A new study from our USC group led by Carrie Tackett and Tze Woei Tan and published today in Diabetology, adds important evidence to a troubling pattern: in the United States, who pays for your care can be just as consequential as the care itself — especially when your foot is on the line.
Carrie Tackett, Kevin Sun, Chia-Ding Shih, Laura Shin, Elizabeth Miranda, David G. Armstrong, and Tze-Woei Tan analyzed a national cohort of more than 258,000 adults with newly diagnosed diabetic foot ulcers (DFUs) drawn from the PearlDiver insurance claims database (2010–2020). Their question was direct: does insurance type — Medicaid, Medicare, commercial, or self-pay — independently predict who goes on to develop a diabetic foot infection (DFI) or lose a limb?
The answer is a clear yes.
After propensity score matching to balance for age, comorbidity burden, and major health conditions, Medicaid beneficiaries had 18% higher odds of DFI-related hospitalization within 12 months (aOR 1.18, 95% CI 1.14–1.24) and a striking 72% higher odds of major amputation within 3 years (aOR 1.72, 95% CI 1.39–2.13) compared to matched non-Medicaid patients.
What makes this particularly striking is that Medicaid patients were actually younger — on average a decade younger than their Medicare and commercially insured counterparts (50.1 vs. 60.6 years). Their overall comorbidity burden, once matched, was essentially identical. This isn’t a story about sicker patients getting worse outcomes. It’s a story about a system that reaches some patients too late, too infrequently, and with too few coordinated resources.
Peripheral vascular disease stood out as the single strongest predictor of major amputation, with an aOR of 6.25 — a reminder that ischemia remains the great amplifier of every other risk factor in the diabetic foot. But Medicaid status, independent of all clinical variables, held firm as a significant predictor across both infection and amputation endpoints.
The structural mechanisms driving these disparities are not mysterious. Lower Medicaid reimbursement rates reduce provider participation, limit specialty access, and create fragmented care pathways. Patients in distressed communities face barriers that compound biological risk: limited transportation, fewer podiatric and vascular specialists nearby, inadequate coverage for routine foot surveillance, and competing life priorities that push preventive visits down the list. By the time a Medicaid patient enters the vascular or wound care system, the disease has often already progressed beyond the window for early intervention.
As the authors frame it, Medicaid coverage in this context functions less as a measure of underlying health and more as a marker of structural vulnerability — a signal embedded in our healthcare architecture that predicts who will fall through the cracks.
This work reinforces what we already know about the diabetic foot disease continuum: ulcer to infection to amputation is not an inevitable trajectory. It is a modifiable one — but only if the right interventions arrive at the right time. DFI is the critical inflection point. Every hospitalization for foot infection is a near-miss for amputation. Given that five-year mortality after diabetes-related major amputation approaches 60–70% — exceeding survival rates for many cancers — these are not abstract statistics.
The implications extend beyond the U.S. Medicaid program. The underlying mechanisms — socioeconomic disadvantage, delayed specialty access, fragmented care — are generalizable to any health system, publicly funded or otherwise, where structural inequity shapes who receives timely limb-preserving care.
The paper calls for future integration of claims data with clinical, vascular, and wound-level data to better understand exactly how access to outpatient foot care and timeliness of multidisciplinary intervention mediate the path from DFU to DFI to limb loss. That roadmap is worth pursuing urgently.
Read the full paper: Tackett C, Sun K, Shih C-D, Shin L, Miranda E, Armstrong DG, Tan T-W. Medicaid Insurance Is Independently Associated with Higher Risks of Diabetic Foot Infection and Amputation: A National Cohort Study. Diabetology 2026, 7, 52. https://doi.org/10.3390/diabetology7030052
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