 2014, and through the third quarter of 2015.

Hospitalization data from 12 states that had expanded Medicaid by January 2014 were compared with those of 7 states that did not adopt the policy by that time. Using International Classification of Diseases, Ninth Revision (ICD-9) diagnosis codes, the researchers identified major amputations for DFUs, both above and below the knee, while US Bensus Bureau data were used to quantify the number of minority and White adults in each state from 2013 and 2015.

Of the 115,071 hospitalizations for DFUs among racial minority populations, 61% were among African American adults, 25% were among Hispanic adults, and 14% were among adults in the other category (Asian, American Indian, and other). Medicaid beneficiaries accounted for 32% of the total, and 9.1% of patients were uninsured.

In comparison, “there were 152,986 hospitalizations for White adults with DFUs (32,564 [21.3%] Medicaid beneficiaries and 11, 562 [7.6%] uninsured),” the authors wrote.

Analyses of racial and ethnic minority adults revealed:

  • Hospitalizations increased 3% (95% CI, 1%-5%) in early-adopter states and increased 8% (95% CI, 6%-10%) in nonadopter states after expansion, a significant difference (for interaction < .001)
  • Although there was no change in the amputation rate (0.08%; 95% CI, −6% to 7%) in early-adopter states after expansion, there was a 9% (95% CI, 3%-16%) increase in nonadopter states, a significant change (P = .04)
  • For uninsured adults, the amputation rate decreased 33% (95% CI, 10%-50%) in early-adopter states and did not change (12%; 95% CI, −10% to 38%) in nonadopter states after expansion, a significant difference (P = .006)
  • There was no difference in the change of amputation rate among Medicaid beneficiaries between state types after expansion

Overall, “in the first 21 months following Medicaid expansion, the major amputation rate increased 9% among African American adults, Hispanic adults, and adults in the other category in nonadopter states, whereas there was no significant change in early-adopter states,” the authors wrote.

“The blunted rise in amputation corresponded with a 33% reduction in major amputation among uninsured African American adults, Hispanic adults, and adults in the other category in early-adopter states after expansion," they added.

Findings also suggest that the relative improvement of major amputation rates in states that did expand Medicaid could indicate a redistribution of at-risk, uninsured, racial minority adults into the Medicaid program.

Increased risk of amputation for DFUs among the populations studied can be attributed in part to disparities in socioeconomic class and insurance status—reflecting barriers to care access.

Prior to the passage of the ACA, Hispanic and African American adults had the highest uninsured rates compared with White adults, the researchers explained. “Although disparities in uninsured rates persist, coverage improved substantially across different racial and ethnicity groups after ACA implementation, with the most substantial gain among Hispanic and African American individuals,” they said.

Furthermore, improvements in health insurance coverage in this patient population led to increased diabetes diagnoses among Medicaid beneficiaries and a greater number of Medicaid-insured visits for African American and Hispanic patients with diabetes.

The retrospective nature of the investigation and a lack of information on presentation severity mark limitations to the study. The researchers also did not have data on DFU care in ambulatory settings prior to or following hospitalizations.

“Taken together, this study highlights the potential benefit of the ACA for populations at disproportionately elevated risks of diabetes-related amputation,” the authors concluded.


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. Published online March 24, 2021. doi:10.1001/jamanetworkopen.2022.3991

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