This study contributes to the large body of literature about the importance of health insurance coverage. It also confirms more recent reports about how a USC is independently associated with better receipt of diabetes-specific services. Beyond the approaches taken in past research, this study not only addresses these two individual factors, but it also uses a novel approach to examine the combined effects of having a USC and/or health insurance. Among U.S. adults with diabetes, having both insurance and a USC was a far superior option compared with having only a USC, only health insurance, or neither one. In every case, uninsured diabetic individuals without a USC had the highest risk for not receiving services. Interestingly, the results were more mixed when the two half-way groups with either insurance or a USC were compared. Those with only a USC fared better in receipt of recommended diabetes-specific care, appearing more similar to the reference group; however, those with only insurance (and no USC) were closer to the reference group in reporting fewer unmet needs. The mixed patterns of association when health insurance was compared with a USC illustrate the importance of measuring access to all health care services and not just disease-specific care when one is assembling “report cards” on the progress of diabetic care. If we had only examined diabetes-specific services, as in , we might have mistakenly concluded that having a USC provides diabetic individuals with better access to health care services than health insurance, thus suggesting that having a USC or further improving the delivery system with new medical homes might be a good substitute for health insurance. However, demonstrates the importance of also having stable health insurance coverage for this population.
It is clear that diabetic individuals need both continuous health insurance coverage and a stable USC. However, in the current political environment, incremental solutions are being proposed that may trade one for the other. The aim of some policies, such as expanding the number of community health centers or building medical homes for all patients, is to improve access to a USC while leaving thousands of Americans without insurance. Other proposals expand insurance coverage without a mechanism to ensure adequate provider capacity (24
). Findings from this study call into question some proposals to build community health centers while leaving millions uninsured or others that mandate health insurance coverage without enacting major workforce reforms. The ideal long-term approach to improving access to healthcare for diabetic individuals includes expanding health insurance coverage while, at the same time, ensuring access to comprehensive and continuous primary care services. Access to health insurance and/or a USC is not randomly distributed and can sometimes appear counterintuitive (). For example, those employed were less likely to have insurance and a USC, illustrating an eroding employer-sponsored insurance system and the likelihood that people working may have less time to establish a USC. Ideally, this type of sociodemographic information can assist efforts aimed to increase the number of insured diabetic individuals while, at the same time, ensuring that all persons with diabetes have a USC.
Our results should be considered in the context of several limitations. First, secondary analyses rely on the methods used to gather information about households. For example, we could not revise MEPS-HC questions that pertained to the objectives of our particular study. Second, as with all observational studies that rely on self-report, response bias remains a possibility. Third, although the MEPS-HC is representative of the civilian, noninstitutionalized U.S. population, theformat of our analyses limits causal inferences. Finally, a USC is not synonymous with a medical home, which could not be comprehensively evaluated with the MEPS-HC dataset.
In the current political climate, it seems more feasible to take a two-pronged approach: provide a usual source of care for some populations while extending health insurance coverage to others. In fact, current efforts to expand medical homes have focused on patients with chronic diseases such as diabetes, whereas private insurers prefer to expand their coverage to person without chronic disease and to exclude preexisting conditions. For diabetic individuals, a USC and health insurance, together, are associated with the highest likelihood that they will have optimal access to all necessary healthcare services. Thus, it is crucial that we simultaneously strengthen both the financing and delivery of healthcare services while, at the same time, generate forces to maximize the synergy between these two important aspects to achieve access to needed care.