American Diabetes Association
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The Affordable Care Act – Effects of Insurance on Diabetes Biomarkers

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posted on 2020-07-01, 15:43 authored by Miguel Marino, Heather Angier, Rachel Springer, Steele Valenzuela, Megan Hoopes, Jean O’Malley, Andrew Suchocki, John Heintzman, Jennifer DeVoe, Nathalie Huguet
Objective: We sought to understand how Affordable Care Act (ACA) Medicaid expansion insurance coverage gains are associated with changes in diabetes-related biomarkers.

Research Design and Methods: Retrospective observational cohort study using electronic health record data from 178 community health centers (CHCs) in the ADVANCE network. We assessed changes in diabetes-related biomarkers among adult patients with diabetes in 10 Medicaid expansion states (n=25,279), comparing newly insured with continuously insured, discontinuously insured, and continuously uninsured patients pre- to post-ACA expansion. Primary outcomes included 24 months pre- to 24 months post-ACA changes in glycosylated hemoglobin (HbA1c), systolic (SBP) and diastolic (DBP) blood pressure, and low-density lipoprotein (LDL) cholesterol levels.

Results: Newly insured patients exhibited a reduction in adjusted mean HbA1c levels [8.24% (67 mmol/mol) to 8.17% (66 mmol/mol)], which was significantly different from continuously uninsured patients, whose HbA1c levels increased [8.12% (65 mmol/mol) to 8.29% (67 mmol/mol); difference-in-difference (DID)=-0.24%; p<0.001]. Newly insured patients showed greater reductions in adjusted mean SBP than continuously uninsured patients (DID=-1.8 mmHg; p<0.001), DBP (DID=-1.0 mmHg; p<0.001), and LDL (DID=-3.3 mg/dL; p<0.001). Among patients with elevated HbA1c in the 3 months prior to expansion, newly insured patients were more likely than continuously uninsured to have a controlled HbA1c measurement by 24 months post-ACA [Hazard Ratio=1.25; 95% CI=1.02-1.54].

Conclusions: 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.


This study was supported by the National Heart, Lung and Blood Institute (grant #R01HL136575). This publication was made possible by Cooperative Agreement Number U18DP006116 jointly funded by the U.S. Centers for Disease Control and Prevention and the National Institute of Diabetes and Digestive and Kidney Disease, and Patient-Centered Outcomes Research Institute. The views presented in this article are solely the responsibility of the authors and do not necessarily represent the views of the funding agencies. ADVANCE (Accelerating Data Value Across a National Community Health Center Network) is led by the OCHIN Community Health Information Network in partnership with Health Choice Network (HCN), Fenway Health, Oregon Health and Science University (OHSU), and the Robert Graham Center/HealthLandscape. ADVANCE is funded through PCRF contract number 1237.


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