Impact of State Mandatory Health Insurance Coverage on the Utilization of Selected Diabetes Care Services Rui Li, Ph.D. Ping Zhang, Ph.D. Dekeely Hartsfield, M.P.H Division of Diabetes Translation Centers for Disease Control and Prevention Contact:

2 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

4 Diabetes is Serious and Costly in US Seven percent of US population Serious complications Cost more than 132 billion per year in 2002 Complications can be prevented or delayed

5 Research question State Mandatory Laws and Regulations Utilization of the services Health Insurance Coverage

6 State Mandates Affect private insurance Group and individual policies from Insurance companies or HMOs within a state Self-insured companies are exempted by Employee Retirement Income Security Act (ERISA) Employee Retirement Income Security Act (ERISA) 30-50% employees are exempted 30-50% employees are exempted Forty-six states and D.C. have mandate

7 Name of the States with Laws and Effective Year Effective Year States 1987 WI 1994 MN, NY 1995 FL 1996 ME, NJ, RI, WV 1997 AK, NV, NM, OK, TN, TX 1998 CO, CT, GA, IN, KS, KY, LA, MD, MS, MO, NH, NC, VT, WA 1999 AZ, IL, IA, PA, VA 2000 AK, CA, DE, MA, NE, SC, SD, UT 2001 HI, MI, WY, D.C MT, OR

8 Coverage of State Mandates Coverage Number of states Self-management education 40 Medical nutritional therapy 24 Therapeutic foot wear 12 Periodical eye and foot exams 3 HbA1c test 5 General coverage of pharmaceuticals, devices, and supplies 41 Devices for insulin self-administration 23 Monitors and strips 32 Insulin34 Oral agents 31 High-risk assessment 1 Vaccination1

9 Hypotheses Mandate 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 complications Having all three

10 Data Sources Behavioral Risk Factors Surveillance Survey (BRFSS)  Annual, state-based, random telephone- survey of 150, ,000 community- dwelling US adults (aged 18 or older)  Survey questions designed by CDC  Core questionnaire required to report by states  More than 40 states reported special diabetes module

11 Study Population People with self-reported diabetes 9215 observations in the final analysis Health insurance type Employer provided Self-bought

12 Econometric model Prob (Utilization i,k,t )= Logit (  +  1 *Law k,t=m +  2 *Law k,t>m +  3 *Z i +  4 *X k +  5 *Time t )+  Z—Individual characteristics X—State level characteristics i—Individual indicator k—State indicator t—Time indicator m—Year that law took effect We used STATA 8 survey commands to do all the analysis

13 Dependent Variables based on Healthy People 2010 National Goals for Diabetes If Self-monitoring blood glucose (DSMG) at least once daily  “About how often do you check your blood for glucose or sugar? Include times when checked by a family member or friend, but do not include times when checked by a health professional.” If receiving annual eye dilated exams  “When was the last time you had an eye exam in which the pupils were dilated? This would have made you temporarily sensitive to bright light.”

14 Dependent Variables (Cont’d) If receiving annual foot exams  “About how many times in the last year has a health professional checked your feet for any sores or irritations?” If receiving all three services

15 Results *** * * ***

16 Effect of State Mandates on Daily Self-monitoring Blood Glucose level Coefficient (s.e.) First Year (monitors & strips) a 0.02 (0.03) Years after 0.05* (0.02) First year (SME) b 0.01 (0.03) Years after 0.04 (0.02) First year (HbA1c test) c 0.09 (0.05) Years after 0.02 (0.03) a,b,c: Results were from three regressions for different law components The reported coefficients were marginal probabilities *: p<=0.05; **: p<=0.01; ***: p<=0.001

17 Effects of State Mandates on Annual Eye Exams Coefficient (s.e.) First year (SME) (0.03) Years after 0.01 (0.02) First year (eye exams) 0.01 (0.03) Years after (0.03)

18 Effects of State Mandates on Annual Foot Exams Coefficient( s.e.) First year (SME) 0.05 (0.03) Years after 0.04 (0.02) & First year (foot exam) 0.11 (0.07) Years after 0.02 (0.03) First year (foot wear) 0.06 (0.04) Years after 0.04 (0.03) &: significant at 0.1 level

19 Effects of Having State Mandate on Receiving all Three Services Coefficient (s.e.) First year 0.07** (0.03) Years after 0.04** (0.02)

20 Conclusion and Implications State mandatory health insurance coverage has some effect on the utilization of selected diabetes care services Coverage on diabetes monitor and strips increased likelihood of daily SMBG State mandated did not have an effect on annual eye and foot exams Increased SMBG increased likelihood of receiving all three services Further studies are needed to understand why the state mandates had limited effect on selected diabetes services