Advertisement

Impact of Expanded Medicaid Eligibility on the Diabetes Continuum of Care Among Low-Income Adults: A Difference-in-Differences Analysis

  • Lily D. Yan
    Correspondence
    Address correspondence to: Lily D. Yan, MD, MSc, Department of Internal Medicine, Center for Global Health, Weill Cornell Medicine, 402 East 67th Street, 2nd Floor, New York, NY 10065.
    Affiliations
    Department of Internal Medicine, Boston Medical Center, Boston, Massachusetts

    Health Law, Policy and Management, Boston University School of Public Health, Boston, Massachusetts
    Search for articles by this author
  • Mohammed K. Ali
    Affiliations
    Hubert Department of Global Health, Emory University Rollins School of Public Health, Atlanta, Georgia

    Department of Family and Preventive Medicine, Emory University School of Medicine, Atlanta, Georgia
    Search for articles by this author
  • Kiersten L. Strombotne
    Affiliations
    Health Law, Policy and Management, Boston University School of Public Health, Boston, Massachusetts
    Search for articles by this author
Published:November 11, 2020DOI:https://doi.org/10.1016/j.amepre.2020.08.013

      Introduction

      The impact of Medicaid expansion on linkage to care, self-maintenance, and treatment among low-income adults with diabetes was examined.

      Methods

      A difference-in-differences design was used on data from the Behavioral Risk Factor Surveillance System, 2008–2018. Analysis was restricted to states with diabetes outcomes and nonpregnant adults aged 18–64 years who were Medicaid eligible on the basis of income. Separate analyses were performed for early postexpansion (1, 2, 3) and late postexpansion years (4, 5). Analyses were performed from September 2019 to March 2020.

      Results

      In comparing expansion with control states, low-income residents with diabetes had similar ages (48.9 vs 49.1 years) and similar proportions who were female (54.4% vs 55.0%) but were less likely to be Black, non-Hispanic (20.8% vs 29.2%, standardized difference= −16.3%). In expansion states, health insurance increased by 7.2 percentage points (95% CI=3.9, 10.4), and the ability to afford a physician increased by 5.5 percentage points (95% CI=1.9, 9.1) in the early years, but no difference was found in late years. Medicaid expansion led to a 5.3-percentage point increase in provider foot examinations in the early period (95% CI=0.14, 10.4) and a 7.2-percentage point increase in self-foot examinations in the late period (95% CI=1.1, 13.3). No statistically significant changes were detected in self-reported linkage to care, self-maintenance, or treatment.

      Conclusions

      Although health insurance, ability to afford a physician visit, and foot examinations increased for Medicaid-eligible people with diabetes, there was no statistically significant difference found for other care continuum measures.
      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'

      Subscribe:

      Subscribe to American Journal of Preventive Medicine
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect

      REFERENCES

      1. National diabetes statistics report, 2020. Centers for Disease Control and Prevention, HHS. https://www.cdc.gov/diabetes/data/statistics/statistics-report.html. Updated January 2020. Accessed February 20, 2020.

        • Kochanek KD
        • Murphy SL
        • Xu J
        • Arias E
        Deaths: final data for 2017.
        Natl Vital Stat Rep. 2019; 68: 1-77
        • American Diabetes Association
        1. Improving care and promoting health in populations: standards of medical care in diabetes-2019.
        Diabetes Care. 2019; 42: S7-S12
        • Low Wang CC
        • Hess CN
        • Hiatt WR
        • Goldfine AB
        Clinical update: cardiovascular disease in diabetes mellitus: atherosclerotic cardiovascular disease and heart failure in type 2 diabetes mellitus - mechanisms, management, and clinical considerations.
        Circulation. 2016; 133: 2459-2502
        • Giordano TP.
        The HIV treatment cascade–a new tool in HIV prevention.
        JAMA Intern Med. 2015; 175: 596-597
        • Perlman DC
        • Jordan AE
        • Nash D
        Conceptualizing care continua: lessons from HIV, hepatitis C virus, tuberculosis and implications for the development of improved care and prevention continua.
        Front Public Health. 2016; 4: 296
        • Ali MK
        • Bullard KM
        • Gregg EW
        • Del Rio C
        A cascade of care for diabetes in the United States: visualizing the gaps.
        Ann Intern Med. 2014; 161: 681-689
        • Nelson KM
        • Chapko MK
        • Reiber G
        • Boyko EJ
        The association between health insurance coverage and diabetes care; data from the 2000 Behavioral Risk Factor Surveillance System.
        Health Serv Res. 2005; 40: 361-372https://doi.org/10.1111/j.1475-6773.2005.0d362.x
        • Doucette ED
        • Salas J
        • Scherrer JF
        Insurance coverage and diabetes quality indicators among patients in NHANES.
        Am J Manag Care. 2016; 22: 484-490
        • Zhang X
        • Geiss LS
        • Cheng YJ
        • Beckles GL
        • Gregg EW
        • Kahn HS
        The missed patient with diabetes: how access to health care affects the detection of diabetes.
        Diabetes Care. 2008; 31: 1748-1753
        • Garfield RL
        • Damico A.
        Medicaid expansion under health reform may increase service use and improve access for low-income adults with diabetes.
        Health Aff (Millwood). 2012; 31: 159-167
        • Kazemian P
        • Shebl FM
        • McCann N
        • Walensky RP
        • Wexler DJ
        Evaluation of the cascade of diabetes care in the United States, 2005-2016.
        JAMA Intern Med. 2019; 179: 1376-1385
        • Wherry LR
        • Miller S.
        Early coverage, access, utilization, and health effects of the Affordable Care Act Medicaid expansions: a quasi-experimental study.
        Ann Intern Med. 2016; 164: 795-803
        • Loehrer AP
        • Chang DC
        • Scott JW
        • et al.
        Association of the Affordable Care Act Medicaid expansion with access to and quality of care for surgical conditions.
        JAMA Surg. 2018; 153e175568
        • Cole MB
        • Galárraga O
        • Wilson IB
        • Wright B
        • Trivedi AN
        At federally funded health centers, Medicaid expansion was associated with improved quality of care.
        Health Aff (Millwood). 2017; 36: 40-48
        • Goldman AL
        • Sommers BD.
        Among low-income adults enrolled in Medicaid, churning decreased after the Affordable Care Act.
        Health Aff (Millwood). 2020; 39: 85-93
        • Choi S
        • Lee S
        • Matejkowski J
        The effects of state Medicaid expansion on low-income individuals’ access to health care: multilevel modeling.
        Popul Health Manag. 2018; 21: 235-244
        • Gotanda H
        • Kominski G
        • Tsugawa Y
        Association between the ACA Medicaid expansions and primary care and emergency department use during the first 3 years.
        J Gen Intern Med. 2020; 35: 711-718
        • Sommers BD
        • Blendon RJ
        • Orav EJ
        • Epstein AM
        Changes in utilization and health among low-income adults after Medicaid expansion or expanded private insurance.
        JAMA Intern Med. 2016; 176: 1501-1509
        • Courtemanche C
        • Marton J
        • Ukert B
        • Yelowitz A
        • Zapata D
        Effects of the Affordable Care Act on health care access and self-assessed health after 3 years.
        Inquiry. 2018; 5546958018796361
        • McWilliams JM
        • Meara E
        • Zaslavsky AM
        • Ayanian JZ
        Health of previously uninsured adults after acquiring Medicare coverage.
        JAMA. 2007; 298: 2886-2894
        • Guth M
        • Garfield R
        • Rudowitz R
        The effects of Medicaid expansion under the ACA: updated findings from a literature review.
        Kaiser Family Foundation, San Francisco, CAPublished March 17, 2020 (Published)
        • Mazurenko O
        • Balio CP
        • Agarwal R
        • Carroll AE
        • Menachemi N
        The effects of Medicaid expansion under the ACA: a systematic review.
        Health Aff (Millwood). 2018; 37: 944-950
        • Khatana SAM
        • Bhatla A
        • Nathan AS
        • et al.
        Association of Medicaid expansion with cardiovascular mortality [published correction appears in JAMA Cardiol. 2019;4(7):714].
        JAMA Cardiol. 2019; 4: 671-679
        • Kravitz-Wirtz N
        • Davis CS
        • Ponicki WR
        • et al.
        Association of Medicaid expansion with opioid overdose mortality in the United States.
        JAMA Netw Open. 2020; 3e1919066
        • Cher BAY
        • Morden NE
        • Meara E
        Medicaid expansion and prescription trends: opioids, addiction therapies, and other drugs.
        Med Care. 2019; 57: 208-212
        • Wen H
        • Hockenberry JM
        • Borders TF
        • Druss BG
        Impact of Medicaid expansion on Medicaid-covered utilization of buprenorphine for opioid use disorder treatment [published correction appears in Med Care. 2019;57(3):243].
        Med Care. 2017; 55: 336-341
        • Kaufman HW
        • Chen Z
        • Fonseca VA
        • McPhaul MJ
        Surge in newly identified diabetes among Medicaid patients in 2014 within Medicaid expansion states under the Affordable Care Act.
        Diabetes Care. 2015; 38: 833-837
        • Casagrande SS
        • McEwen LN
        • Herman WH
        Changes in health insurance coverage under the Affordable Care Act: a national sample of U.S. adults with diabetes, 2009 and 2016.
        Diabetes Care. 2018; 41: 956-962
        • Yue D
        • Zhu Y
        • Rasmussen PW
        • Godwin J
        • Ponce NA
        Coverage, affordability, and care for low-income people with diabetes: 4 years after the Affordable Care Act's Medicaid expansions.
        J Gen Intern Med. 2020; 35: 2222-2224
        • Luo H
        • Chen ZA
        • Xu L
        • Bell RA
        Health care access and receipt of clinical diabetes preventive care for working-age adults with diabetes in states with and without Medicaid expansion: results from the 2013 and 2015 BRFSS.
        J Public Health Manag Pract. 2019; 25: E34-E43
        • Lee J
        • Callaghan T
        • Ory M
        • Zhao H
        • Bolin JN
        The impact of Medicaid expansion on diabetes management.
        Diabetes Care. 2020; 43: 1094-1101
        • Andersen RM.
        Revisiting the behavioral model and access to medical care: does it matter?.
        J Health Soc Behav. 1995; 36: 1-10
        • Rosenbaum S
        • Westmoreland TM.
        The Supreme Court's surprising decision on the Medicaid expansion: how will the federal government and states proceed?.
        Health Aff (Millwood). 2012; 31: 1663-1672
        • Dimick JB
        • Ryan AM.
        Methods for evaluating changes in health care policy: the difference-in-differences approach.
        JAMA. 2014; 312: 2401-2402
        • Pierannunzi C
        • Hu SS
        • Balluz L
        A systematic review of publications assessing reliability and validity of the Behavioral Risk Factor Surveillance System (BRFSS), 2004-2011.
        BMC Med Res Methodol. 2013; 13: 49
        • Centers for Disease Control and Prevention
        Behavioral risk factor surveillance System: 2018 summary data quality report.
        Centers for Disease Control and Prevention, Atlanta, GAPublished July 17, 2019 (Published)
        • Altonji JG
        • Elder TE
        • Taber CR
        Selection on observed and unobserved variables: assessing the effectiveness of Catholic schools.
        National Bureau of Economic Research, Cambridge, MAPublished August 2000
        https://www.nber.org/papers/w7831.pdf
        Date accessed: March 11, 2020
        (Published)
      2. Prior HHS poverty guidelines and federal register references. Office of the Assistant Secretary for Planning and Evaluation, HHS. https://aspe.hhs.gov/prior-hhs-poverty-guidelines-and-federal-register-references. Updated January 2020. Accessed March 11, 2020.

        • Hest R.
        Four methods for calculating income as a percent of the federal poverty guideline (FPG) in the Behavioral Risk Factor Surveillance System (BRFSS).
        State Health Access Data Assistance Center, Minneapolis, MNPublished May 2019 (Published)
        • Kaiser Family Foundation
        Status of state Medicaid expansion decisions: interactive map.
        Kaiser Family Foundation, San Francisco, CAPublished February 19, 2020 (Published)
        • Harris MI
        Frequency of blood glucose monitoring in relation to glycemic control in patients with type 2 diabetes.
        Diabetes Care. 2001; 24: 979-982
        • Baicker K
        • Taubman SL
        • Allen HL
        • et al.
        The Oregon Experiment–effects of Medicaid on clinical outcomes.
        N Engl J Med. 2013; 368: 1713-1722
        • Austin PC.
        Using the standardized difference to compare the prevalence of a binary variable between two groups in observational research.
        Commun Stat Simul Comput. 2009; 38: 1228-1234
        • Greene W.
        The behaviour of the maximum likelihood estimator of limited dependent variable models in the presence of fixed effects.
        Econometrics J. 2004; 7: 98-119
      3. Zeldow B, Hatfield LA. Confounding and regression adjustment in difference-in-differences. ArXiv. 191112185 Stat. Preprint posted online November 27, 2019. http://arxiv.org/abs/1911.12185. Accessed February 13, 2020.

        • Bertrand M
        • Duflo E
        • Mullainathan S
        How much should we trust differences-in-differences estimates?.
        Q J Econ. 2004; 119: 249-275
        • Myerson R
        • Laiteerapong N.
        The Affordable Care Act and diabetes diagnosis and care: exploring the potential impacts.
        Curr Diab Rep. 2016; 16: 27
        • van den Arend IJ
        • Stolk RP
        • Krans HM
        • Grobbee DE
        • Schrijvers AJ
        Management of type 2 diabetes: a challenge for patient and physician.
        Patient Educ Couns. 2000; 40: 187-194
        • Myerson R
        • Lu T
        • Tonnu-Mihara I
        • Huang ES
        Medicaid eligibility expansions may address gaps in access to diabetes medications.
        Health Aff (Millwood). 2018; 37: 1200-1207