Coverage Matters

Here’s a quick history lesson: employer-sponsored health insurance in the United States is a legacy of the tight job market during World War II where companies relied on fringe benefits to attract workers. Once established, that tradition has endured and, in spite of recent declines, employers remain the most common source of health insurance in the United States. 

But what are the effects of tying insurance so closely to employment? For one thing, switching between jobs can lead to interruptions in insurance. And switching jobs is common. According to the Bureau of Labor Statistics, even Americans born between 1957-1964 have held an average of 12 jobs over their lives. In theory, the Consolidated Omnibus Budget Reconciliation Act of 1985 (COBRA) solves this issue by allowing Americans to buy into their previous employer-sponsored plan. However, in reality the massive premiums offered under COBRA prevent most people from taking up the offer. 

This study delves into the impact of those interruptions in insurance on individuals with type 1 diabetes. The absolute necessity of insulin and related supplies in this population renders them vulnerable to disruptions in coverage. Using a database from a commercial health insurer, the researchers found 24.3% of people with diabetes suffered an interruption in coverage of at least one month. Such interruptions were not trivial, leading to 3.6% relative increase in hemoglobin A1c and an increase in the use of acute healthcare services by a factor of five. 

Interestingly, it was also found that those with a history of diabetic complications such as ketoacidosis were less likely to experience an interruption (18%-22.4%) than people without a history of diabetic complications (28.4%). This may indicate job lock, where people with worse health status are afraid to leave their jobs over concerns for losing access to health insurance.      

These findings clearly demonstrate that having health insurance matters and even short interruptions can be detrimental to those with certain pre-existing conditions. They also raise the suggestion that the current model of employer-sponsored insurance may be reducing the dynamism of the U.S. economy by trapping employees in jobs they might otherwise leave. Health insurance matters—but how it’s delivered matters too.   

Abstract

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.

PMID: 29985705

Rogers, MAM, et al. Health Affairs. 2018; 37 (7): 1024-1032.