The Association Between Medicaid Expansion and Diabetic Ketoacidosis Hospitalizations

Background and objective Diabetic ketoacidosis (DKA) is a potentially fatal complication of uncontrolled diabetes and remains a significant source of morbidity and mortality even though it is considered preventable. Diabetes is a chronic illness that requires constant monitoring and regular check-ups. Delaying or foregoing necessary diabetes care due to a lack of health insurance can result in severe complications. The Affordable Care Act (ACA) Medicaid expansion is intended to increase access to healthcare and improve health outcomes. This study aimed to examine the relationship between the ACA Medicaid expansion and hospitalizations with DKA. Methods This retrospective cross-sectional study used discharge records from 2010 to 2017 for hospitals in Texarkana, located on the border of Texas and Arkansas. The study employed a difference-in-differences method. Patients from Arkansas, which expanded Medicaid in 2014, constituted the treatment group, while those from Texas, which did not adopt the expansion, were the control group. A triple difference methodology was used to compare the impact of the expansion on patients with different socioeconomic backgrounds. The main outcome measure was DKA per 1000 discharges. Results A total of 89,184 inpatient discharges from Texarkana hospitals were analyzed; 43,286 patients were from Arkansas (48.54%) and 45,898 (51.46%) were from Texas. Even though DKA cases increased from pre-expansion (2010-2013) to post-expansion (2014-2017) period among patients from Arkansas (by a mean of 4.33) and Texas (by a mean of 8.28), the increase was milder among Arkansas patients with an adjusted decrease of 4.17 per 1000 discharges (95% CI: -5.04 to -3.31; p<0.001), implying a 42% lower risk of hospitalizations with DKA compared to the baseline averages. The triple difference analysis suggested that the decrease in incidences was more pronounced for patients from low-income areas with an adjusted decrease of 13.47 per 1000 discharges (95% CI: -22.45 to -4.49; p=0.003). Conclusions Based on our findings, Medicaid expansion decreases hospitalizations with DKA, presumably due to better monitoring and care of diabetes made possible by increasing access to healthcare among individuals with low incomes.