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Diabetes Care Barriers, Use, and Health Outcomes in Younger Adults With Type 1 and Type 2 Diabetes
abstract
This abstract is available on the publisher's site.
Access this abstract nowIMPORTANCE
Treatment challenges exist for younger adults with type 1 (T1D) and type 2 diabetes (T2D). Health care coverage, access to, and use of diabetes care are not well delineated in these high-risk populations.
OBJECTIVE
To compare patterns of health care coverage, access to, and use of diabetes care and determine their associations with glycemia among younger adults with T1D and with T2D.
DESIGN, SETTING, AND PARTICIPANTS
This cohort study analyzed data from a survey that was jointly developed by 2 large, national cohort studies: the SEARCH for Diabetes in Youth (SEARCH) study, an observational study of individuals with youth-onset T1D or T2D, and the Treatment Options for Type 2 Diabetes in Adolescents and Youth (TODAY) study, a randomized clinical trial (2004-2011) followed by an observational study (2012-2020). The interviewer-directed survey was administered during in-person study visits in both studies between 2017 and 2019. Data analyses were performed between May 2021 and October 2022.
MAIN OUTCOMES AND MEASURES
Survey questions addressed health care coverage, usual sources of diabetes care, and frequency of care use. Glycated hemoglobin (HbA1c) levels were assayed in a central laboratory. Patterns of health care factors and HbA1c levels were compared by diabetes type.
RESULTS
The analysis included 1371 participants (mean [range] age, 25 [18-36] years; 824 females [60.1%]), of whom 661 had T1D and 250 had T2D from the SEARCH study and 460 had T2D from the TODAY study. Participants had a mean (SD) diabetes duration of 11.8 (2.8) years. More participants with T1D than T2D in both the SEARCH and TODAY studies reported health care coverage (94.7%, 81.6%, and 86.7%), access to diabetes care (94.7%, 78.1%, and 73.4%), and use of diabetes care (88.1%, 80.5%, and 73.6%). Not having health care coverage was associated with significantly higher mean (SE) HbA1c levels in participants with T1D in the SEARCH study (no coverage, 10.8% [0.5%]; public, 9.4% [0.2%]; private, 8.7% [0.1%]; P < .001) and participants with T2D from the TODAY study (no coverage, 9.9% [0.3%]; public, 8.7% [0.2%]; private, 8.7% [0.2%]; P = .004). Medicaid expansion vs without expansion was associated with more health care coverage (participants with T1D: 95.8% vs 90.2%; participants with T2D in SEARCH: 86.1% vs 73.9%; participants with T2D in TODAY: 93.6% vs 74.2%) and lower HbA1c levels (participants with T1D: 9.2% vs 9.7%; participants with T2D in SEARCH: 8.4% vs 9.3%; participants with T2D in TODAY: 8.7% vs 9.3%). The T1D group incurred higher median (IQR) monthly out-of-pocket expenses than the T2D group ($74.50 [$10.00-$309.00] vs $10.00 [$0-$74.50]).
CONCLUSIONS AND RELEVANCE
Results of this study suggested that lack of health care coverage and of an established source of diabetes care were associated with significantly higher HbA1c levels for participants with T1D, but inconsistent results were found for participants with T2D. Increased access to diabetes care (eg, through Medicaid expansion) may be associated with improved health outcomes, but additional strategies are needed, particularly for individuals with T2D.
Additional Info
Disclosure statements are available on the authors' profiles:
Diabetes Care Barriers, Use, and Health Outcomes in Younger Adults With Type 1 and Type 2 Diabetes
JAMA Netw Open 2023 May 01;6(5)e2312147, C Pihoker, BH Braffett, TJ Songer, WH Herman, M Tung, S Kuo, A Bellatorre, E Isganaitis, ET Jensen, J Divers, P Zhang, DM Nathan, K Drews, D Dabelea, PS ZeitlerFrom MEDLINE®/PubMed®, a database of the U.S. National Library of Medicine.
Young adults with diabetes face unique structural challenges as they transition from pediatric to adult care; many age out of their parents health insurance and have difficulty finding their own health coverage, especially if comprehensive health insurance it is not provided through employment. For many, adequate insurance coverage may be too expensive or too complicated to obtain.
This study characterizes trends in healthcare coverage and utilization (office visits), for youth aged 18 to 36 years with type 1 and type 2 diabetes. Surveys were distributed through two large cohort studies, the SEARCH for Diabetes in Youth Study and the TODAY Study between 2017 and 2019. In this paper, they present data from 1371 study participants, fairly evenly split between those who had type 1 and type 2 diabetes. Survey items were consistent with those used in nationwide surveys (Medical Expenditure Panel Survey) and reflected barriers to healthcare coverage that were correlated with health outcomes, specifically HbA1c levels.
The association of lower HbA1c levels for individuals with diabetes who reside in states with expanded Medicaid is an extremely important finding. While the study was unable to report a causal relationship between expanded Medicaid and improved diabetes health outcomes, the broader implication is that increasing access to Medicaid may help improve health for individuals with diabetes and other chronic medical conditions.
It is striking that nearly 15% of individuals with type 2 diabetes reported not having healthcare coverage. This is a disturbingly high proportion of individuals that highlights the need to make health insurance more accessible. Furthermore, individuals in the study were near large medical canters that likely had access to additional resources that smaller community practices may lack, suggesting that the data likely underrepresent overall healthcare coverage for those with type 2 diabetes in the United States.
While the paper highlights the potentially high out-of-pocket expenses related to managing diabetes, it does not address whether or not participants in the study are taking all of their medications as prescribed, or if they are not obtaining their medications and supplies due to cost. It is well-known that as many as 1 in 4 individuals with diabetes ration insulin due to cost, and the cost of managing diabetes to achieve American Diabetes Association recommended HbA1c targets is likely much higher than what is reported in the paper. Further, those with type 1 diabetes were more likely to report out-of-pocket expenses if they had healthcare coverage than if they did not, meaning that many with private health insurance are still underinsured and obtaining medications and supplies may be cost-prohibitive.
Overall, this is an excellent study that highlights the association of improved health outcomes for those with access to more comprehensive health coverage. This data should prompt a call to action for national and local leaders to improve access and affordability of healthcare.