Rui Li, Ph.D. Ping Zhang, Ph.D. Dekeely Hartsfield, M.P.H Division of Diabetes Translation

1. 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: Rli2@cdc.gov

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

3. 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 Utilization of the services State Mandatory Laws and Regulations 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) • 30-50% employees are exempted • Forty-six states and D.C. have mandate

7. Name of the States with Laws and Effective Year

8. Coverage of State Mandates

9. Hypotheses Increase Mandate Coverage Utilization Outcome Coverage of Monitors and strips HbA1c test Self-management education (SME) Eye exams Foot exams Footwear Having Law DSMG Lower HbA1c level Lower Mortality Annual eye exams Annual foot exams Less eye complications Having all three Less foot complications

10. Data Sources • Behavioral Risk Factors Surveillance Survey (BRFSS) 1996-2000 • Annual, state-based, random telephone-survey of 150,000-210,000 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 (Utilizationi,k,t)= Logit ( + 1*Lawk,t=m + 2*Lawk,t>m + 3*Zi + 4*Xk + 5*Timet)+  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 Variablesbased 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 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

18. Effects of State Mandates on Annual Foot Exams &: significant at 0.1 level

19. Effects of Having State Mandate on Receiving all Three Services

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