Racial Differences in Insurance Type between Diabetes Mellitus Type 2 Patients in the United States

Mannaa I. Mannaa1*

¹Geisinger Commonwealth School of Medicine, Scranton, PA 18509 *Master of Biomedical Sciences Program Correspondence: mannaaonly@yahoo.com

Abstract

Background: The Centers for Disease Control and Prevention (CDC) categorizes diabetes as an epidemic in the United States (U.S.). It further stands among health disparities with a disproportionate distribution among minorities. The expansion of Medicaid access under the Affordable Care Act (ACA), which serves the medical needs of disabled, chronically ill, and low-income residents, has not been enough to bridge the gap of health and health care disparities. This is in part due to Medicaid expansion being optional for states, leaving 2.2 million residents in the coverage gap. Past analysis of the annual National Hospital Ambulatory Medical Care Survey (NHAMCS) has elucidated the burden of diabetes on the health care system. It has also gauged how expansion of Medicaid has armed an appreciable number of working-age residents with health insurance. NHAMCS stands in a position to potentially highlight continued inequities in health care despite Medicaid expansion. Methods: Differences in insurance type between diabetes mellitus Type 2 patients based on race in the U.S. was analyzed in the 2018 NHAMCS. Results: Medicaid coverage as well as the lack of insurance coverage was found to be significantly higher among Black (42.3%, 9.9% respectively) compared to White patients (30.2%, 7.8% respectively) visiting Emergency Departments (EDs). Conclusion: Analyses of NHAMCSs stand as checkpoints as the U.S. strives in progression toward health and health care equities. They have revealed the burden of diabetes on the health care system. Further, they have illuminated success of Medicaid expansion where it has been adopted. Finally, disproportionate reliance upon Medicaid between Black as compared to White patients, along with unequal distribution of lack of health insurance between these races, have been made apparent.

Introduction

The World Health Organization (WHO) identified 1.6 million deaths directly caused by diabetes in 2016 (1). While WHO classifies the disease as an epidemic globally, the CDC also confirms diabetes as an epidemic in the U.S. (1, 2). One in 10 Americans suffer from the disease while 1 in 3 are considered pre-diabetic and, for the most part, are unaware (2). Type 2 diabetes, once considered adult-onset and appearing over 45 years of age, is now appearing among American youths between 10 and 19. (2, 3) This deadly disease, a major cause of serious health issues including blindness, kidney failure, heart attack, stroke, and lower limb amputation, was counted by WHO as among the top 10 causes of death globally as of December 2020 (4). It also stands among health disparities with a disproportionate distribution among minorities in the U.S. In 2017 to 2018, the CDC found the prevalence of diabetes to be 11.7% for adult non-Hispanic blacks versus 7.5% for adult non-Hispanic Whites (1). Contributors to this disproportionate distribution including obesity and differences in neighborhood, psychosocial, socioeconomic, and behavioral factors (5). The NHAMCS is a national probability sample survey of outpatient visits to hospitals, emergency departments (EDs), and hospital-based ambulatory surgery centers (6). Analysis of NHAMCS from 1993 to 2005 revealed an average of 380,000 visits/year for hypoglycemia, a serious complication among diabetic patients (7). Demographic disparities were found for hypoglycemia-related ED visits by age, sex, race, ethnicity, and region. Thirty-four per 1,000 visits were by diabetic patients (7). Diabetes patient visit rates were significantly higher for female, Black, and Hispanic patients as compared to male, White, and non-Hispanic patients (7). In 2015, the epidemic of diabetes accounted for 92 per 1,000 ED visits by patients 45 and older, about 24% of all ED visits (8). Despite having this data available, health care utilization and cost for diabetes in the U.S. may be underestimated, and by extension, the severity of the disease underrealized. The American Diabetes Association was found to have utilized NAMCS and NHAMCS surveys to estimate utilization and costs in a 2012 report after quantifying diabetes-related ED visits using providers’ diagnosis codes and medication lists to quantify those visits (9). However, evaluations of NHAMCS data from 2006 and 2010 determined that solely using provider’ diagnosis codes and medication lists to identify diabetic patient visits would fail to identify approximately one quarter of outpatient visits by patients with diabetes (9). Regarding insurance coverage for diabetes patients, 24% of the diabetes ED visits for those age 45 to 64 had Medicare as the primary expected payment source, versus 14% of the ED visits for patients age 45 to 64 without diabetes (8). There was a significant increase from 66.0% to 71.8% in the percentage of working-age adult ED patients who had at least one form of health insurance in the first 2 years following ACA implementation. This was almost entirely due to Medicaid coverage increase, the expansion of which has been associated with improvements in self-reported access to health care and self-reported diabetes management (10, 11). Recent trends reveal the long-time inequities that have plagued African Americans and other minorities in the U.S., keeping many from fair access to income, education, neighborhoods, and health care equal to that of White Americans (12). As a result, minorities have more chronic or serious health conditions and have significantly lower financial resources than White Americans (13). Given these facts and the considerable role that Medicare has among diabetic patients as shown previously, it would be worth exploring other insurance trends among

diabetic ED visits. Regarding diabetes-associated ED visits in the NHAMCS, it was investigated if there was a statistically significant difference in insurance types between diabetes mellitus (DM) Type 2 patients based on race in the U.S. in 2018.

Methods

Participants This study was an analysis of data from the 2018 NHAMCS. The sample hospital emergency room visits were from noninstitutional general and short-stay hospitals as well as hospital-associated ambulatory surgery centers, none of which were associated with federal, military or Veterans Administration Hospitals (13). The total number of visits was 20,291. This sample was examined for ED visits associated with diabetes mellitus Type 2 was 1,215 (N=1,215, 67.3% White, 26.5% Black, 6.2% Other).

Procedure

The annual NHAMCS is based on sample visits from randomly assigned hospitals and outpatient departments. The 2018 NHAMCS analysis was limited to visits associated with patients having the valid diagnosis code for DM Type 2 which was assigned following affirmation to the question “Does the patient have diabetes mellitus Type 2?” Of note, as of 2005, many disease diagnoses, including diabetes, are input into the Patient Record Form of the NAMCS and NHAMCS survey by means of a checkbox (9). The checkbox enables surveyors to indicate a particular diagnosis of the patient regardless of the reason for the ED visit. This yields a far more accurate quantification of ED visits by patients with a particular disease. Previously, ED visit primary diagnosis codes and medication lists were solely used to make a diabetes diagnosis determination. This was problematic as medications could go unreported. Further, the Patient Record Form only allowed three diagnosis codes, which could also lead to underreporting of diabetes if the patient visit was associated with multiple primary diagnosis codes for that particular ED visit. Therefore, while it was possible that diabetic patients went underreported in surveys previous to 2005, the checkbox increased accuracy of reporting (9). In total, 1,215 patient visits were found, representing 7.9 million encounters, after appropriate weighting. Because NHAMCS datasets are publicly available and de-identified, this study was deemed exempt by the Institutional Review Board at Geisinger Commonwealth School of Medicine.

Table 1. Comparison of count and percentage by race of ED visits associated with diabetes mellitus Type 2 patients stratified by source of payment from the National Hospital Ambulatory Care Survey public use files, 2018. Data analysis The 2018 NHAMCS data was imported into SPSS so that diabetes mellitus Type 2 relevant visits could be captured. As instructed by the NHAMCS documentation, data was first weighted in SPSS for patient visits (“PATWT”) to facilitate national representation of the sample data (14). Next, all visits associated with diabetes mellitus Type 2 patients were aggregated, stratified, and summed by race and expected payment type via IBM SPSS (14). Of note, PAYTYPER uses a hierarchy of 8 payment types/categories to allow visits to be associated with a primary expected source of payment (14). Crosstabulations were then performed by race and payment type for these visits, Table 1. The rationale was to look for any patterns related to health insurance between races. Four of the 9 categories of expected sources of payment in the crosstabulations table were merged into 2 categories to reduce variables. Expected sources of payment “Unknown” and “Blank” were merged into “Unknown” and expected sources of payment “Other” and “No Charge/Charity” were merged into “Other.” The crosstabulations were exported to excel for 2x2 tables for Chi square testing. Statistical differences with p<0.05 were considered significant. This was performed for 3 of the 9 categories which correspond to actual insurance as well as uninsured (Private, Medicaid, Uninsured). Data for these tables were imported to GraphPad Prism for creation of figures.

Results

Emergency department visits associated with diabetes mellitus Type 2 patients were stratified by race and primary expected sources of payment. Statistical significance was found for private insurance versus Medicaid between White and Black (p=0.001) and for private insurance versus uninsured between White and Black (p<0.006, Figure 1). There was no difference for private insurance versus Medicaid between races White and Other (p=0.879) or for private insurance versus uninsured between races White and Other (p=0.637).

Discussion

Statistical significance was found for private insurance versus Medicaid and for private insurance versus uninsured between races White and Black. Therefore, Medicaid coverage as well as the lack of insurance coverage was found to be significantly higher among Black (42.3%, 9.9% respectively) compared to White patients (30.2%, 7.8% respectively) visiting the ED. Chi Square testing was performed for 2x2 tables where primary expected sources of payment of private insurance, Medicaid, and uninsured for White race was tested against the same

Figure 1. Comparison of insurance types between diabetes mellitus Type 2 patients visiting the ED based on race in the U.S. in 2018, National Hospital Ambulatory Medical Care Survey. Private insurance versus Medicaid between races white and Black (p<0.001) and for private insurance versus uninsured between races white and Black (p<0.006). **p < 0.01.

for Black race and again for Other race. When comparing emergency department visits by White patients with diabetes mellitus Type 2 to Black patients with the disease, there were significantly more visits associated with private insurance among White patients. Additionally, there were significantly more visits associated with Medicaid or a lack of insurance among Black compared to White patients. Analysis of NHAMCS points to the need for heightened efforts to make health insurance and appropriate health care equally accessible to all. NHAMCS has been analyzed on other occasions to gauge growing health crises or to trend cost of care. Surveys spanning 1999 through 2005 were screened for ED visits associated with severe hypoglycemia and revealed about 5.0 million (380,000 per year) related ED visits. (7) The increased number of hypoglycemia visits to the ED did not equate to an increase in rate and was attributed to the increased overall prevalence of diabetes and intensive glucose control through insulin (7, 15, 16). This NHAMCS analysis further found disparities in hypoglycemia related ED visits in age, sex, ethnicity, race, and region (7). Visit rates among the diabetic population for female, Black and Hispanic patients were higher than those for male, White, and non-Hispanic patients (p<0.001) (7). A retrospective study of NHAMCS between 1999 and 2013 reported longitudinal trends in opioid-related ED visits along with resource utilization to gauge stress to emergency care systems. ED encounters increased 170% during that time (17). One-third of the visits arrived by EMS, nearly one-third required imaging studies, and there was a 250% increase in hospital admissions accounted for during that time (17). The results of this data were consistent with other data, showing drastic upward trends of opioid-related ED visits and cost related to care (18). Using the National Survey on Drug Use and Health (NSDUH), cost analysis from a prevalence-based estimation approach confirmed NHAMCS and other data showing that in 2007 abuse of prescription opioids cost workplace productivity, the judiciary system, and health care about $55.7 billion (19). In addition to the disparities of diabetes and hypoglycemia, analyses of NHAMCS either solely or in conjunction with National Ambulatory Medical Care Survey have also pointed to other medical conditions disproportionately affecting subpopulations. These include findings that asthma-related ED visits disproportionately affect more children than adults, more Blacks than Whites, and more Hispanics than Whites (20). Other findings in 2003–2005 NHAMCS ED visits and NAMCS outpatient visits showed that hepatitis C virus-related visits were more than twice as likely to occur among non-White than White patients and more than three times as likely to occur among Medicaid than non-Medicaid patients (21). Finally, a study of NHAMCS and NAMCS visits between 1999 and 2004 looked at dermatophyte and cutaneous yeast infections and associated high cost of care (22). For tinea capitis, there was an average of 433,690 visits per year and the prevalence among the Black population was 12 times that of the White population (22). Moreover, of all the tinea capitis cases, 85.6% occurred among children less than 15 years old, making Black school-aged children disproportionately impacted (22). Another significant finding was that Medicare covered visits for the conditions that predominantly affected children at that time (tinea capitis, 56.9%; tinea corporis, 34.7%; Candida of the skin and nails, 43.6%) (22). All findings above have had or continue to have a level of public health significance. NHAMCS has had an important role in identifying these conditions. Limitations include the NHAMCS may be subject to selection bias, errors in the medical record, and errors during the data abstraction process. Medicare was not included for statistical significance evaluation as this insurance can become primary for retired persons, and factors including differences in life expectancy between races would potentially confound the data in this category. Worker’s compensation was also not tested because it is considered temporary coverage which can only be obtained because of work-related injuries. Currently, the ACA continues to give states the option to expand Medicaid. This coverage was found to have a significant impact on insurance status of working-age adult ED patients as previously brought out, yet there are still 12 states which have not adopted the expansion (10, 23). Eight of the 12 states not expanding Medicaid are southern states which comprise 92% of the 2.2 million people in the coverage gap (24). These eight have higher Black populations, which are among the most likely to be uninsured compared to other populations (25). If Medicaid expansion were to be adopted by more states in the future, it would be worth reexamining NHAMCS data for a direct impact on visits associated with Medicaid or a lack of insurance among Black compared to White patients.

Acknowledgements

Thank you to Brian Piper, PhD, for invaluable feedback throughout the secondary analysis.

Disclosures

Mannaa I. Mannaa has no conflicts of interest to report.

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