Medicaid Expansions Due to ACA Bump Up Diabetes Diagnoses

Miriam E Tucker

March 26, 2015

More people are being diagnosed with diabetes and at an earlier stage of disease in the US states that expanded their Medicaid programs under the Affordable Care Act (ACA), a new study indicates.

The results, from an analysis of the clinical laboratory database of Quest Diagnostics (Madison, New Jersey), were published online March 22 in Diabetes Care by Harvey W Kaufman, MD, Quest's senior medical director, Office of Medical Health Trends Affairs, and colleagues.

When the law was passed in 2010, the ACA was intended to expand Medicaid eligibility for all nonelderly adults in the country with incomes at or below 138% of the federal poverty level, about $11,670 for an individual and $23,850 for a family of four.

However, in June 2012, the US Supreme Court ruled that states could not be required to expand their Medicaid programs. When the law took effect in January 2014, 26 states and the District of Columbia had expanded their Medicaid programs while the other 24 states had not, with eligibility limited to individuals with an average upper median income limit of just 50% of the poverty level (about $5835 for one person and $11,925 for a family of four) and in most states only for adults with children or disabilities.

In the study, the investigators used Quest's nationwide clinical laboratory database of nearly half a million people newly diagnosed with diabetes to compare diabetes diagnosis rates before and after January 2014 in states that had expanded Medicaid vs those that hadn't.

There was a dramatic 23% rise in the number of people newly diagnosed with diabetes in the expansion states, compared with just a 0.4% increase in the nonexpansion states.

Mean HbA1c levels at the time of diagnosis were significantly lower in the expansion states: 7.96% vs 8.14% in the nonexpansion states (P < .0001), suggesting that the diabetes was also being diagnosed at an earlier stage of disease, the authors say.

"The Affordable Care Act has provisions to fully cover the costs for many preventative services, which lowers a financial barrier to medical care. We hope our study provides insight into the association between expansion of coverage and early identification of chronic disease, as a means of containing long-term costs," Dr Kaufman told Medscape Medical News.

And, he noted, "This finding may suggest that a physician in a nonexpansion state has a higher probability of encountering patients at more advanced stages of disease….This has implications regarding future development of the devastating complications of diabetes among Medicaid patients."

The study demonstrates "that Medicaid expansion increases the number of low-income Americans with newly identified diabetes and will likely improve their outcomes," say William H Herman, MD, of the University of Michigan, Ann Arbor, and William T Cefalu, MD, of the Pennington Biomedical Research Center, Louisiana State University, Baton Rouge, in an editorial accompanying the paper.

They add, "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."

The editorial is provocatively titled "Policy and Diabetes Care: Is It Time to Put Politics Aside?" Asked to respond to that question, Dr Kaufman said, "Quest Diagnostics does not take a position on the politics of the Affordable Care Act. Our goal is to enlighten the discussion….We leave it to policy makers and individual clinicians and patients to refer to the findings of our study to guide their decisions about reforms impacting the health of tens of millions of Americans."

The Effect of Coverage

Of a total 434,288 newly diagnosed diabetes patients from all 50 US states and DC, there was an overall 1.6% increase in newly diagnosed diabetes from the first 6 months of 2013 (control period) to the study period (January–June 2014). Among Medicaid patients, 13% more were newly diagnosed with diabetes after the ACA took effect than before (29,673 vs 26,237).

Within the expansion states, 14,625 were newly diagnosed with diabetes in the control period vs 18,020 after the ACA kicked in, a 23% increase. By contrast, those numbers in nonexpansion states were 11,612 vs 11,653, a mere 0.4% increase.

The surge in newly identified Medicaid patients with diabetes in expansion states was seen for every age category and for both men and women (P < .0001).

Among non-Medicaid patients, there was little difference in diabetes diagnosis rates before and after the ACA began.

Consistent with the significant 0.18-percentage-point difference in HbA1c at diagnosis between expansion and nonexpansion state residents, the proportion who had HbA1c values of 6.5% to 6.9% at diagnosis was also higher in the expansion vs nonexpansion states, 44.1% vs 39.3% (P < .0001).

And again, these differences were not seen among non-Medicaid patients.

Benefits of Catching Diabetes Earlier

The findings have major cost implications, Dr Kaufman told Medscape Medical News. "Most experts agree that earlier diagnosis of diabetes is beneficial. Delay in medical management means that elevated levels of glucose continue to damage blood vessels and organs throughout the body. Earlier intervention allows for patients to begin the arduous journey of lifestyle changes including diet, nutrition, and regular physical exercise."

He added, "Many studies have looked at the progression of diabetes and the progression of HbA1c. The national annual costs of treating diabetes and effects of decreased productivity are about $322 billion — or roughly $1000 for every person in the United States. Clearly, better diabetes outcomes should translate into lower costs across the healthcare spectrum."

And the phenomenon identified in this study might extend to other chronic conditions, he noted.

"While our study focused on early identification of diabetes, the findings suggest that similar patterns of newly diagnosed disease for conditions such as hypertension and chronic kidney disease may be observed in states that expanded Medicaid."

Dr Kaufman is a Quest employee. Disclosures for the coauthors are listed in the article. Dr Herman and Dr Cefalu have no relevant financial relationships.

Diabetes Care. Published online March 22, 2015. Abstract, Editorial


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