Impact of State Mandatory Health Impact of State Mandatory Health Insurance Coverage on the Insurance Coverage on the

Utilization of Selected Diabetes Utilization of Selected Diabetes Care ServicesCare Services

Rui Li, Ph.D.Rui Li, Ph.D.Ping Zhang, Ph.D.Ping Zhang, Ph.D.

Dekeely Hartsfield, M.P.HDekeely Hartsfield, M.P.H

Division of Diabetes TranslationDivision of Diabetes TranslationCenters for Disease Control and PreventionCenters for Disease Control and Prevention

Contact: Rli2@cdc.govContact: Rli2@cdc.gov

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The findings and conclusions in this presentation have not been formally disseminated by the Centers for Disease Control and Prevention and should not be construed to represent any agency determination or policy

14 million diagnosed with diabetes

7 million with un-diagnosed diabetes

41 million with pre-diabetes

NHANES

44

Diabetes is Serious and Costly in USDiabetes is Serious and Costly in US

Seven percent of US populationSeven percent of US population

Serious complications Serious complications

Cost more than 132 billion per year in Cost more than 132 billion per year in 20022002

Complications can be prevented or Complications can be prevented or delayeddelayed

55

Research questionResearch question

State State Mandatory Mandatory Laws and Laws and

RegulationsRegulationsUtilization of the services

Health Insurance Coverage

66

State MandatesState Mandates

Affect private insuranceAffect private insuranceGroup and individual policies from Insurance Group and individual policies from Insurance companies or HMOs within a statecompanies or HMOs within a stateSelf-insured companies are exempted by Self-insured companies are exempted by

Employee Retirement Income Security Act Employee Retirement Income Security Act (ERISA)(ERISA) 30-50% employees are exempted30-50% employees are exempted

Forty-six states and D.C. have mandate Forty-six states and D.C. have mandate

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Name of the States with Laws and Effective YearName of the States with Laws and Effective Year

Effective YearEffective Year StatesStates19871987 WIWI

19941994 MN, NYMN, NY

19951995 FLFL

19961996 ME, NJ, RI, WVME, NJ, RI, WV

19971997 AK, NV, NM, OK, TN, TXAK, NV, NM, OK, TN, TX

19981998 CO, CT, GA, IN, KS, KY, LA, MD, MS, MO, NH, CO, CT, GA, IN, KS, KY, LA, MD, MS, MO, NH, NC, VT, WANC, VT, WA

19991999 AZ, IL, IA, PA, VAAZ, IL, IA, PA, VA

20002000 AK, CA, DE, MA, NE, SC, SD, UTAK, CA, DE, MA, NE, SC, SD, UT

20012001 HI, MI, WY, D.C.HI, MI, WY, D.C.

20022002 MT, ORMT, OR

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Coverage of State Mandates Coverage of State Mandates CoverageCoverage Number of statesNumber of states

Self-management educationSelf-management education 4040

Medical nutritional therapyMedical nutritional therapy 2424

Therapeutic foot wearTherapeutic foot wear 1212

Periodical eye and foot examsPeriodical eye and foot exams 33

HbA1c testHbA1c test 55

General coverage of pharmaceuticals, General coverage of pharmaceuticals, devices, and suppliesdevices, and supplies

4141

Devices for insulin self-administrationDevices for insulin self-administration 2323

Monitors and stripsMonitors and strips 3232

InsulinInsulin 3434

Oral agentsOral agents 3131

High-risk assessmentHigh-risk assessment 11

VaccinationVaccination 11

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HypothesesHypothesesMandate Coverage Utilization

Coverage of Monitors and strips

HbA1c test

Self-management education (SME)

Eye exams

Foot exams

Footwear

Having Law

DSMG

Annual foot exams

Annual eye exams

Increase

Outcome

Lower HbA1c level

Lower Mortality

Less eye complications

Less foot complicationsHaving all three

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Data SourcesData Sources

Behavioral Risk Factors Surveillance Behavioral Risk Factors Surveillance Survey (BRFSS) 1996-2000 Survey (BRFSS) 1996-2000 Annual, state-based, random telephone-Annual, state-based, random telephone-

survey of 150,000-210,000 community-survey of 150,000-210,000 community-dwelling US adults (aged 18 or older)dwelling US adults (aged 18 or older)

Survey questions designed by CDCSurvey questions designed by CDC Core questionnaire required to report by Core questionnaire required to report by

statesstates More than 40 states reported special diabetes More than 40 states reported special diabetes

modulemodule

1111

Study PopulationStudy Population

People with self-reported diabetesPeople with self-reported diabetes

9215 observations in the final 9215 observations in the final analysisanalysis

Health insurance typeHealth insurance typeEmployer providedEmployer provided

Self-boughtSelf-bought

1212

Econometric modelEconometric model

Prob (UtilizationProb (Utilization i,k,ti,k,t)=)=Logit (Logit ( + + 11*Law*Lawk,t=mk,t=m + + 22*Law*Lawk,t>mk,t>m + + 33*Z*Zii + + 44*X*Xkk + +

55**TimeTimett)+ )+

Z—Individual characteristicsZ—Individual characteristicsX—State level characteristicsX—State level characteristicsi—Individual indicatori—Individual indicatork—State indicatork—State indicatort—Time indicatort—Time indicatorm—Year that law took effectm—Year that law took effect

We used STATA 8 survey commands to do all the analysisWe used STATA 8 survey commands to do all the analysis

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Dependent VariablesDependent Variablesbased on Healthy People 2010 National Goals for based on Healthy People 2010 National Goals for

DiabetesDiabetes

If Self-monitoring blood glucose (DSMG) If Self-monitoring blood glucose (DSMG) at least once dailyat least once daily ““About how often do you check your blood for glucose or About how often do you check your blood for glucose or

sugar? Include times when checked by a family member or sugar? Include times when checked by a family member or friend, but do not include times when checked by a health friend, but do not include times when checked by a health professional.”professional.”

If receiving annual eye dilated examsIf receiving annual eye dilated exams ““When was the last time you had an eye exam in which the When was the last time you had an eye exam in which the

pupils were dilated? This would have made you pupils were dilated? This would have made you temporarily sensitive to bright light.”temporarily sensitive to bright light.”

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Dependent Variables (Cont’d)Dependent Variables (Cont’d)

If receiving annual foot examsIf receiving annual foot exams ““About how many times in the last year has a health About how many times in the last year has a health

professional checked your feet for any sores or irritations?”professional checked your feet for any sores or irritations?”

If receiving all three servicesIf receiving all three services

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Figure I. Percentage of People with Diabetes Using the Selected Diabetes Care Services Before and After Mandate (unadjusted)

0%

20%

40%

60%

80%

100%

DailySMBG

Annualfoot

exams

Annualeye

exams

Combine

Before mandate

First year of Mandate

The follow ing years

Healthy People 2010 Goal

ResultsResults

***

* ** *

* ***

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Effect of State Mandates on Daily Self-monitoring Effect of State Mandates on Daily Self-monitoring Blood Glucose levelBlood Glucose level

Coefficient (s.e.)Coefficient (s.e.)First Year (monitors & strips) First Year (monitors & strips) aa 0.02 (0.03)0.02 (0.03)

Years afterYears after 0.05* (0.02)0.05* (0.02)

First year (SME)First year (SME)bb 0.01 (0.03)0.01 (0.03)

Years afterYears after 0.04 (0.02)0.04 (0.02)

First year (HbA1c test)First year (HbA1c test)cc 0.09 (0.05)0.09 (0.05)

Years afterYears after 0.02 (0.03)0.02 (0.03)

a,b,c: Results were from three regressions for different law componentsThe reported coefficients were marginal probabilities*: p<=0.05; **: p<=0.01; ***: p<=0.001

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Effects of State Mandates on Annual Eye ExamsEffects of State Mandates on Annual Eye Exams

Coefficient (s.e.)Coefficient (s.e.)

First year (SME)First year (SME) -0.01 (0.03)-0.01 (0.03)

Years afterYears after 0.01 (0.02)0.01 (0.02)

First year (eye exams)First year (eye exams) 0.01 (0.03)0.01 (0.03)

Years afterYears after -0.03 (0.03)-0.03 (0.03)

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Effects of State Mandates on Annual Foot Effects of State Mandates on Annual Foot ExamsExams

Coefficient( s.e.)Coefficient( s.e.)

First year (SME)First year (SME) 0.05 (0.03)0.05 (0.03)

Years afterYears after 0.04 (0.02)0.04 (0.02)&&

First year (foot exam)First year (foot exam) 0.11 (0.07)0.11 (0.07)

Years afterYears after 0.02 (0.03)0.02 (0.03)

First year (foot wear)First year (foot wear) 0.06 (0.04)0.06 (0.04)

Years afterYears after 0.04 (0.03)0.04 (0.03)

&: significant at 0.1 level

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Effects of Having State Mandate on Effects of Having State Mandate on Receiving all Three ServicesReceiving all Three Services

Coefficient (s.e.)Coefficient (s.e.)First yearFirst year 0.07** (0.03)0.07** (0.03)

Years afterYears after 0.04** (0.02)0.04** (0.02)

2020

Conclusion and ImplicationsConclusion and Implications

State mandatory health insurance coverage has State mandatory health insurance coverage has some effect on the utilization of selected some effect on the utilization of selected diabetes care servicesdiabetes care services

Coverage on diabetes monitor and strips increased likelihood Coverage on diabetes monitor and strips increased likelihood of daily SMBGof daily SMBGState mandated did not have an effect on annual eye and State mandated did not have an effect on annual eye and foot examsfoot examsIncreased SMBG increased likelihood of receiving all three Increased SMBG increased likelihood of receiving all three services services

Further studies are needed to understand why Further studies are needed to understand why the state mandates had limited effect on the state mandates had limited effect on selected diabetes servicesselected diabetes services