Diabetes diagnoses surge in states that expanded Medicaid under the affordable care act

People in states that expanded Medicaid under the Affordable Care Act (ACA) are far more likely to be newly identified with diabetes than in states that elected not to expand the public health care program, finds a new study by researchers at Quest Diagnostics (NYSE: DGX). Published online in Diabetes Care, the official publication of the American Diabetes Association, the study is believed to be one of the first nationally representative analyses of the impact of the ACA in promoting earlier diagnosis of, and potentially better outcomes for, diabetes.

In an accompanying editorial, William T. Cefalu, M.D., editor in chief, Diabetes Care, and William H. Herman, M.D., wrote, "Kaufman et al. have again demonstrated that Medicaid expansion increases the number of low-income Americans with newly identified diabetes and will likely improve their outcomes. 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 analysis of de-identified test results of 434,288 people with newly identified diabetes, tested by Quest Diagnostics, found that newly identified diabetes surged 23 percent in Medicaid-enrolled patients in states that expanded Medicaid, but increased less than one percent (0.4 percent) in states that did not expand. The newly identified patients with diabetes were also more likely to be identified at earlier stages of disease in states that expanded Medicaid than in those that did not.

In the United States, approximately 1.7 million people are diagnosed with diabetes each year; overall, the cost of health care and lost productivity associated with diabetes is estimated at about $322 billion annually. Undetected and untreated, diabetes typically worsens, causing heart disease, blindness, kidney failure or death.

"This seminal study demonstrates that the ACA promotes earlier diagnosis of one of the most prevalent and treatable chronic health conditions in the United States," said study co-investigator Vivian A. Fonseca, M.D., FRCP, past president, medicine and science, American Diabetes Association and professor of medicine, Tulane University School of Medicine. "But these benefits were not shared equally across states. This study demonstrates the need for additional debate on the merits of health care reform to promote equal access to health services."

"Our study demonstrates the value of objective insights gleaned from aggregate diagnostic data for informing population health strategies that can promote better health outcomes," said Jay Wohlgemuth, M.D., senior vice president and chief scientific officer - research, development and medical, Quest Diagnostics. "We hope that the use of our population data in this research enlightens the decisions of policy makers considering reforms in the area of preventive health services."

Effective January 1, 2014, the Affordable Care Act expanded Medicaid for uninsured adults with income at or below 138% of the federal poverty level, expanding access to millions of people who were previously excluded from the public health insurance program and who likely did not have private health insurance. At the time of the Quest Diagnostics analysis, twenty-six states and the District of Columbia had agreed to expand Medicaid, while twenty-four states had not.

Researchers at Quest Diagnostics analyzed de-identified test results for people between the ages of 19 and 64 of both genders across the United States who met the definition of newly diagnosed diabetes during the first six months of 2013 (prior to Medicaid expansion) and the first six months of 2014 (following Medicaid expansion). Newly diagnosed diabetes was determined based on at least one blood test for hemoglobin A1c, a marker of diabetes, greater than 6.4% or an ICD-9 code for diabetes mellitus with no prior diagnosis for the preceding year.

Key findings:

• Diabetes diagnosis rates surged in states that expanded Medicaid. Newly identified diabetes in Medicaid patients surged 23.2 percent in Medicaid expansion states, but increased less than one percent (0.4 percent) in states that chose not to expand.
• People with diabetes were caught at earlier stages in states that expanded Medicaid. Hemoglobin A1c blood levels generally correspond to disease severity. The Quest scientists found lower hemoglobin A1c levels in newly identified patients in expansion states versus those in non-expansion states. Patients with diabetes may experience better disease management when diagnosed and treated at an earlier stage.
• Older patients experienced the highest rates of diabetes diagnoses in Medicaid expansion states. For older patients (50-64 years of age), the increase of Medicaid patients with newly identified diabetes was 31.2 percent in the expansion states, compared to only 0.5 percent in the non-expansion states. For younger patients (19-49 years of age), Medicaid patients with newly identified diabetes increased nearly 15 percent in the expansion states, with essentially no change in the non-expansion states.
• Men had higher rates of diabetes diagnosis than women. Diagnoses of Medicaid-enrolled men increased 25.5 percent in the expansion states, while diagnoses for women increased 22 percent. Among Medicaid enrollees in non-expansion states, rates of diagnoses for men increased 4.6 percent and decreased 1.4 percent for women. The Quest researchers hypothesize that because women tend to use health services more than men, women with diabetes may have been more likely to have been previously diagnosed. Men may also have higher diabetes risk than women.

"Not only did states with expanded Medicaid programs catch more people with diabetes, they caught them at earlier stages, when the disease is more manageable," said study lead investigator Harvey W. Kaufman, M.D., senior medical director, Quest Diagnostics. "These findings likely apply to other chronic conditions, like heart and chronic kidney disease, for which early diagnosis and treatment strongly correlate with better health outcomes.

"While more research is needed, we theorize that states that have expanded Medicaid may experience fewer diabetes complications and health care costs over time than those that did not expand, and that this pattern may apply to other chronic diseases," added Dr. Kaufman. "We look forward to results of additional research into the long-term health and economic impacts of greater access to healthcare services as a result of Medicaid expansion."

Study Strengths and Limitations

The study's strengths are its size and national scope; the significant percentage of the Medicaid testing being provided by Quest Diagnostics laboratories, leading to a representative sampling; and the use of an objective laboratory method, versus surveys or polls, which may be subject to user misrepresentation or error. Study limitations include reliance on testing requisitions and results rather than clinical information to determine a newly diagnosed individual. Quest Diagnostics does not provide services to all clinicians in the U.S., so results are not broadly representative of all patients tested in the U.S. The study was performed in compliance with applicable privacy regulations and the company's strict privacy policies, and was determined to be exempt from Western Institutional Review Board.