Every 1.2 seconds, someone with diabetes develops a wound on their foot. Every 20 seconds a limb is lost due to diabetes, worldwide. In the United States, as in many other parts of the world, this occurs at least twice as frequently in people of color. At today’s American Diabetes Association 80th Annual symposium, investigators from the University of Arizona College of Medicine and the Keck School of Medicine of University of Southern California, evaluated the role of the Affordable Care Act (ACA) in minority patients being admitted to hospital with diabetic foot ulcers. “We show, for the first time, a substantial difference in major amputation between states that adopted ACA and those that didn’t”, noted Tze Woei Tan, Associate Professor of Surgery at the University Arizona and the study’s lead author. “There was a 1% increase in states that didn’t expand Medicaid and a dramatic 17% reduction in major amputation amongst those that did.” The reasons for this are likely manifold, but the authors believe some of it may have to do with access to care outside of the hospital. “This study showed us something really fascinating”, noted David G. Armstrong, Professor of Surgery at Keck School of Medicine of University of Southern California and the study’s senior author, “People of color with wounds were more than 20 percent LESS likely to be admitted to hospital in states that expanded medicaid than before expansion. This is compared to a 78% INCREASE in hospitalization amongst non-adopter states. It looks like outpatient prevention really can be a limbsaver in these patients who are frequently the breadwinners in their homes.” Armstrong went on to say. “This likely can have a dramatic effect not only on limbs but lives in people of color, nationwide.”

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217-OR: ADA Presidents’ Select Abstract: The Affordable Care Act Medicaid Expansion Correlated with Reduction in Lower Extremity Amputation among Minorities with Diabetic Foot Ulcerations

1. TZE-WOEI TAN, 
2. ELIZABETH CALHOUN, 
3. SHANNON M. KNAPP, 
4. DAVID G. MARRERO, 
5. WEI ZHOU and 
6. DAVID G. ARMSTRONG

Diabetes 2020 Jun; 69(Supplement 1): – https://doi.org/10.2337/db20-217-OR

Abstract

Objectives: Lack of insurance and non-white race are associated with increased risks of amputation. It is unclear how expanded insurance coverage affects the care of minorities with diabetes. The aim was to evaluate the effect of Medicaid expansion under the Affordable Care Act (ACA) on outcomes of minorities with diabetic foot ulcerations (DFUs).

Methods: We analyzed the State Inpatient Databases from 19 states to identify people who were either uninsured or on Medicaid with DFUs from 2013 to 2015. Patients were categorized into early-adopter states (implemented the ACA expansion by January 2014) and non-adopter states. Logistic regression was performed to examine the effects of state type (early vs. non-adopter), time (pre- vs. post-ACA), and their interaction on the proportion of amputation.

Results: The study included 25,493 non-white Medicaid beneficiaries and 9,863 uninsured patients with DFUs. Among the minorities aged 20 to 64 years, there was an increase (180.7%) in the number of admissions for Medicaid beneficiaries and a reduction (21.5%) in the admissions of uninsured patients in early-adopter states after expansion. In comparison, there was an increase in the number of admissions of the uninsured patients (78.2%) in non-adopter states during the same period. The odds of major amputation among non-white Medicaid beneficiaries with DFUs decreased 17.3% in early-adopter states and increased 0.9% in non-adopter states (p=0.045), while the odds of minor amputation increased 14% in early-adopter states and decreased 8.1% in non-adopter states (p=0.003).

Conclusion: The ACA Medicaid expansion appears to have substantial positive effects on the care of minorities with DFUs. Racial and ethnic minorities in states that expanded Medicaid experienced a significant reduction in the number of uninsured with DFUs and a reduction in major amputations. The broadening of the ACA may reduce disparities in diabetes-related amputations.

Disclosure T. Tan: None. E. Calhoun: None. S.M. Knapp: None. D.G. Marrero: None. W. Zhou: None. D.G. Armstrong: None.

Funding National Institute of Diabetes and Digestive and Kidney Diseases (K23DK122126)