The Impact of the Affordable Care Act Medicaid Expansion on Acute Diabetes Complications Among Community Health Center Patients

Abstract

Objective:

This study evaluates whether patients residing in expansion states have a greater increase in outpatient diagnoses of acute diabetes complications than those living in non-expansion states following the implementation of the Affordable Care Act (ACA).

Methods:

This retrospective cohort study uses electronic health records (EHR) from 10,665 non-pregnant patients, aged 19 to 64 years old who were diagnosed with diabetes in 2012 or 2013 from 347 community health centers (CHCs) across 16 states (11 expansion and 5 non-expansion states). Patients included had ≥1 outpatient ambulatory visit in each of these periods: pre-ACA: 2012 to 2013, post-ACA: 2014 to 2016, and post-ACA: 2017 to 2019. Acute diabetes-related complications were identified using International Classification Diseases (ICD-9-CM and ICD-10-CM) codes classification and could occur on or after diagnosis of diabetes. We performed difference-in-differences (DID) analysis using a generalized estimating equation to compare the change in rates of acute diabetes complications by year and by Medicaid expansion status.

Results:

There was a greater increase after year 2015 in visits related to abnormal blood glucose among patient living in Medicaid expansion states than in non-expansion states (2017 DID = 0.041, 95% CI = 0.027-0.056). Although both visits due to any acute diabetes complications and infection-related diabetes complications were higher among patients living in Medicaid expansion states, there was no difference in the trend overtime between expansion and non-expansion states.

Conclusion:

We found a significantly greater rate of visits for abnormal blood glucose in patients receiving care in expansion states relative to patients in CHCs in non-expansion states starting in 2015. Additional resources for these clinics, such as the ability to provide blood glucose monitoring devices or mailed/delivered medications, could substantially benefit patients with diabetes.

Keywords

community health centers glucose Medicaid access to care diabetes

Introduction

Diabetes mellitus is the seventh leading cause of death worldwide and one of the most common chronic conditions affecting over 11% of the US population.¹ Diabetes is associated with avoidable and preventable acute complications. These serious and potentially life-threatening complications can profoundly affect the health and well-being of patients with diabetes and can lead to increases in emergency and overall care utilization. Moreover, medical expenditures for patients with diabetes can be up to 3 times higher than for the general population without diabetes.²

Economically and socially marginalized populations are at an increased risk for developing diabetes and, subsequently, diabetes complications.³ People experiencing economic and social disadvantages are more likely to have poor metabolic control, higher rates of being overweight or obese, as well as report higher rates of smoking and substance use,^4,5 all risk factors for diabetes complications.⁶ These patients face barriers to accessing diabetes care—many lack adequate insurance coverage and at-home health monitoring devices and face food insecurity, increasing their risk for diabetes complications.⁷ The Patient Protection and Affordable Care Act (ACA) substantially increased access to health insurance through state-based Medicaid eligibility expansions and individual health insurance marketplaces.⁸ Many studies have demonstrated associations between the ACA and improvements in diabetes diagnosis, access to ambulatory care, preventive services, medications, behavioral and mental health care, and chronic disease management; improved diabetes control; and reduction in diabetes expenditures.^9-19 The impact of ACA Medicaid expansions on acute diabetes complications is unknown. Related studies demonstrated that switching to high deductible health plans led to a rise in preventable acute diabetes complications among patients with low income;²⁰ others found an increase in diagnosis of health conditions following gaining insurance.^12,17 Based on this evidence, we hypothesize that patients residing in expansion states will have a greater increase in outpatient diagnoses of acute diabetes complications than those living in non-expansion states post-ACA. We test this hypothesis among patients receiving care in community health centers (CHCs). CHCs serve about 29 million patients yearly and provide services regardless of a patient’s ability to pay.^21,22 A substantial proportion of patients receiving care at CHCs have low income, with over 90% reporting incomes at or below 150% of the federal poverty level (FPL).²² Further, recent evidence found that the prevalence of acute diabetes complications among CHC patients with diabetes was 13%.²³

Methods

We conducted a retrospective cohort study using electronic health records (EHR) data from the Accelerating Data Value Across a National Community Health Center Network (ADVANCE) of CHCs.²⁴ ADVANCE data are from OCHIN (not an acronym) and Health Choice Network (HCN). OCHIN is one of the largest networks of CHCs utilizing a single instance of 1 EHR system. Similarly, HCN is a group of CHCs on a single EHR system. The data from OCHIN and HCN are centralized and standardized in the ADVANCE warehouse using the PCORnet common data model.²⁴

Data were obtained for 10 665 non-pregnant patients between 2012 and 2019, aged 19 to 64 years old without a history of Medicare coverage, who were diagnosed with diabetes (identified based on ICD-9-CM and ICD-10-CM codes from problem list and encounter diagnoses) in 2012 or 2013 and received care in 347 CHCs across 16 states (11 expansion and 5 non-expansion states). Patients included had ≥1 outpatient ambulatory visit in each of the following periods: (1) pre-ACA: 2012 to 2013, (2) post-ACA: 2014 to 2016, and (3) post-ACA: 2017 to 2019.

Our main independent variable was whether a patient lived in a state that expanded Medicaid (California, Hawaii, Maryland, Minnesota, New Mexico, Nevada, Ohio, Oregon, Rhode Island, Washington, and Wisconsin) or in a state that did not expand (Florida, Kansas, Missouri, North Carolina, and Texas).

Acute diabetes-related complications were identified using ICD-9-CM and ICD-10-CM codes classification and could occur on or after the first diagnosis of diabetes. Acute diabetes complications are defined by Wharam et al²⁰ as those requiring timely care by medical professional. Each qualifying acute diabetes complication was counted distinctly if the interval between each encounter diagnosis was at least 10 days. For example, if a patient had been diagnosed with a specific acute diabetes complication (eg, infection) twice in 2017 with an interval between the 2 diagnoses of ≥10 days, then 2 acute complications would have been counted. We assessed overall acute diabetes complications and also specific complications: infection-related diabetes complications (e.g., urinary tract infection, cellulitis, and hear infections) and abnormal blood glucose diabetes (e.g., hyperosmolarity, hypoglycemic with or without coma) complications; which are the most common complications in this patient population. A study of CHCs patients found that the most common acute complications were infections (54.4%), abnormal blood glucose or related metabolic abnormalities (22.3%), and myocardial infarction or transient coronary artery ischemia (7.6%).²³

Characteristics of patients with diabetes included the following sociodemographic and health-related factors: sex, age, race and ethnicity, federal poverty level, patient rural/urban residential classification,²⁵ and insurance status (public, private, uninsured, other) at time of the diabetes diagnosis. We also assessed body mass index (at the time of diabetes diagnosis), average glycosylated hemoglobin (HbA1_C) levels over the study period, whether insulin was prescribed during the study period, number of ambulatory visits, and a modified Charlson comorbidity index score²⁶ which excluded the diabetes diagnosis. Patients with BMI < 25 (including normal and underweight) were grouped together as very few patients were underweight. We also included the size of the clinic categorized using tertiles.

We summarized the characteristics of the patients and estimated unadjusted rates of acute diabetes complication by Medicaid expansion status. We performed difference-in-differences (DID) using a generalized estimating equation (GEE) model assuming a Gaussian distribution and an identity link function with clustering on patients to account for the temporal correlation of visits within patients assuming an exchangeable working correlation structure. The DID study design compares the changes in acute complication outcomes that occurred during the expansion of Medicaid between states that expanded to those that did not. GEE models included indicators for categorical time (year), expansion status, their interaction and controlled for patient self-reported race and ethnicity, age, sex, federal poverty level, insurance, number of ambulatory visits, patient location, Charlson score, body mass index, and for clinic size. Similar GEE models were applied on infection-related and abnormal blood glucose diabetes complication outcomes. All models employed robust standard errors. Statistical tests were performed with a 2-sided α = .05. Analyses were conducted using R (version 4.1.1) and Stata (version 17). The study was approved by the Oregon Health & Science University Institutional Review Board (IRB#00011858).

Results

Patient characteristics were similar in expansion and non-expansion states (Table 1). A greater proportion of patients with diabetes were Hispanic and non-Hispanic Black, uninsured at time of diagnosis, and overweight or obese. Overall acute diabetes complications increased over time and were higher among patients from expansion states than non-expansion states (Figure 1, panel A), though the difference in the trend overtime by expansion status was mainly non-significant in the adjusted model (Table 2). The rate of diabetes-related infections (Figure 1, panel B) increased slightly over time and had a similar trend (Table 2) in expansion and non-expansion states. Figure 1 panel C shows a significantly higher increase after 2015 in abnormal blood glucose complications among patients in expansion states than those in in non-expansion states. For example, the estimated covariate-adjusted average difference (Table 2) in the 2017 versus 2013 rates of abnormal blood glucose complications was 4 per 100 patients (DID = 0.041, 95% CI = 0.027-0.056) higher in expansion states than the estimated difference in non-expansion states; similar difference-in-differences estimates were found across the other years post-2015.

Table 1.

Characteristics of Patients Diagnosed With Diabetes in 2012 or 2013 By Expansion Status.

	Expansion states^a (N = 6241)	Non-expansion states^b (N = 4424)
Sex, n (%)
Male	2802 (44.9)	1898 (42.9)
Female	3439 (55.1)	2526 (57.1)
Age at diabetes diagnosis visit, n (%)
19-44	2546 (40.8)	1597 (36.1)
45-64	3695 (59.2)	2827 (63.9)
Race/ethnicity, n (%)
Hispanic	3102 (49.7)	2027 (45.8)
NH Black	891 (14.3)	1342 (30.3)
NH White	1767 (28.3)	769 (17.4)
NH other	270 (4.3)	79 (1.8)
Unknown	211 (3.4)	207 (4.7)
Household income, n (%)^c
>138% FPL	4245 (68.0)	3650 (82.5)
≤138% FPL	628 (10.1)	429 (9.7)
Unknown	1368 (21.9)	345 (7.8)
Insurance status, n (%)^c
Uninsured	3210 (51.4)	2765 (62.5)
Medicaid	1905 (30.5)	805 (18.2)
Private insurance	849 (13.6)	386 (8.7)
Other	277 (4.4)	468 (10.6)
BMI at diabetes diagnosis visit, n (%)^c,d
≤25 kg/m²	533 (8.5)	470 (10.6)
>25	5684 (91.1)	3953 (89.4)
Unknown	24 (0.4)	1 (0.0)
Insulin prescription during the period, n (%)
Yes	2701 (43.3)	2092 (47.3)
No	3540 (56.7)	2332 (52.7)
HbA1c over the period, mean (SD)	8.00 (1.73)	8.21 (1.82)
Total Charlson comorbidities at the end of 2019, n (%)^e
0	3038 (48.6)	2493 (56.4)
1	1913 (30.7)	1225 (27.7)
≥2	1290 (20.7)	706 (15.9)
Ambulatory visits/patient in the first year after diabetes diagnosis, mean (SD)	6.48 (4.78)	5.31 (3.63)
Yearly ambulatory visits/patient in the first 5 years following diabetes diagnosis, mean (SD)	4.81 (3.24)	3.96 (2.35)
Clinic location, n (%)
Rural clinic	1667 (26.7)	915 (20.7)
Suburban	238 (3.8)	183 (4.1)
Urban Clinic	4336 (69.5)	3326 (75.2)
Clinic size, n (%)
Large (>2544 patients)	1809 (29.0)	1779 (40.2)
Medium	2191 (35.1)	1379 (31.2)
Small (<1387 patients)	2241 (35.9)	1266 (28.6)
Acute diabetes complication over the entire period, n (%)
0	3261 (52.3)	2876 (65.0)
≥1	2980 (47.7)	1548 (35.0)

Expansion states include California, Hawaii, Maryland, Minnesota, New Mexico, Nevada, Ohio, Oregon, Rhode Island, Washington, and Wisconsin. ^bNon-expansion states include Florida, Kansas, Missouri, North Carolina, and Texas. ^cThese measurements were recorded after and closest to their first diabetes diagnosis dates. ^dPatients with BMI < 25 (including normal and underweight) were grouped together as very few patients were underweight. ^eCharlson comorbidity index score was calculated excluding the diabetes diagnosis because all included patients had diabetes.

Figure 1.

Annual rates of all, infection-related, and abnormal blood glucose complications by years and expansion status among patients diagnosed with diabetes in 2012 or 2013. Panel A: All acute diabetes complications, Panel B: Infections, and Panel C: Abnormal blood glucose.

Table 2.

GEE Estimates in Modeling Acute Diabetes Complications From Pre- to Post-Medicaid Expansion in 347 Community Health Centers Across 16 States.

	All acute complications	Infection complication	Abnormal blood glucose
	Estimate [95% CI]	Estimate [95% CI]	Estimate [95% CI]
Expansion status
Non-expansion	Reference	Reference	Reference
Expansion	0.030 [0.012, 0.048]	0.021 [0.006, 0.036]	0.00 [−0.005, 0.005]
Year
2013	Reference	Reference	Reference
2014	0.008 [−0.006, 0.022]	0.009 [−0.003, 0.021]	0.000 [−0.003, 0.004]
2015	0.042 [0.026, 0.058]	0.025 [0.011, 0.038]	0.013 [0.007, 0.019]
2016	0.028 [0.011, 0.044]	0.009 [−0.004, 0.022]	0.016 [0.009, 0.024]
2017	0.038 [0.022, 0.054]	0.017 [0.003, 0.03]	0.016 [0.010, 0.022]
2018	0.076 [0.059, 0.094]	0.033 [0.019, 0.047]	0.025 [0.018, 0.032]
2019	0.070 [0.053, 0.087]	0.026 [0.013, 0.039]	0.026 [0.018, 0.034]
Difference-in-differences
Expansion status × year
Expansion × 2014	0.002 [−0.020, 0.025]	0.000 [−0.02, 0.019]	0.001 [−0.005, 0.007]
Expansion × 2015	−0.027 [−0.052, −0.002]	−0.017 [−0.038, 0.003]	−0.01 [−0.017, −0.002]
Expansion × 2016	0.014 [−0.013, 0.040]	−0.007 [−0.027, 0.014]	0.018 [0.006, 0.029]
Expansion × 2017	0.022 [−0.006, 0.049]	−0.022 [−0.043, −0.002]	0.041 [0.027, 0.056]
Expansion × 2018	0.014 [−0.014, 0.043]	−0.016 [−0.037, 0.005]	0.036 [0.022, 0.049]
Expansion × 2019	0.011 [−0.016, 0.038]	−0.014 [−0.035, 0.006]	0.023 [0.010, 0.036]

Models were adjusted for race and ethnicity, sex, age, federal poverty level, Charlson score, body mass index, health insurance coverage, patient geographic location, clinic size, and number of ambulatory visits in each observation year. Bolded results at significant at P < .05.

Conclusion

We found a significantly greater rates of visits for abnormal blood glucose in CHCs patients receiving care in expansion states relative to patients in non-expansion states starting in 2015. A wealth of evidence demonstrates that people without adequate health insurance coverage forgo or delay care, which can result in emergency department use.²⁷ Conversely, gaining insurance leads to improved access to and utilization of outpatient clinic visits and preventive services, which are mechanisms through which health conditions can be diagnosed. It is likely that gaining health insurance helped improve access to needed care for CHC patients with diabetes, especially in expansion states. This access likely allowed for a better quantification of their abnormal blood glucose events and demonstrated the need for CHCs to provide chronic disease management and enhanced support to assist patients with diabetes improve self-management. Repeated visits with abnormal blood glucose also reveal that diabetes self-care continues to be challenging for patients, even after gaining health insurance. For example, many of these patients may still be unable to afford healthy food, be physically active, adhere to prescription medication schedules, or have no access to blood glucose monitoring devices.²⁸ CHCs play a critical role in reducing, but not completely eliminating, the adverse effect of social risks among their patients.⁷ Additional resources for these clinics, such as the ability to provide blood glucose monitoring devices or mailed/delivered medications, could substantially benefit socioeconomically marginalized patients with diabetes.

The results clearly demonstrate that patients have access to care with numerous visits over the study period and an average HbA1c of about 8% suggesting some diabetes control. These findings highlight the quality of care CHCs provide regardless of expansion status. Notably, previous studies have shown that gaining insurance in states that expanded Medicaid was associated with increase diabetes control,²⁹ especially among patients of Hispanic ethnicity receiving care in CHCs. Future studies are needed to assess whether the findings observed here differ by population subgroups.

Several limitations must be acknowledged. The Centers for Disease Control and Prevention reports that nearly 1 in 4 individuals with diabetes are undiagnosed.³⁰ It is possible that the rates of acute complications reported underestimate the actual rates of diabetes-related complications because we considered complications among patients with a recorded diabetes diagnosis. Additionally, it is also possible that acute diabetes complications were underestimated due to the fact that we did not have access to emergency department or hospitalization records for our study population. Wharam et al²⁰ defined their acute complication as requiring “urgent or emergent” care which is better identified in emergency department codes than outpatient data. Further, it is possible that some complications identified as acute are in fact chronic. Also, our sample included CHCs that are part of the ADVANCE network and may not be representative of all primary care clinics and all US states. Lastly, by design (to limit the impact of the length of time since diabetes diagnosis on acute complications), we limited our sample to include patients diagnosed in 2012 and 2013 resulting in 1 pre-ACA year data point, and thus were unable to rigorously assess the pre-ACA parallel trend assumption. Visual inspection of the pre-ACA among the 2012 cohort only, show parallel trends (data not shown).

In summary, using electronic health records, we found a greater increase in rate of abnormal blood glucose among patients receiving care in outpatient community health centers in expansion states than in non-expansion states.

Footnotes

Acknowledgements

The authors acknowledge the significant contribution to this study that were provided by collaborating investigators in the NEXT-D3 (Natural Experiments in Translation for Diabetes 3.0) Study. This work was conducted with the Accelerating Data Value Across a National Community Health Center Network (ADVANCE) Clinical Research Network (CRN). ADVANCE is a CRN in PCORnet^®, the National Patient Centered Outcomes Research Network. ADVANCE is led by OCHIN in partnership with Health Choice Network, Fenway Health, and Oregon Health & Science University.

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: Research reported in this publication was supported by the Centers for Disease Control and Prevention (CDC) grant (U18DP006536). The content is solely the responsibility of the authors and does not necessarily represent the official views of the CDC. ADVANCE’s participation in PCORnet^® is funded through the Patient-Centered Outcomes Research Institute (PCORI), contract number RI-OCHIN-01-MC.

ORCID iDs

Nathalie Huguet

Annie E. Larson

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