Objective This study sought to identify the temporal trends of presenting diagnoses and vascular procedures performed for peripheral arterial disease (PAD) along with the rates of procedures and in‐hospital outcomes by payer status. Background Previous studies suggest that patients with Medicare, Medicaid, or lack of insurance receive poorer quality of care leading to worse outcomes. Methods We analyzed 196,461,055 discharge records to identify all hospitalized patients with PAD records (n = 1,687,724) from January 2007 through December 2011 in the Nationwide Inpatient Sample database. Results The annual frequency of vascular procedures remained unchanged during the study period. Patients with Medicaid were more likely to present with gangrenes, whereas patients with Medicare were more likely to present with ulcers. After adjustment, patients with Medicare and Medicaid were more likely to undergo amputations when compared with private insurance/HMO (OR = 1.13, 95% CI = 1.10–1.16 and OR = 1.24, 95% CI = 1.20–1.29, respectively). Patients with both Medicare and Medicaid were less likely to undergo bypass surgery (OR = 0.82, 95% CI = 0.81–0.84 and OR = 0.87, 95% CI = 0.85–0.90, respectively), but more likely to undergo endovascular procedures (OR = 1.18, 95% CI = 1.17–1.20 and OR = 1.03, 95% CI = 1.01–1.06, respectively). Medicare and Medicaid status versus private insurance/HMO was associated with worse adjusted odds of in‐hospital outcomes, including mortality after amputations, endovascular procedures, and bypass surgeries. Conclusions In this analysis, patients with Medicare and Medicaid had more comorbid conditions at baseline when compared with private insurance/HMO cohorts, were more likely to present with advanced stages of PAD, undergo amputations, and develop in‐hospital complications. These data unveil a critical gap and an opportunity for quality improvement in the elderly and those with poor socioeconomic status. © 2015 Wiley Periodicals, Inc.