By Mary A. M. Rogers, Joyce M. Lee, Renuka Tipirneni, Tanima Banerjee, and Catherine Kim
Health Affairs, July 2018
Type 1 diabetes mellitus, which often originates during childhood, is a lifelong disease that requires intensive daily medical management. Because health care services are critical to patients with this disease, we investigated the frequency of interruptions in private health insurance, and the outcomes associated with them, for working-age adults with type 1 diabetes in the United States in the period 2001–15. We designed a longitudinal study with a nested self-controlled case series, using the Clinformatics Data Mart Database. The study sample consisted of 168,612 adults ages 19–64 with type 1 diabetes who had 2.6 mean years of insurance coverage overall. Of these adults, 24.3 percent experienced an interruption in coverage. For each interruption, there was a 3.6 percent relative increase in glycated hemoglobin. The use of acute care services was fivefold greater after an interruption in health insurance compared to before the interruption and remained elevated when stratified by age, sex, or diabetic complications. An interruption was associated with lower perceived health status and lower satisfaction with life. We conclude that interruptions in private health insurance are common among adults with type 1 diabetes and have serious consequences for their well-being.
From the Introduction
The Bureau of Labor Statistics estimates that between the ages of 18 and 50, Americans hold an average of twelve different jobs. Particularly for younger workers, the jobs tend to be of short duration: 69 percent of jobs held by people ages 18–24 last for less than one year, as do 36 percent of jobs held by people ages 35–44. This has health consequences because, for the majority of working adults in the United States, health insurance coverage has traditionally been tied to employment. For working adults without employer-sponsored insurance, the Affordable Care Act (ACA) Marketplaces provide an opportunity for coverage. However, there remain challenges regarding affordability with self-funded plans and disparities in premiums across different areas of the country.
Interruptions in health insurance affect access to health care services, particularly for patients with chronic conditions. Type 1 diabetes mellitus is one such lifelong chronic disease, often originating in childhood, and requires intensive daily medical management. People with type 1 diabetes are at exceptional risk because of their requirement for insulin and the supplies necessary for insulin delivery.
From the Discussion
Interruptions in private health insurance are common among working-age adults with type 1 diabetes in the United States. Overall, one in four experienced at least one interruption in coverage, over an average period of 2.6 years. There were considerable consequences associated with the interruptions. Use of acute care services increased greatly after an interruption in coverage—with differences ranging from fourfold to sevenfold, depending upon the length of the interruption. As the number of interruptions increased, so did HbA1c levels, in a dose-response manner. For each additional break in coverage, there was a 3.6 percent relative increase in HbA1c. Satisfaction with life and perceived health status were lower among adults with interruptions in insurance, compared to those with continuous coverage.
Patients with type 1 diabetes face particular challenges in the management of their disease. Interruptions in health insurance are common in the United States, and such interruptions increase the use of costly acute care services such as ED visits and hospitalizations. We do not anticipate that these challenges will diminish in the near future, because of the instability of health insurance markets and the increase in temporary employment and contract work without employer-sponsored insurance. In the US, 50.1 percent of private-sector establishments offered health insurance to their employees in 2012, a share that declined to 45.3 percent in 2016.
By Don McCanne, M.D.
One of the most serious policy defects of the U.S. health care financing system is that it is uniquely characterized by interruptions in health care coverage, yet we seem to take that for granted. This study of type 1 diabetics who have a continual need for health care brings into focus the seriousness of gaps in health care coverage, but these gaps can affect all of us because of the unpredictability of future health care needs.
Our health care coverage is heavily dependent on employer-sponsored plans, yet job stability is no longer the norm; it is the exception. Almost everyone can anticipate some interruptions in their health care coverage.
For the type 1 diabetics in this study, interruptions in private insurance coverage resulted in poorer control of their diabetes as measured by their glycated hemoglobin levels; they required a fivefold increase in health care services, and the interruptions were associated with lower perceived health status and lower satisfaction with life. Imagine the difficulties that other individuals with interruptions in coverage would have if they suddenly experienced severe traumatic events or the onset of a major illnesses.
Yet we accept this, even praising our employer-sponsored plans as the part of our health care financing system that is working very well and that we want to protect. Nonsense. As the authors state, “We do not anticipate that these challenges will diminish in the near future, because of the instability of health insurance markets and the increase in temporary employment and contract work without employer-sponsored insurance.”
By design, a single payer national health program – an improved Medicare for all – never has any interruptions in coverage, throughout life. And this is only one of a great multitude of advantages of a well designed, single, publicly financed and publicly administered health care financing program that covers absolutely everyone and would cost no more than our current, highly dysfunctional system. What are we waiting for?
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