The Affordable Care Act: Effects of Insurance on Diabetes Biomarkers.

Abstract

We sought to understand how Affordable Care Act (ACA) Medicaid expansion insurance coverage gains are associated with changes in diabetes-related biomarkers. This was a retrospective observational cohort study using electronic health record data from 178 community health centers (CHCs) in the ADVANCE (Accelerating Data Value Across a National Community Health Center Network) network. We assessed changes in diabetes-related biomarkers among adult patients with diabetes in 10 Medicaid expansion states (<i>n</i> = 25,279), comparing newly insured with continuously insured, discontinuously insured, and continuously uninsured patients pre- to post-ACA expansion. Primary outcomes included changes from 24 months pre- to 24 months post-ACA in glycosylated hemoglobin (HbA_1c), systolic (SBP) and diastolic (DBP) blood pressure, and LDL cholesterol levels. Newly insured patients exhibited a reduction in adjusted mean HbA_1c levels (8.24% [67 mmol/mol] to 8.17% [66 mmol/mol]), which was significantly different from continuously uninsured patients, whose HbA_1c levels increased (8.12% [65 mmol/mol] to 8.29% [67 mmol/mol]; difference-in-differences [DID] -0.24%; <i>P</i> < 0.001). Newly insured patients showed greater reductions than continuously uninsured patients in adjusted mean SBP (DID -1.8 mmHg; <i>P</i> < 0.001), DBP (DID -1.0 mmHg; <i>P</i> < 0.001), and LDL (DID -3.3 mg/dL; <i>P</i> < 0.001). Among patients with elevated HbA_1c in the 3 months prior to expansion, newly insured patients were more likely than continuously uninsured patients to have a controlled HbA_1c measurement by 24 months post-ACA (hazard ratio 1.25; 95% CI 1.02-1.54]. Post-ACA, newly insured patients had greater improvements in diabetes-related biomarkers than continuously uninsured, discontinuously insured, or continuously insured patients. Findings suggest that health insurance gain via ACA facilitates access to appropriate diabetes care, leading to improvements in diabetes-related biomarkers.