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Diabetes and Poverty

Despite having insurance, difficulty paying for food and medications affects a persons ability to cope with their diabetes.

In a recent post on the multifaceted quality of health, Keith Carlson, RN, BSN, NC-BC, wrote about financial health, questioning how diabetes is impacted for people living on the edge of poverty—feeding and housing themselves from paycheck to paycheck.

According to a new study, difficulty paying for food and medications may affect patients’ ability to cope with diabetes even with increased health care access in the U.S.1

In fact, the study found that the Patient Protection and Affordable Care Act (Obamacare), with expanded health care provision for people with diabetes, may not improve control of the disease among low income groups. This may result from social causes outside the scope of medical care such as difficulty paying for food, medications, housing, or utilities.

The American Diabetes Association acknowledges that, “halting U.S. diabesity epidemic and curtailing its health cost may necessitate addressing poverty,” pointing to the fact that counties with the greatest rates of poverty have the greatest diabetes rates.

Successful self-management for patients with diabetes can be expensive even among patients with insurance. In 2009, 27% of Americans with annual household outcomes below $25,000 were uninsured, representing 15,483,000 people, 5 million with obesity and 1 million with diabetes. With increased access to health care, the potential health care costs of diabetes alone for these individuals is nearly $9 billion a year, or $9,000 per new diabetes patient a year.

Study Findings

Recognizing the need to address these issues, Seth A. Berkowitz, MD, MPH, of Massachusetts General Hospital, Boston, and coauthors sought to examine multiple unmet social needs and their relationship with diabetes control and the use of health care resources.

The study was conducted in Boston, Massachusetts, a state which has had health insurance coverage for almost 10 years with plan requirements similar to those being enacted nationally under Obamacare. The study of 411 patients included data from June 2012 through October 2013  and focused on 4 issues:

  • difficulty affording food
  • cost-related medication underuse
  • housing instability
  • and energy insecurity (household heating or cooling).

Overall 39.1% of patients reported at least one material need insecurity. Poor diabetes control (as measured by factors including hemoglobin A1c, low-density lipoprotein cholesterol level, or blood pressure) was seen in 46% of patients.

“I think the main thing this research adds is that we took a more comprehensive look at both material needs insecurities and diabetes outcomes. We think the finding that food insecurity and cost-related medication underuse are particularly associated with these diabetes outcomes provides good evidence that these factors may be good targets for intervention,” said Dr. Berkowitz.

Although all economic challenges had some association with poor diabetes control or increased use of health care resources, the outcomes varied with each individual issue. Difficulty affording food was strongly related to maintenance of blood sugar levels and number of doctor’s visits, whereas cost-related medication underuse, while similarly related to poor control of blood sugar levels was also associated with cholesterol, blood pressure, and increased hospital visits. Over-all the study showed that the efforts of patients and clinicians are insufficient in situations where patients could not afford basic needs.

“Health care systems are increasingly accountable for health outcomes that have roots outside of clinical care. Because of this development, strategies that increase access to health care resources might reasonably be coupled with those that address social determinants of health, including material need insecurities,” the study concluded.

Health Literacy

In addition to examining the effects of material insecurities, the study also looked at noneconomic social circumstances, like health literacy.

“Clearly interventions like making educational materials appropriate for all levels of literacy are important. However, given that low health literacy likely indicates major socioeconomic disadvantage across the life course, and probably has a lot of carryover into non-health care settings like job opportunities, ability to access social services, etc., it's not clear to me that simply addressing the literacy level of patient information will be enough,” said Dr. Berkowitz.

In developing future public health programs, the findings suggest that a population with frequent doctor’s visits and poorly controlled diabetes might point to a group of patients with social needs that are not being addressed and a situation in which the health care system is underprepared to intervene.

Solutions that seek to address multiple issues at once, such as programs that provide food along with medication, could serve to address these issues, a situation which might indicate a need for increased cooperation between the health care system, government programs, and community health worker and peer support interventions.

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