OBJECTIVE To examine the relationship between access to health care and diabetes control.

RESEARCH DESIGN AND METHODS Using data from the National Health and Nutrition Examination Survey, 1999–2008, we identified 1,221 U.S. adults (age 18–64 years) with self-reported diabetes. Access was measured by current health insurance coverage, number of times health care was received over the past year, and routine place to go for health care. Diabetes control measures included the proportion of people with A1C >9%, blood pressure ≥140/90 mmHg, and non-HDL cholesterol ≥130 mg/dL.

RESULTS An estimated 16.0% of known diabetic adults were uninsured. Diabetes control profiles were worse among uninsured than among insured persons (A1C >9% [34.1 vs. 16.5%, P = 0.002], blood pressure ≥140/90 mmHg [31.8 vs. 22.8%, P < 0.05], and non-HDL cholesterol ≥130 mg/dL [67.1 vs. 65.4%, P = 0.7]). Compared with insured persons, uninsured persons were more likely to have A1C >9% (multivariate-adjusted odds ratio 2.4 [95% CI 1.2–4.7]). Compared with those who reported four or more health care visits in the past year, those who reported no health care visits were more likely to have A1C >9% (5.5 [1.2–26.3]) and blood pressure ≥140/90 mmHg (1.9 [1.1–3.4]).

CONCLUSIONS In people with diabetes, lack of health care coverage is associated with poor glycemic control. In addition, low use of health care service is associated with poor glucose and blood pressure control.

In 2010, an estimated 25.8 million people in the U.S. had diabetes (1). People with diabetes are at high risk of a heart attack, a stroke, and other micro- or macrovascular complications (2). While diabetes poses a huge health and economic burden to society, effective diabetes control and management such as control of ABCs of diabetes—glycemic control (A1C control [“A”]), blood pressure control (“B”), and lipid control (cholesterol control [“C”])—can decrease the diabetes burden through prevention or delay of complications (2).

In 2008, 46 million people, or 15.4% of the population in the U.S., lacked health care insurance coverage (3), and between January and September 2010, the estimated number was up to 49.5 million (4). Access to health care, including insurance coverage, plays a crucial role in the receipt of preventive services (5). Both lack of insurance coverage and inadequate coverage have been associated with lower use of preventive services (6,7). In addition, absence of a physician or usual source of care is a barrier to the control of hypertension (8). Furthermore, lack of health insurance is associated with an increased risk of overall health decline among late-middle-age adults (9). On the contrary, in a randomized controlled trial, access to Medicaid was found to be beneficial to both physical and mental health outcomes (10).

While preventive care practices and diabetes control can delay or prevent complications of diabetes (2), optimal preventive care and control depend on access to health care (11,12). Uninsured people with diabetes are less likely to receive needed care and to effectively manage their disease than those who are insured, and those with inadequate coverage have difficulty obtaining needed care (11,12). Those with insurance coverage are more likely to maintain glycemic control than those without (13,14). Despite these findings, we are unaware of any studies that have examined the relationship between access to health care and control of ABCs of diabetes among persons with diabetes.

Therefore, we explored the relationship between access to health care and multiple diabetes control outcomes. Specifically, we examined how insurance coverage, frequency of health care use, and routine place to go for health care affected glycemic control, blood pressure control, and lipid control in a representative sample of U.S. adults with self-reported diabetes.