States that chose to expand Medicaid for low-income Americans under President Barack Obama's health care law have seen a surge in diabetes diagnoses, a new study shows, particularly during the disease's earlier stages when changes in lifestyle can have a significant impact on a person's later health.

Patients with newly identified diabetes in expansion (blue) and nonexpansion (red) states. Courtesy American Diabetes Association/Diabetes Care

Conducted by Quest Diagnostics and published Monday in the journal Diabetes Care, the analysis found that newly identified diabetes cases among Medicaid-enrolled patients jumped 23 percent in states that expanded the program, but increased by less than 1 percent – 0.4 percent – in states that did not.

The portion of the Affordable Care Act that deals with Medicaid has come under political and financial scrutiny, and finally resulted in a legal battle. The law originally intended for all states to expand Medicaid, but the Supreme Court ruled in 2012 that states could choose whether they wanted to do so.

At the time of the analysis, 26 states and the District of Columbia had expanded Medicaid. Since then, two additional states have expanded the program, and more are considering the move. More than 11 million Americans have enrolled in Medicaid or the Children's Health Insurance Program – which provides coverage for children in low-income families that earn too much to qualify for Medicaid – since the first open enrollment period for Obamacare began in October 2013.

The new study shows the direct impact Obamacare can have on people's health.



"It allowed for a very interesting natural experiment to see what coverage and access would do to the diagnosis of diabetes," says Dr. Robert Ratner, chief scientific and medical officer for the American Diabetes Association, which publishes Diabetes Care.

Reducing financial barriers to health care, as Obamacare aims to do, tends to lead to more use of medical care. And in diabetes cases, there is room for significant improvement regarding diagnosis and treatment: 1 in 4 Americans who have diabetes don't know it, according to the Centers for Disease Control and Prevention.

Without health insurance coverage, people are likely to delay getting care until symptoms of the disease get worse.



"Really, [the study] is telling us the primary reasons why we are not making the diagnosis: It’s access to care and coverage for care," Ratner says.

The study did not distinguish between the types of diabetes diagnosed. Type 2 diabetes is a condition in which the body doesn't use insulin properly, causing blood sugar levels to rise. It can result from lifestyle factors, such as poor diet and low physical activity. Type 1 diabetes is a condition in which the body doesn't produce insulin. It accounts for roughly 5 percent of patients with diabetes and is usually diagnosed in children. Thus, most cases included in the study were likely to be Type 2, says Dr. Harvey Kaufman, senior medical director at Quest Diagnostics and a study co-investigator.

"We looked at diabetes because of its high prevalence," he says.

Ratner noted also that treatment for the disease is effective. "By intervening aggressively early, there is good evidence you can stabilize the disease," he says. "It doesn't deteriorate and become more difficult to treat over time."

In the U.S., 1.7 million people are diagnosed with diabetes each year, and screening for the disease is crucial in setting someone up for treatment. Diabetes typically gets worse when not treated, and can cause heart disease, blindness, kidney failure or death. Some patients also can face amputation.

The Affordable Care Act pushes the expansion of Medicaid coverage for uninsured adults under 65 with incomes up to 138 percent of the federal poverty level, which is $16,243 a year for an individual and $33,465 for a family of four.

says many lie in the "Diabetes Belt" – meaning primarily in the Southeastern part of the country. "We know diabetes occurs in lower socioeconomic groups," he says. "They depend on Medicaid for insurance coverage."



Researchers analyzed test results for people between the ages of 19 and 64 who had a newly diagnosed diabetes case during the first six months of 2013 (before Medicaid expansion took effect) and the first six months of 2014 (after expansions), finding trends related to early diagnosis, age and gender.

For example, patients newly diagnosed with diabetes were more likely to be diagnosed during earlier stages of the disease if they were in states that had expanded Medicaid than if they were in a state that had not.

"The advantage of that earlier diagnosis is that the progression of diabetes can be slowed through making lifestyle changes, such as losing weight, being more physically active or changing the food you eat," Kaufman says.



Ratner points out that part of the reason the average diagnosis occurred in an earlier stage of the disease may have been due to people in later stages who had severe enough symptoms to land them in the emergency room before the expansion of Medicaid, even if they did not have coverage or the ability to pay.

When breaking down the data by age, researchers found that Medicaid expansion states saw new diabetes diagnoses increase in older Medicaid patients – ages 50 to 64 – by 31 percent, while non-expansion states saw an increase of just 0.5 percent. Diabetes diagnoses in younger patients – ages 19 to 49 – increased about 15 percent in expansion states, while non-expansion states showed little change.



Patients with newly identified diabetes in all states, Medicaid expansion states, and nonexpansion states by age group.

Courtesy American Diabetes Association/Diabetes Care

The gender breakdown showed men had slightly higher rates of diabetes diagnosis than women. New diagnoses in Medicaid-enrolled men increased 25.5 percent in expansion states, while diagnoses for women increased 22 percent. Among Medicaid enrollees in non-expansion states, new diagnoses for men increased 4.6 percent and decreased 1.4 percent for women.

Patients with newly identified diabetes in all states, Medicaid expansion states, and nonexpansion states by gender.

Courtesy American Diabetes Association/Diabetes Care

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 be at higher risk for diabetes than women.

Those involved in the study say they hope it will propel more research into how other chronic disease diagnoses are affected by Medicaid and Obamacare.

"The observation likely applies to everything else, whether heart disease, kidney disease or HIV," Kaufman says. "The fact that they are going [to the doctor] most likely has broad applications to common medical conditions."



The expansion of Medicaid was designed to fill gaps in program eligibility, which used to be determined by states. States that expand Medicaid can receive federal funding to help with the costs, though lawmakers often cite financial concerns as a reason for not making the move. Politics also are at play.

Researchers point out that the cost of health care and lost productivity associated with diabetes is estimated at about $322 billion each year. It's far more expensive to do surgery after the disease has progressed than it is to do a blood test for an earlier diagnosis, Ratner says, adding that screening costs as little as $4. "If policymakers think that not finding diabetes saves money, they’re wrong," he says. "In essence, we are just putting our heads in the sand if we try to ignore the problems associated with diabetes and don’t want to diagnose it and deal with it.

"We need to come to some level of acceptance that what we don’t know can hurt us."





