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
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
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14 million diagnosed with diabetes
7 million with un-diagnosed
diabetes
41 million with
pre-diabetes
NHANES
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
4
Research question
State
Mandatory
Laws and
Regulations
Utilization of
the services
Health Insurance
Coverage
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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
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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.
2002
MT, OR
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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
Insulin
34
Oral agents
31
High-risk assessment
1
Vaccination
1
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Hypotheses
Mandate Coverage
Coverage of
Monitors and strips
Increase
Utilization
DSMG
Lower
HbA1c level
HbA1c test
Self-management
education (SME)
Outcome
Annual eye exams
Eye exams
Lower Mortality
Annual foot exams
Less
eye complications
Having all three
Less
foot complications
Foot exams
Footwear
Having Law
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Data Sources
Behavioral Risk Factors Surveillance
Survey (BRFSS) 1996-2000
 Annual, state-based, random telephonesurvey of 150,000-210,000 communitydwelling 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
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Study Population
People with self-reported diabetes
9215 observations in the final
analysis
Health insurance type
Employer provided
Self-bought
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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
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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.”
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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
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Results
Before mandate
First year of Mandate
100%
The follow ing years
80%
60%
* **
Healthy People 2010 Goal
*
***
40%
* ***
20%
0%
Daily
SMBG
Annual
foot
exams
Annual
eye
exams
Combine
Figure I. Percentage of People with Diabetes Using
the Selected Diabetes Care Services
Before and After Mandate (unadjusted)
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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
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Effects of State Mandates on Annual Eye Exams
Coefficient (s.e.)
First year (SME)
-0.01 (0.03)
Years after
0.01 (0.02)
First year (eye exams)
0.01 (0.03)
Years after
-0.03 (0.03)
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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
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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)
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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
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