Discussion
In this nationally representative sample of US adults with diabetes, delaying or forgoing medical care due to cost decreased over the past decade; this trend was consistent by sociodemographic characteristics, insurance type, and clinical characteristics. However, being uninsured was significantly associated with delaying or forgoing medical care due to cost compared with those who were insured. Notably, adults aged 18–64 years with Medicaid were significantly less likely to delay or forgo care due to cost compared with those with private insurance. Adults aged 18–64 years with Medicare were also more likely to delay or forgo medical care after adjustment for age, sex, and race/ethnicity, but the association was not significant after further adjustment for education and poverty income ratio. The associations between insurance status and delaying or forgoing medical care were robust and remained significant after adjustment for sociodemographic characteristics.
There are few studies that have assessed the association between health insurance and delays in seeking medical care among adults with diabetes. However, our findings are consistent with studies in other populations. Using NHIS data, it has been reported that among uninsured adults, 68% of cancer survivors and 32% of adults without cancer reported delaying or missing medical care due to cost.8 Among adults enrolled in Minnesota’s public health programs, 42% of those who reported financial barriers to medical care delayed medical care in the past year and 23% reported forgoing medical care.6 Lastly, findings from another NHIS study showed that adults who were uninsured were six times more likely to delay healthcare due to cost compared with those who were insured after accounting for sociodemographic characteristics and comorbidities.10
In 2022–2023 among adults with diabetes aged 18–64 years with private insurance, 9%–10% reported delaying or forgoing medical care due to cost compared with 5%–6% of adults with diabetes insured by Medicaid. Therefore, despite being privately insured, the costs of diabetes care were burdensome enough to delay care. In 2014, a survey conducted in Massachusetts-based emergency departments and outpatient clinics found that privately insured respondents were more likely to delay care due to cost compared with publicly insured respondents.11 However, a study conducted in 2010–2015 among non-elderly adults with heart disease showed that publicly insured persons more often delay medical care compared with those with private insurance.12 The association between health insurance type and delaying medical care may be nuanced by several factors at both the individual level (eg, sociodemographic characteristics including access to employment-based health insurance, health status, comorbidities, health awareness), the environmental level (eg, number of medical providers, public transportation), and the policy level (eg, state and federal level health insurance related programs).
The decrease in prevalence of delaying or forgoing medical care due to cost was likely due to the implementation of the ACA in 2010 with most provisions mandated by 2014.13 First, the ACA expanded coverage by providing subsidies for individuals procuring insurance through the Marketplace, which lowered costs for households with incomes between 100%–400% the federal poverty level.3 Second, states that expanded Medicaid covered all persons with incomes below 138% the federal poverty line; in 2014, Medicaid had expanded to 26 states and, by 2023, to 40 states.4 Therefore, the expansion of Medicaid likely reduced the prevalence of delaying care due to cost among lower-income persons by raising the income threshold for Medicaid eligibility and reducing the coverage gap. The perceived cost burden of medical care may be less for someone with Medicaid compared with someone with private insurance who is paying premiums, deductibles, which are potentially high, and out-of-pocket co-pays that may limit their healthcare utilization even though they are insured. However, the current study also showed that, in 2022, adults with diabetes and Medicaid were more likely to delay care due to not finding a doctor, clinic, or hospital that accepts their insurance compared with adults with private insurance. This association was significant after adjustment for sociodemographic characteristics but was not significant after further adjustment for duration of diabetes and having at least two other chronic conditions. While we could not explore these findings further, it appears that adults with diabetes and Medicaid had a more difficult time finding physicians compared with their counterparts with private insurance, possibly due to network limitations or administrative barriers. However, when ≥two additional chronic conditions were accounted for in these analyses, adults with Medicaid fared similarly to those with other insurance types in finding a doctor, clinic, or hospital that accepts their insurance. On further exploration, we found that those with Medicaid had more chronic conditions compared with those with private insurance; in 2022–2023 among adults aged 18–64 years, 55.1% with Medicaid had ≥ two chronic conditions versus 20.6% with private insurance (data not shown). Therefore, the extra burden of comorbidities may be associated with the ability to find healthcare that accepts their Medicaid insurance. For example, a person with diabetes and other chronic health conditions on Medicaid may have more challenges in securing healthcare than a counterpart without other chronic health conditions and, thus, be more likely to delay medical care. Nevertheless, a 2017 meta-analysis showed that Medicaid patients had greater difficulty obtaining appointments compared with privately insured patients across a variety of medical facilities; there was no adjustment for individual characteristics, such as comorbidities.14 Another study showed that in 2014–2015, the 2 years after implementation of Medicaid expansion, being in an expansion state was associated with more insurance coverage and access to care but also longer wait times for appointments, and thus delays in care, compared with being in a non-expansion state.15 As federal-level and state-level health insurance policies may be further modified, future studies can assess how any changes at the policy level impact individuals’ decisions to delay medical care.
NHIS is a cross-sectional survey; thus, causal associations between insurance status and delays in medical care cannot be determined. Limitations of this study were that all data were self-reported, which could have resulted in misclassification of diabetes status, insurance type, or delays in care due to recall bias. While diabetes type could not be determined in NHIS, patients with type 1 and type 2 diabetes both need regular medical care; thus, we would expect any differences in the outcome to be non-differential. The majority of adults with diabetes in the US have type 2 diabetes (90%–95%); therefore, it is possible that the results may not be generalizable to adults with type 1 diabetes. However, this study used a nationally representative sample allowing generalization to the US population with diabetes.
While there has been progress made in reducing delays in care due to cost among adults with diabetes, certain subpopulations more often reported delaying or forgoing medical care due to cost, particularly persons aged 18–64 years with lower education and income and who are uninsured. Over one-third of adults aged 18–64 years who were uninsured reported delaying or forgoing medical care due to cost, which highlights the importance of health insurance among adults with diabetes who need regular medical care. However, the expansion of Medicaid appeared to reduce the likelihood of delaying or forgoing medical care among adults with Medicaid coverage. As private and government-supported insurance has the potential to evolve in the USA, it will be equally important to understand how changes to insurance coverage may impact the ability for patients to manage and control their diabetes and its complications.
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