ABSTRACT
This study represents a timely investigation that addresses race/ethnic disparities in type 2 diabetes (T2DM)
care over a period that included a major pandemic shock. T2DM is burdensome and disproportionately impacts
vulnerable and disenfranchised populations; of note, there are stark race/ethnic disparities in T2DM care goals,
emergency department (ED) visits, and hospitalizations. Medicaid covers 25% of Americans with T2DM. More
than 80% of Medicaid beneficiaries nationally receive at least some of their care from Medicaid managed care
organizations (MMCO). States contract with private (non-profit or for-profit) MMCOs to lower costs, increase
quality, and pass on financial risks of covering Medicaid beneficiaries. Heterogeneity across and within state
programs can have implications for quality of T2DM care and, specifically, race/ethnic disparities through
benefit generosity or by affecting MMCO entry and post-entry behavior. State policymakers also have
significant influence over marketplaces in which MMCOs compete, which can have consequences for
race/ethnic disparities, given that Medicaid disproportionately covers non-white populations. Little is known
about whether and how MMCOs and the state programs they operate in influence disparities in T2DM care
and, if or how the COVID-19 pandemic changed the trajectory of health disparities. We propose to answer
these unknowns using a convergent mixed-methods study: we will compile a database of MMCO/state
program features that could influence care using a health disparities conceptual framework (Aim 1); we will
empirically explore race/ethnic disparities among adults with T2DM and whether these vary by MMCO/state
features and pre-/post-COVID-19 using comprehensive data from the Transformed Medicaid Statistical
Information System over 2016-2025 (Aims 2 and 3); and we will collect and analyze qualitative data from
Medicaid stakeholders to triangulate and contextualize the quantitative findings (Aim 4). We focus on non-
disabled, non-pregnant 18-64-year-old adults with T2DM who tend to remain stably covered by Medicaid over
time. To reduce selection bias, we focus our analyses on 12 states and the District of Columbia that mandate
enrollment in comprehensive MMCOs. We will use panel data models to examine race/ethnic and sex-specific
receipt of key T2DM services and ED visits and hospitalizations, overall and by MMCO/state features. We will
also follow a continuously enrolled cohort over 2020-2025 to assess if and how MMCO/state program features
moderate the pandemic’s effects on T2DM disparities. Sensitivity analyses will explore the influence of churn.
Further, our preliminary analyses identify Kentucky and Florida as having the lowest and highest disparities in
T2DM care, respectively; we will conduct interviews in these states to examine what MMCO/state features and
implementation might explain these disparities. This policy-relevant work will provide critical insights into how
Medicaid managed care programs can be designed to reduce disparities in chronic disease burdens.