Managing Diabetes: Health Plan Coverage of Services and Supplies
Published: 2005-02-25T00:00:00

Fast Facts:

Highlights:
section_title: Why GAO Did This Study
paragraphs: Diabetes, which afflicts millions of Americans, is a manageable disease whose effects can be mitigated with proper care, regularly received. Experts recommend certain services and supplies for managing diabetes. Because these can be costly, concerns exist about whether individuals with diabetes have access to and receive what they need. Little is known, however, about health plan coverage of diabetes services and supplies. GAO reviewed the extent to which (1) states require insurance policies to cover diabetes services and supplies, (2) health coverage not subject to state requirements includes diabetes services and supplies, and (3) individuals with diabetes ages 18 and older receive services and supplies. GAO analyzed all 50 states' and the District of Columbia's laws and regulations pertaining to diabetes coverage. GAO also obtained from selected health plans providing coverage not subject to state requirements--13 large-employer plans and 3 plans in the Federal Employees Health Benefits Program (FEHBP)--information on coverage of 10 services and nine supplies identified as important for individuals with diabetes. In addition, GAO obtained national data from the Centers for Disease Control and Prevention (CDC) on individuals' receipt of diabetes services and supplies. GAO received technical comments from CDC and incorporated them in the report as appropriate.
section_title: What GAO Found
paragraphs: In 2004, 47 states, including the District of Columbia, had laws or regulations related to coverage of diabetes services or supplies, although specific requirements varied by state. Services for which states most often required coverage were diabetes education (45 states) and medical nutrition therapy (27 states). All 47 required coverage of diabetes supplies, although some states were more specific than others about which supplies must be covered. Health plans GAO contacted that provide coverage not subject to state insurance requirements--those offered by 13 large Fortune 500 companies and the 3 largest health plans in FEHBP--covered most of the services and supplies recommended for individuals with diabetes, generally without limits on the coverage. Each plan covered at least 7 of 10 diabetes services, such as an annual blood glucose test, cholesterol and blood pressure monitoring, and influenza vaccinations, as well as at least five of nine diabetes supplies, such as insulin and insulin-administering supplies. According to a 2003 CDC nationwide survey, the majority of individuals with diabetes reported receiving at least one diabetes service within the past 12 months. Significantly fewer individuals, however, reported receiving five services that individuals with diabetes are recommended to receive at least once a year. For example, an estimated 88 percent reported receiving a test for blood glucose, whereas an estimated 33 percent had received the five recommended services: blood glucose and cholesterol tests, eye and foot exams, and an influenza vaccination. Receipt of diabetes services and supplies varied by service, state, and whether an individual had health coverage. For example, 71 percent of individuals with diabetes who had health coverage at the time of the survey received eye exams, compared with 46 percent of individuals with diabetes who lacked coverage.

section_title: Letter
paragraphs: Diabetes afflicts an estimated 18 million Americans, and the number of  newly diagnosed cases has been rising, according to the Centers for  Disease Control and Prevention (CDC). Diabetes is characterized by a  high level of blood glucose, which damages nerve endings and blood  vessels; this damage in turn leads to serious health complications such as  blindness, heart disease and stroke, kidney disease, and poor circulation in  the extremities potentially resulting in foot or leg amputations.  Complications like these can be delayed or prevented with proper care,  provided that such care is accessible and used. Specifically, federal health  agencies and national organizations recommend that individuals with  diabetes receive certain services to manage their disease—including  periodic tests for blood glucose, eye and foot exams, medical nutrition  therapy, and diabetes education—along with other services, such as  cholesterol tests, smoking cessation services, and influenza  immunizations, which help reduce the risk of complications. Supplies that  many individuals with diabetes use to track and control their blood  glucose levels include blood glucose monitors; test strips; insulin; and, to  administer insulin, insulin pumps or disposable needles and syringes.
Because diabetes services and supplies can be costly, you and others have  raised concerns about whether individuals with diabetes have access to  and receive all the services and supplies they need. Certain national  organizations concerned with diabetes patient care have advocated state  laws mandating that health insurance cover certain services and supplies  benefiting these individuals. Although states generally do not regulate  employment-based benefit plans, such as health plans provided by  employers, they do regulate insurance; consequently, health coverage  employers provide through the purchase of insurance is generally subject  to state insurance regulation. Although the exact number is unknown,  many individuals with diabetes have health coverage not subject to state  insurance regulation because their employers self-fund their health plans;  that is, the employers pay the cost of health benefits directly, instead of  purchasing insurance. In addition, the Federal Employees Health Benefits  Program (FEHBP)—through which the federal Office of Personnel  Management (OPM) contracts with private health insurance carriers to  offer health coverage to federal employees, retirees, and their  dependents—is not subject to state insurance requirements.
In this context, we examined the following three questions:  1.  To what extent do state laws or regulations require health insurance  policies to cover diabetes services and supplies?  2.  To what extent does health coverage not subject to state insurance  requirements—specifically, coverage provided by the largest health  plans participating in FEHBP and the largest private self-funded health  plans—include diabetes services and supplies?  3.  To what extent do individuals with diabetes, including those with  health coverage and those without, receive diabetes services and  supplies?
To answer these questions, we obtained information from federal health  agencies and national organizations concerned with diabetes patient care,  and we identified 10 services and nine supplies that individuals with  diabetes may need. To examine the extent to which states require health  insurance policies to cover diabetes services and supplies, we reviewed  state laws and regulations related to diabetes coverage. To assess the  extent to which health coverage not subject to state requirements—such  as coverage provided by the largest plans participating in FEHBP and by  selected large employers’ self-funded plans—includes diabetes services  and supplies, we contacted the three largest national plans participating in  FEHBP—Blue Cross and Blue Shield, Mail Handlers, and Government  Employees Hospital Association, Inc.—as well as a random sample of 15  of the largest 50 Fortune 500 companies regarding their plans’ coverage of  diabetes services and supplies in 2004. We received responses from all  three FEHBP plans, which covered approximately 5.3 million people in  2003, and from 13 of 15 of the employers we contacted, which together  employed about 2.4 million people in 2003. To collect information on the  extent to which individuals with diabetes with and without health  coverage receive diabetes services and supplies, we analyzed data  provided by CDC from an annual national survey of individuals ages 18  and older known as the Behavioral Risk Factor Surveillance System  (BRFSS). This survey, conducted by the states, consists of self-reported  data gathered from telephone interviews. We used data collected during  2003, the most recent year available. We also obtained data from another  CDC survey known as the National Health and Nutrition Examination  Survey (NHANES). Unlike BRFSS, this survey combines an in-home  interview with a physical examination to assess the health of a nationally  representative sample of the noninstitutionalized U.S. population,  including a representative sample of individuals with diabetes. We used  data collected by this survey from 1999 through 2002 for individuals ages  18 and older. To assess data reliability, we reviewed CDC documentation  of its data collection and discussed the data and their appropriate use with  CDC officials. We determined that the data were sufficiently reliable for  our purposes.
We conducted our work according to generally accepted government  auditing standards from July 2004 through January 2005. Additional details  about our scope and methodology appear in appendix I.
subsections: section_title: Background
paragraphs: Diabetes, a chronic disease, was the sixth leading cause of death in the  United States in 2000, contributing to the loss of more than 200,000 lives,  according to CDC. Type 1 diabetes, in which the body fails to produce  insulin, is usually diagnosed in children and young adults. Type 2 diabetes,  in which the body fails to use insulin properly, is associated with aging, a  family history of diabetes, physical inactivity, and obesity and accounts for  90 to 95 percent of all diabetes cases. Although type 2 diabetes occurs  most often among adults, it is increasingly being diagnosed in children and  adolescents. One study found that, on average in 2002, individuals with  diabetes incurred about $13,243 in health care expenditures, compared  with about $2,560 in expenditures for individuals without diabetes. These  estimates include costs attributed to complications of diabetes, such as  cardiovascular disease, neurological symptoms, and kidney disease.
Federal health agencies and national organizations concerned with  diabetes patient care have identified a number of services and supplies  that individuals with diabetes often need to help manage their disease.  Table 1 lists services considered important for diabetes patient care by the  American Association of Diabetes Educators; the American Dietetic  Association; and the National Diabetes Quality Improvement Alliance  (Alliance), a consortium of 13 private-sector organizations and  government agencies, including the American Diabetes Association (ADA),  CDC, and the Centers for Medicare & Medicaid Services.
In addition to such services, according to federal agencies and  organizations concerned with diabetes patient care, individuals with  diabetes often need certain supplies to manage their disease. Needed  supplies may include blood glucose monitors, glucose control solutions  (used to check the accuracy of testing equipment and test strips), test  strips, lancets and lancet devices (used to prick the skin for a blood  sample to self-test blood glucose levels), insulin (when necessary), insulin  pumps (to administer insulin), disposable needles and syringes (also to  administer insulin), alcohol swabs, and therapeutic shoes (for individuals  with severe diabetic foot disease).
Health coverage may be provided through the purchase of insurance  policies that are subject to state laws and regulations or through means  other than insurance. Health coverage provided through the purchase of  insurance in a given state, whether purchased by individuals or by  employers, is subject to insurance requirements in that state, including  requirements to cover specified illnesses, services, or supplies. For  example, states often require coverage of cancer-screening services such  as mammography or tests for colorectal cancer. These state requirements  are in addition to coverage requirements established by federal law. In  2001, two-thirds of Americans younger than 65 (the age at which people  generally become eligible for Medicare), received health coverage  through their own employer or that of a family member. Large private  employers often self-fund their health plans, and coverage provided by  these plans is not subject to state insurance regulation, although it is  generally subject to federal requirements. Health coverage provided by  the federal government is also not subject to state insurance regulation.  For FEHBP, OPM is responsible for contracting with private health  insurance carriers to offer health benefit plans to federal employees. By  federal law, the terms of any FEHBP contract negotiated by OPM that  relate to coverage or benefits preempt any inconsistent state or local law  or regulation. OPM routinely preempts state requirements to ensure a  consistent set of benefits among nationwide FEHBP plans, according to an  OPM official.
section_title: Most States Require Insurance Policies to Cover Diabetes Services and Supplies, Although Specific Requirements Vary
paragraphs: In 2004, 47 states had laws or regulations related to coverage of diabetes  services or supplies, although specific requirements varied by state (see  fig. 1 and app. II). Forty-five states required insurance policies to cover  specific services or supplies for diabetes. Two more states, Mississippi  and Missouri, required “mandated offerings”; that is, these states required  insurance policies to provide coverage for diabetes at the option of  purchasers. Some states’ requirements applied only in narrow  circumstances. For example, Arizona and Wisconsin required coverage of  diabetes supplies only when a health insurance policy covered the  treatment of diabetes. The services most frequently specified in state  requirements were diabetes education and medical nutrition therapy: 45  states required that insurance policies cover diabetes education, and 27  states required coverage of medical nutrition therapy. State requirements  may have focused more often on these two services in part because  national organizations concerned with diabetes patient care—including  ADA, the American Dietetic Association, and the American Association of  Diabetes Educators—have supported “model” legislation centered on  these two services. According to ADA and the American Dietetic  Association, the organizations focused on these two services in particular  because others, such as eye and foot exams, were thought to be covered  by most policies as general medical services. The model legislation also  includes coverage of “diabetes equipment and supplies,” and 47 states  required such coverage. Twenty-eight states identified which supplies  must be covered, although their specific requirements varied.
Some states had specific requirements regarding the coverage of certain  services, such as diabetes education. Forty-two states specified at least  some criteria for the training or education that health care professionals  must have to provide diabetes education. These criteria varied widely from  state to state. To provide diabetes education in Louisiana, for example,  health professionals must have demonstrated expertise in diabetes and  must have completed an educational program in compliance with the  National Standards for Diabetes Self-Management Education established  by ADA. In contrast, several states required educators to be licensed  professionals with expertise in diabetes but did not define the term  expertise. Eight states referred to ADA’s national standards in setting their  requirements for diabetes education programs. Some of these states  required programs to be consistent with these standards, while others  mentioned them as an example of acceptable standards.
Among the 47 states whose laws or regulations required coverage of  diabetes supplies, specific coverage requirements varied. For example, 19  states did not specify which supplies must be covered; instead, these  states typically required coverage of all medically necessary equipment  and supplies prescribed by a physician. The remaining 28 states specified  covered supplies, either in laws or regulations, but the number of supplies  varied among the states. For example, Michigan had requirements related  to insulin, blood glucose monitors, test strips, lancets, lancet devices,  syringes, and insulin pumps. In contrast, Mississippi required coverage of  equipment and supplies, including supplies used in connection with blood  glucose monitoring and insulin administration, but did not specify which  supplies. Some states that listed covered supplies also prescribed  procedures for adding new supplies to the list. For example, in New  Jersey, the Commissioner for Insurance, in consultation with the  Commissioner of Health, may update the list of supplies.
While nearly all states have required some coverage of diabetes services or  supplies in the insurance policies they regulate, some states have  authorized a class of health insurance policies that are not bound by many  of the state coverage requirements, which may include those for coverage  of diabetes services and supplies. Known as “flexible health benefit” or  “limited-benefit” policies, and typically marketed to small employers or  individuals, such policies may, through lower premiums, reduce the cost  of coverage. At least two states, Louisiana and Arkansas, have authorized  limited-benefit policies that are not bound by requirements related to  diabetes services and supplies. Louisiana has authorized such policies for  individuals not otherwise able to obtain health coverage and for small  employers (3–35 employees), and Arkansas has authorized them for all  groups, regardless of size. ADA is concerned that limited-benefit policies  may not provide sufficient coverage of the services and supplies that  individuals with diabetes need to manage their condition.
section_title: Selected Health Plans Providing Coverage Not Subject to State Regulation Cover Most but Not All Diabetes Services and Supplies
paragraphs: The 3 largest plans participating in FEHBP—Blue Cross and Blue Shield,  Mail Handlers, and Government Employees Hospital Association, Inc.— and the 13 large-employer self-funded plans we contacted covered most of  the diabetes services and supplies we reviewed. All 16 plans covered at  least 7 of the 10 diabetes services, as well as at least five of nine diabetes  supplies. Few of the plans we contacted placed limits on coverage for  diabetes services and supplies.
subsections: section_title: Three Largest FEHBP Plans Cover Most Diabetes Services and Supplies
paragraphs: The three largest FEHBP plans covered at least 8 of the 10 diabetes  services we reviewed (see table 2). Both diabetes education and medical  nutrition therapy were covered by two of the three plans, although one  plan placed conditions on these services: diabetes education was covered  when provided at a hospital and medical nutrition therapy when provided  by a physician. The three plans stated that coverage requirements for  diabetes services and supplies applied only in cases of medical necessity.  The plans generally did not, however, set monetary limits on their  coverage for diabetes services. One exception was smoking cessation  therapy, for which one plan set $100 lifetime limits per enrollee for both  counseling and drug therapy. Another plan set $100 lifetime limits per  enrollee for smoking cessation counseling.
The three FEHBP plans all covered at least seven of nine diabetes  supplies, including blood glucose monitors, glucose control solutions, test  strips, lancets and lancet devices, insulin, insulin pumps, and disposable  needles and syringes. One plan did not cover alcohol swabs, and two plans  did not cover therapeutic shoes. One plan limited its coverage of supplies;  specifically, this plan set lifetime durable medical equipment limits of  $10,000 per person for specific supplies, including blood glucose monitors  and insulin pumps.
section_title: Large Employers’ Self- Funded Health Plans Reviewed Cover Most Diabetes Services and Supplies
paragraphs: Each of the 13 large employers’ self-funded health plans we reviewed  covered at least 7 of 10 diabetes services, specifically, blood glucose, lipid,  and urine tests; eye and foot exams; blood pressure management, and  influenza vaccinations. The remaining 3 services were covered by at least 9  plans (see fig. 2). Among these plans, we found limits on coverage only for  smoking cessation therapy. One plan, for example, had a lifetime  maximum of three drug therapy treatments for smoking cessation, and  another plan had a maximum of two smoking-cessation programs per  lifetime for each enrollee for both counseling and drug therapy.
In a few cases, the plans specified certain conditions for coverage. For  example, among the 11 plans offering coverage of diabetes education, 4  did so only if an employee with diabetes was enrolled in the plan’s  diabetes management program. Three of the 10 plans offering coverage of  medical nutrition therapy did so only as part of their diabetes management  program. Of the 9 plans covering smoking cessation therapy, 5 restricted  coverage to drug therapy and did not cover smoking cessation counseling.  Most of the self-funded plans stipulated that diabetes services and supplies  were covered only when medically necessary. In addition, 7 plans  required waiting periods ranging from 30 days to 6 months after an  employee was hired before health coverage began. One plan did not cover  preexisting conditions—either an injury or illness—occurring during the  90 days before a newly hired employee began the waiting period.
All 13 self-funded plans covered at least five of nine diabetes supplies,  including insulin, insulin pumps, disposable needles and syringes, test  strips, and lancets and lancet devices, and all but 1 covered blood glucose  monitors (see fig. 3). Only 1 of the 13 plans reported having limits on the  quantity of supplies covered, covering one blood glucose monitor per year.  Two of the 13 plans reported placing conditions on their coverage of  supplies. For example, 1 plan told us that it allowed up to a 90-day supply  of items for each claim, and another plan covered therapeutic shoes when  prescribed by a physician and purchased through an authorized supplier.
section_title: Nationwide, Receipt of Diabetes Services and Control of Related Health Conditions Are Uneven
paragraphs: Data from CDC’s 2003 nationwide survey showed that individuals with  diabetes received some but not all diabetes services, and those who had  health coverage were more likely to have received services than those who  did not. The proportion of individuals with diabetes receiving diabetes  services varied widely by type of service and among states. Another CDC  survey, which included a physical examination of participants, indicated  that many individuals with diabetes did not have their diabetes-related  conditions adequately controlled.
subsections: section_title: Individuals with Diabetes Report Receiving Many but Not All Services
paragraphs: National data show that individuals with diabetes ages 18 and older  receive many but not all diabetes services. In a nationwide telephone  survey conducted in 2003, the majority of individuals with diabetes  reported receiving at least one of six identified diabetes services for which  national data were available. Substantially fewer individuals reported  receiving within the past 12 months the five services recommended that  individuals with diabetes receive at least once a year. Although the receipt  of services varied by service, half or more of the individuals with diabetes  reported receiving each given service. For example, an estimated 88  percent had received a test for blood glucose within the past 12 months,  and an estimated 52 percent had received diabetes education. A much  smaller proportion, 33 percent, had received the five services  recommended that individuals with diabetes receive at least once a year— specifically, a blood glucose test, a cholesterol test, an eye exam, a foot  exam, and an influenza vaccination (see fig. 4).
CDC’s survey also indicated that an estimated 82 percent of individuals  with diabetes were taking insulin or diabetes medication to control their  blood glucose. Otherwise, use of diabetes supplies was not captured in  CDC’s survey.
section_title: Individuals with Diabetes Who Have Health Coverage More Likely to Receive Services Than Those Who Lack Coverage
paragraphs: According to CDC’s 2003 survey, in comparison with individuals with  diabetes who lacked health coverage, a larger proportion who had health  coverage reported receiving one or more services. For example, an  estimated 90 percent of individuals with diabetes who had health coverage  at the time of the survey had received a blood glucose test, compared with  71 percent of those who reported not having such coverage (see fig. 5).  Moreover, the estimated proportion of individuals with diabetes who  received all of the five diabetes services was more than twice as high for  those who had coverage than for those who did not. For example,  although an estimated 35 percent of those with health coverage had  received a blood glucose test, a cholesterol test, eye exam, foot exam, and  influenza vaccination, just 14 percent of those without health coverage  received the same set of services.
section_title: Receipt of Diabetes Services Varies Widely among States
paragraphs: CDC’s 2003 survey showed substantial variation among states in the  receipt of diabetes services. Depending on the service, the estimated state- by-state percentages of individuals with diabetes who reported receiving  services varied widely. For example, the estimated state-by-state  percentages of individuals with diabetes who reported receiving an eye  exam ranged from 55 to 84 percent (see table 3). Despite this state-by-state  variation, the same services were generally the most received across all  states. In most states, for example, more individuals received blood  glucose and cholesterol tests than received foot exams or diabetes  education.
section_title: Many Individuals with Diabetes Do Not Have Adequate Control of Related Conditions That May Increase Their Risk of Complications
paragraphs: For 1999–2002, data from CDC’s NHANES—a nationally representative  survey that involves a physical examination to assess each participant’s  health—indicated that many individuals with diabetes ages 18 and older  did not have adequate control of related conditions that could lead to  health complications. Experts say that controlling blood glucose and  cholesterol levels lowers the risk of nerve damage, vision disorders, and  cardiovascular disease; detecting renal disease early decreases the risk of  kidney failure. Yet data from CDC’s NHANES showed that about 19  percent of examined participants with diabetes had poor control of their  blood glucose, and about half of them had cholesterol levels putting them  at increased risk for cardiovascular disease. In addition, about 40 percent  were at increased risk of renal disease, as evidenced by a positive test for  abnormal levels of a protein in their urine. The data also showed that  about 38 percent of individuals with diabetes who did not have health  coverage had glucose levels indicative of poor control, compared with  about 16 percent of those who had health coverage.
section_title: Agency Comments
paragraphs: We provided a draft of this report to CDC for comment. The agency  provided us with technical comments, which we incorporated into the  report as appropriate.
As agreed with your offices, unless you publicly announce its contents  earlier, we plan no further distribution of this report until 30 days after its  issue date. At that time, we will send copies to interested congressional  committees and members and make copies available to others upon  request. In addition, the report will be available at no charge on the GAO  Web site at http://www.gao.gov.
If you or your staffs have any questions about this report, please contact  me at (202) 512-7118. Another contact and key contributors to this report  are listed in appendix III.
section_title: Appendix I: Scope and Methodology
paragraphs: To assess health care coverage and receipt of diabetes services and  supplies, we obtained information from federal health agencies and  national organizations concerned with diabetes patient care and identified  10 services and nine supplies that individuals with diabetes often need. To  determine the extent to which states require coverage of diabetes services  and supplies for the health insurance policies they regulate, we examined  state laws and regulations from September 2004 through December 2004  related to diabetes and the extent to which they required coverage of  specific services and supplies. We also reviewed information prepared by  the American Diabetes Association (ADA) and the American Dietetic  Association and interviewed officials there, as well as from states and the  National Conference of State Legislatures. In addition, we reviewed state  requirements for limited-benefit policies—which are not required to  comply with coverage requirements usually applicable to health  insurance—in Louisiana, Arkansas, and Colorado.
To examine the extent to which the largest plans participating in the  Federal Employees Health Benefits Program (FEHBP) and the largest self- funded employer plans cover diabetes services and supplies, we obtained  information from the three largest national FEHBP plans—Blue Cross and  Blue Shield, Mail Handlers, and Government Employees Hospital  Association, Inc.—which together covered approximately 5.3 million  people in 2003, or about 65 percent of employees, retirees, and their  dependents covered by FEHBP plans. We also contacted a random sample  of 15 of the 50 largest Fortune 500 companies, ranked by the number of  employees, regarding their plans’ coverage of diabetes services and  supplies in 2004 and received responses from 13 of them. Together these  13 large companies, which had self-funded health plans, employed about  2.4 million people in 2003. Because employers may offer their employees  more than one health plan option, we asked employers to provide  coverage information related to the health plan that had the largest  enrollment. We relied on the information as reported by officials of the  health plans reviewed and did not independently verify their responses.  Because of our sampling approach, we cannot generalize our findings to  all FEHBP plans or to all large employers. Although we received responses  from most (16 of 18) of the FEHBP plans and employers we contacted, our  results may still reflect some selection bias, in that employers offering  more benefits might have been more likely to respond than those offering  fewer benefits.
To assess information on the extent to which individuals with diabetes  receive diabetes services and use supplies, we analyzed data for  individuals ages 18 and older provided by the Centers for Disease Control  and Prevention (CDC) from two nationwide surveys: the Behavioral Risk  Factor Surveillance System (BRFSS) for 2003 and the National Health and  Nutrition Examination Survey (NHANES) for 1999–2002:    BRFSS is a nationwide telephone survey conducted every year by state  health departments, with technical and methodological assistance  provided by CDC. A “cross-sectional” or point-in-time survey, BRFSS  samples the civilian noninstitutionalized population of adults ages 18 and  older in the United States, including the 50 states and the District of  Columbia; all data from BRFSS are self-reported. The survey’s purpose,  methods, and data analyses are available at http://www.cdc.gov/brfss. We  used data from CDC gathered during 2003 about services individuals with  diabetes reported receiving within the 12 months preceding the survey,  which represented the most recent information available. BRFSS 2003  included a representative sample of 19,162 participants with diabetes. In  addition to questions from the core sections of the survey, we used  questions from a diabetes-specific section, which included data from 46  states in 2003, to collect data on disease management practices from  respondents with diabetes.
NHANES is a nationally representative survey, whose data are collected  every year and released every 2 years by CDC, that samples the civilian  noninstitutionalized U.S. population. It is a two-part survey, consisting of  an in-home interview plus a health examination in a mobile examination  center. Its purpose, methods, and data analyses are available at  http://www.cdc.gov/nchs/nhanes.htm. We used NHANES data from   1999–2002—the most recent information available—for adults ages 18 and  older, which included a representative sample of 904 participants with  diabetes. We relied on NHANES results from the physical examinations,  which included laboratory tests, for specific test values for individuals  who had reported a prior diagnosis of diabetes, including tests for blood  glucose, cholesterol, and kidney disease.
We examined data provided to us by CDC from each survey separately.  When possible, the data were stratified by health coverage status  (respondents who reported having health coverage and those who  reported not having it). For both surveys, we used data only from  respondents who reported receiving a diagnosis of diabetes before the  survey period. Most of CDC’s estimates from BRFSS were stratified by  state, although we could not develop state-level estimates by health  coverage; NHANES estimates were limited to the national level. We  analyzed a total of 10 indicators for diabetes services and supplies from  both surveys (see table 4).
We assessed the reliability of the NHANES and BRFSS data provided by  CDC by (1) reviewing existing information about the data and the methods  used to collect them and (2) interviewing and working with agency  officials knowledgeable about the data. We determined that the data were  sufficiently reliable for the purposes of this report. Our review had several  data limitations. First, BRFSS data were self-reported for each service we  reviewed, and both BRFSS and NHANES used self-reported diagnoses of  diabetes from participants, a practice that can result in recall bias. Second,  BRFSS is a telephone survey, which limits data collection to individuals  who have telephones. Third, both surveys are cross-sectional; that is, they  provide information at one point in time. For example, although health  coverage was assessed at the time the surveys were conducted, we could  not determine whether participants’ coverage changed over the survey  year.
section_title: Appendix II: Summary of Diabetes Coverage Requirements in State Laws or Regulations, 2004
subsections: section_title: Requirement related to diabetes
section_title: Appendix III: GAO Contact and Staff Acknowledgments
subsections: section_title: GAO Contact
section_title: Acknowledgments
paragraphs: Lisa A. Lusk, Jennifer Major, Adrienne Griffin, Craig Winslow, and Ellen W.  Chu made key contributions to this report.