November is National Diabetes Month, an appropriate time to explore why the nation's response to this growing, obesity-driven scourge deserves a grade of F.
Let's start with the troubling statistics. More than 30 million Americans, or 9.4% of the population, are diabetics. That represents a doubling of the disease's prevalence in the past two decades. The U.S. now ranks 32nd out of 33 countries in the Organisation for Economic Co-operation and Development in diabetes prevalence.
A map highlighting the states and counties with the highest incidence of diabetes looks depressingly familiar. It resembles maps of the opioid epidemic. The hardest hit states are in the Deep South and de-industrialized Midwest.
Public awareness campaigns warning people about diabetes and its complications (heart disease, blindness, kidney failure, amputation) have failed. The Centers for Disease Control and Prevention estimates that nearly a quarter of diabetics don't even know they have the disease.
How about prevention? Obesity is the underlying cause of late onset Type 2 diabetes, which accounts for more than 90% of new cases. Today, about 40% of U.S. adults are considered obese, up from about 30% two decades ago, according to the latest CDC report.
Former first lady Michelle Obama's campaign to get American kids up and moving, which left the food and beverage industries off the hook, must be judged a failure. The youth obesity rate climbed to 18.5% in 2016 from 16.8% when her husband took office and 13.9% when his predecessor took office.
How about treatment? Are we at least getting better at helping the third of the population with diabetes and elevated levels of blood sugar (pre-diabetes)?
Not in the slightest, according to the latest issue of Diabetes Care, a journal of the American Diabetes Association. Despite the introduction of 40 drugs and drug combinations since 2005, including several long-acting versions of insulin, the proportion of diabetics achieving adequate blood-sugar control remains stuck at about half.
Among diabetic patients in private HMOs or on Medicaid, which is largely run by managed-care organizations, the share achieving adequate control fell to 40% and 30%, respectively, according to a study in the journal. The authors, both of whom consult with numerous drug companies, blamed poor medication adherence.
There are many reasons for non-adherence, they write. But three stand out: the complexity of the drug regimens, cost, and negative patient perceptions about the efficacy of treatment.
More time with case managers and pharmacists could help patients deal with their skepticism. But many insurers are unwilling or uninterested in providing the resources, which involves incurring short-term costs (more personnel, more filled prescriptions) to achieve long-term gains.
In our fragmented insurance system, where people are constantly changing plans or aging into Medicare, why spend money today when the benefits will accrue to some other payer down the road?
The issues of simpler regimens and higher costs are intimately connected. Prices for longer-acting versions of Insulin have skyrocketed since their introduction in the early 2000s. Each year, the prices set by Sanofi-Aventis and Novo Nordisk rise in lockstep, often by 7% or more. When Eli Lilly and Co. introduced its long-acting insulin in 2016, the price was set within 20% of the drugs already on the market.
The prices for shorter-acting originals, also made by those companies, have also increased dramatically. Whistle-blowers have filed a class-action lawsuit alleging price-fixing; state attorneys general and the U.S. attorney in the Southern District of New York are investigating; and the ADA is demanding a congressional investigation.
Meanwhile, there are reports that diabetics in high-deductible plans are returning to ERs simply to get access to drugs. The ADA warns that thousands of patients are self-rationing their insulin supply because of high prices.
What's the federal government doing about any of this? Nothing I can see beyond public relations claptrap like declaring National Diabetes Month. It gets an F grade, too.
