title: Impact of state mandatory insurance coverage on the use of diabetes preventive care.
abstract: BACKGROUND
  46 U.S. states and the District of Columbia have passed laws and regulations mandating that health insurance plans cover diabetes treatment and preventive care. Previous research on state mandates suggested that these policies had little impact, since many health plans already covered the benefits. Here, we analyze the contents of and model the effect of state mandates. We examined how state mandates impacted the likelihood of using three types of diabetes preventive care: annual eye exams, annual foot exams, and performing daily self-monitoring of blood glucose (SMBG).
  
  
  METHODS
  We collected information on diabetes benefits specified in state mandates and time the mandates were enacted. To assess impact, we used data that the Behavioral Risk Factor Surveillance System gathered between 1996 and 2000. 4,797 individuals with self-reported diabetes and covered by private insurance were included; 3,195 of these resided in the 16 states that passed state mandates between 1997 and 1999; 1,602 resided in the 8 states or the District of Columbia without state mandates by 2000. Multivariate logistic regression models (with state fixed effect, controlling for patient demographic characteristics and socio-economic status, state characteristics, and time trend) were used to model the association between passing state mandates and the usage of the forms of diabetes preventive care, both individually and collectively.
  
  
  RESULTS
  All 16 states that passed mandates between 1997 and 1999 required coverage of diabetic monitors and strips, while 15 states required coverage of diabetes self management education. Only 1 state required coverage of periodic eye and foot exams. State mandates were positively associated with a 6.3 (P = 0.04) and a 5.8 (P = 0.03) percentage point increase in the probability of privately insured diabetic patient's performing SMBG and simultaneous receiving all three preventive care, respectively; state mandates were not significantly associated with receiving annual diabetic eye (0.05 percentage points decrease, P = 0.92) or foot exams (2.3 percentage points increase, P = 0.45).
  
  
  CONCLUSIONS
  Effects of state mandates varied by preventive care type, with state mandates being associated with a small increase in SMBG. We found no evidence that state mandates were effective in increasing receipt of annual eye or foot exams. The small or non-significant effects might be attributed to small numbers of insured people not having the benefits prior to the mandates' passage. If state mandates' purpose is to provide improved benefits to many persons, policy makers should consider determining the number of people who might benefit prior to passing the mandate.
authors.affiliation: Division of Diabetes Translation, Centers for Disease Control and Prevention, Atlanta, USA. Rli2@cdc.gov
authors.forename: Rui
authors.initials: R
authors.lastname: Li
authors.forename: Ping
authors.initials: P
authors.lastname: Zhang
authors.forename: Lawrence
authors.initials: L
authors.lastname: Barker
authors.forename: Dekeely
authors.initials: D
authors.lastname: Hartsfield
mesh_terms: D000293:Adolescent; D000328:Adult; D040343:Behavioral Risk Factor Surveillance System; D015190:Blood Glucose Self-Monitoring / Q000706:statistics & numerical data; D016001:Confidence Intervals; D048909:Diabetes Complications / Q000517:prevention & control*; D003920:Diabetes Mellitus / Q000517:prevention & control / Q000628:therapy*; D005260:Female; D005534:Foot Diseases / Q000175:diagnosis; D006801:Humans; D019458:Insurance Coverage / Q000331:legislation & jurisprudence*; D016015:Logistic Models; D008297:Male; D037141:Mandatory Programs / Q000331:legislation & jurisprudence*; D008875:Middle Aged; D011314:Preventive Health Services / Q000706:statistics & numerical data*; D017149:Private Sector; D012959:Socioeconomic Factors; D013221:State Health Plans / Q000706:statistics & numerical data*; D014481:United States; D014787:Vision Tests / Q000706:statistics & numerical data