Diabetic retinopathy (DR) is a common complication of diabetes mellitus (DM). It is the most common cause of acquired blindness in adults, despite all the recent innovative treatments for DM.
A large epidemiologic study found evidence of DR in 40% of adults with DM and in 3.4% of the general US population.1 Early identification can help avoid progression to blindness, and the American Diabetes Association recommends eye exams every 1-2 years for people with DM. Early diagnosis allows changes in medication regimens and laser treatments as indicated.
There are racial and ethnic disparities that exist in the discussion of diabetic eye exams. Racial and ethnic minorities receive fewer eye exams than recommended, either due to a lack of access, insurance, or knowledge. The Affordable Care Act was enacted in 2010 to address disparities such as these and came into force in 2014.
In a study this year by Monnette2, data from the 2014–2015 Medical Expenditure Panel Survey (MEPS) Household Component data files were studied, evaluating adults (≥18 years old) with a diagnosis of DM. The team looked for evidence of at least one dilated eye exam during those two years. The data were stratified by non-Hispanic whites vs. all others (minorities).
The data included 1,228 adults with diabetes. The sample was 57% female and 65% minority. About half of the population had private health insurance, 40% were on either Medicare or Medicaid, and under 10% were uninsured.
Two-thirds of the adults had an eye exam during the study years. During those years, more minorities underwent eye exams, increasing their rates from about 37% to 52% between 2014 and 2015. Whites also increased their rates of eye exams from 47% to 57%. After statistical analysis, the study found that the racial/ethnic disparity was significantly reduced, although a small difference persisted. Compared to older studies showing much larger discrepancies, these data are encouraging.
The ACA has been one of the most contentious legislation of our time. Despite over 60 attempts to repeal some or all the components of the ACA, it remains influential in American healthcare. It has had major impacts on Medicare, Medicaid, care for children, the insurance industry, employers, pharmaceutical companies – and patients. This study shows the effect that health insurance can make on access to care. A dilated eye exam can easily cost more than $200 when performed by an ophthalmologist, precluding this exam for millions of Americans. Having adequate insurance knocks down at least one of those barriers to care.
Other causes of disparities persist, however. Treatment of diabetes, the ability to afford pharmaceuticals, knowledge about the disease and the monitoring equipment, dietary interventions, qualified healthcare personnel, transportation, and mistrust are not directly remediable by changes in insurance.
Challenges continue even while politicians and healthcare policymakers continue to chip away at the ACA. However, this study showed good news related to disparities in care for DM.
1Kempen JH, O’Colmain BJ, Leske MC, Haffner SM, Klein R, Moss SE, Taylor HR, Hamman RF. The prevalence of diabetic retinopathy among adults in the United States. Archives of ophthalmology (Chicago, Ill.: 1960). 2004 Apr;122(4):552-63.
2Monnette AM, Wharton MK, Zhao Y, Fonseca VA, Shi L. Post-ACA Racial Disparity of Eye Examinations Among the US Noninstitutionalized Population With Diabetes: 2014–2015. Diabetes care. 2019 May 1;42(5):e70-2.