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The diabetes-related major amputation rate improved among adults in underrepresented groups in states with early expansion of Medicaid compared with non-expansion states, according to published results.

“Our cohort study demonstrated reduction in diabetic foot ulcer-related hospitalizations and leg amputation for non-white patients in early Medicaid expansion states compared to non-expansion states following the Affordable Care Act,” Tze-Woei Tan, MD, MPH, FACS, told Healio. “The study highlights the benefit of expanding insurance coverage for low-income populations at disproportionately elevated risks of diabetes related amputation.”


After Medicaid expansion, early adopter states had no change in amputation rate among patients with diabetic foot ulcers (0.08%), while non-adopter states had a 9% increase in amputation rate. Data derived from Tan TW, et al. JAMA Netw Open. 2022;doi:10.1001/jamanetworkopen.2022.3991.

Using the State Inpatient Databases for 19 states and Washington, DC, from 2013 to the third quarter of 2015, Tan and colleagues collected data on hospitalizations for diabetic foot ulcers among African American, Asian and Pacific Islander, American Indian or Alaska Native, and Hispanic adults, as well as patients aged 20 to 64 years who had another racial or ethnic identification of an underrepresented group. Researchers categorized states into early adopter states (n=12) if Medicaid expansion occurred by Jan. 1, 2014, and non-adopter states (n=7). Researchers performed Poisson regression to examine the associations of state type, time and combined association of these with the proportional changes of major amputation rate per year per 100,000 population.

Tze Woei Tan

Tze Woei Tan

Among 115,071 hospitalizations among racial and ethnic adults from underrepresented groups with diabetic foot ulcers, results showed 32% of hospitalizations occurred for Medicaid beneficiaries and 9% for uninsured patients. Researchers found a significant difference in the rate of hospitalizations between early adopter and non-adopter states, with a 3% increase in hospitalizations in early adopter states vs. an 8% increase in non-adopter states after expansion.

Researchers noted, after expansion, early adopter states had no change in amputation rate (0.08%), while non-adopter states had a 9% increase in amputation rate. The decrease in amputation rate differed significantly among uninsured adults, with a 33% decrease in amputation rate in early adopter states and no change in amputation rate (12%) in non-adopter states after expansion, according to results. Researchers found no difference in the change of amputation rate among Medicaid beneficiaries between state types after expansion.

“The major amputation rates for racial and ethnic minority adults with [diabetic foot ulcers] significantly blunted in early adopter states compared with non-adopter states after Medicaid expansion,” the authors wrote in the study. “This finding could be because of the recruitment of uninsured adults into the Medicaid program. Importantly, Medicaid beneficiaries in early adopter states did not experience a significant change in the amputation rate despite the transition of at-risk uninsured adults into the Medicaid program. Taken together, this study highlights the potential benefit of the ACA for populations at disproportionately elevated risks of diabetes-related amputation.”

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