Research shows significantly more people with diabetes got their critical annual dilated eye exam during the first two years following Medicaid expansion under the Affordable Care Act (ACA). However, this encouraging increase in the exam rate did not persist beyond two years. The study’s authors suggest that changes beyond expansion of insurance coverage may be necessary to tackle this leading health challenge, including a national early detection program that uses artificial intelligence and telemedicine to enable broader coverage and more public education. South Jersey Eye Physicians joins the American Academy of Ophthalmology in reiterating the importance of eye exams during the month of November, which is observed as Diabetic Eye Disease Awareness Month.

Diabetes is the leading causes of preventable blindness in the United States among adults age 20 to 74 and is the fifth most common cause of preventable blindness globally. Among the 30 million Americans with diabetes, about one-third have diabetic retinopathy, the potentially blinding complication of diabetes.

People typically don’t notice changes in their vision in the disease’s early stages. But as it progresses, diabetic retinopathy usually causes vision loss that in many cases cannot be reversed. That’s why it’s so important that everyone with diabetes has yearly exams for early detection. But the U.S. Centers for Disease Control and Prevention consistently reports that less than two-thirds of people with diabetes undergo their recommended annual dilated ophthalmic examination. These rates are even lower among children and adolescents with diabetes, with less than half of youth with type 2 diabetes receiving an examination within six years of diagnosis.

Health officials hoped that expanding Medicaid, the state-based insurance program that covers an annual dilated eye exam for people with diabetes, would encourage more people to get their annual exams. To assess the actual impact of this policy, researchers at Harvard and Yale evaluated the rates of diabetic eye exams in states that expanded Medicaid under the ACA compared with states that did not expand Medicaid.

The researchers found that the annual exam rate increased by 6.3 percent during the first two years following expansion (2014-2015). However, the increased rate dropped to 4.1 percent at year three and to 2.3 percent at year four (2016-2017); rates similar to pre-expansion levels. Throughout the study period, expansion states had higher dilated eye examination rates compared with non-expansion states for all but these last two years. This decline in later years suggests that although health insurance did help at-risk patients receive eye exams for early detection, some patients stopped coming in after their first exams.

“We all live busy lives. When patients with diabetes are told nothing is wrong during their first eye exams, are asymptomatic, and have difficulty taking time off work, it’s easy to see how coming in for yet another health appointment might be deprioritized if the risks aren’t communicated to the patient,” said Ravi Parikh, MD, MPH, the study’s senior author. “The health care system as it stands today is not equipped to handle missed exams effectively. Maintaining follow up exams also is a real problem.”

But Dr. Parikh and his colleagues remain hopeful that targeted awareness campaigns and the use of artificial intelligence and telemedicine will help increase the early detection rate, noting that a national diabetic retinopathy program in the United Kingdom has used telemedicine to improve access to early detection and treatment.