Brief Accessing Diabetes Care and Management

Diabetes Overview

Diabetes is characterized as a chronic condition where the body does not produce or properly use insulin. Insulin is necessary to convert sugar, starches and other foods into energy for living. There is currently no known cure for diabetes, but a healthy diet and active lifestyle can help. 

Types of diabetes: 

• Type 1 diabetes is an autoimmune condition where the body produces little or no insulin. Previously known as juvenile diabetes, type 1 is usually diagnosed in children and young adults but can be diagnosed at any age. It requires daily insulin to keep blood glucose levels down. Approximately 5% to 10% of people with diabetes have type 1. 
• Type 2 diabetes causes the body to produce insufficient insulin, or the body becomes resistant to it. It is the most common form of diabetes—90-95% of people with diabetes have type 2—and it is more common in adults over age 45. Type 2 has been rising in children as childhood obesity rates increase. 
• Gestational diabetes develops during pregnancy in women who do not already have diabetes. Every year, 2% to 10% of pregnancies in the U.S. are affected by gestational diabetes. Though it typically subsides after pregnancy, women with gestational diabetes have an increased risk for developing type 2 later in life. 

Additionally, approximately 98 million adults—or more than 1 in 3—have prediabetes. This is when blood sugar levels are higher than normal, but not high enough to be considered type 2 diabetes. More than 8 in 10 adults with prediabetes do not know that they have it.

Marketplace Coverage and Essential Health Benefit Benchmark Plans

The Affordable Care Act (ACA) includes various provisions affecting coverage requirements for individuals with diabetes. For example, all health insurance plans (including employer-sponsored plans) must provide coverage for certain preventive services without imposing cost-sharing on health plans enrollees. This includes screening adults aged 35 to 70 years for abnormal blood glucose levels and type 2 diabetes which is recommended by the United States Preventative Services Task Force (USPSTF).

Additionally, health insurance plans sold in the ACA's individual and small group marketplace must provide coverage for 10 essential health benefits (EHBs). Furthermore, plan enrollees are not subject to annual or lifetime limits. Each state sets standards for EHB coverage through their benchmark plan, so coverage requirements for specific services and treatments (e.g., diabetes-related services) vary from state-to-state. State EHB plans must meet coverage requirements for diabetes-related services and supplies established through state-level insurance mandates.

States may update their EHB plans annually, but are not required to. The Centers for Medicare and Medicaid Services (CMS) maintains a list of EHB benchmark plans for all 50 states and the District of Columbia.

States may include coverage requirements specific to diabetes in their EHB benchmark plans. For example:

• Alabama covers blood glucose regulators and disease management services for diabetes.
• New York covers diabetic equipment, supplies and self-management education if recommended or prescribed by a physician or other authorized health provider.
• Tennessee covers diabetes education, nutritional counseling for diabetes treatment and blood glucose regulators.
• Virginia covers medical supplies, equipment and education for diabetes care. This includes insulin pumps, home blood glucose monitors and outpatient self-management training and education.

Other Diabetes Coverage Mandates

The following chart captures examples of state coverage statutes across Medicaid, commercial insurance and state health plans. This list is not exhaustive.

Insulin Access and Affordability

The most common drug prescribed for diabetes is insulin. For many individuals with diabetes, insulin can be essential for survival as their bodies either don't produce enough insulin or none. From 2017 to 2022, insulin costs have increased by 24%. In another study, the U.S. was the highest in both utilization and price compared to 34 other OECD countries

Recently, the federal government established the Inflation Reduction Act, which caps the monthly copayment for insulin at $35 for Medicare beneficiaries. Within the first few months of its passage, data showed an increase in insulin fills for individuals on Medicare, while fill rates for patients ineligible for Medicare declined during the same time frame. According to a recent study, insulin affordability remains a struggle for many patients impacting insulin adherence and contribute to higher hospitalization rates.

Manufacturers have addressed this issue by offering programs for discounted insulin. For example, eligible consumers may receive a 30-day supply of insulin between $35-$99. In addition, consumers may also qualify for patient assistance programs offered through some manufacturers.

Policymakers in at least 25 states and the District of Columbia have passed legislation to cap the monthly copayment for insulin. However, these limitations only apply to state regulated plans.

Insulin Urgent Need Programs

Some states have established insulin urgent need programs for qualified individuals. These programs create a "safety net", providing access to insulin when an individual cannot obtain it for financial or other reasons. For some, going without insulin could lead to diabetic ketoacidosis, which can result in hospitalization or death. Below are examples of states that have passed urgent insulin access legislation.

• Maine and Colorado allow eligible insulin users a 30-day emergency supply within a 12-month period and caps the cost at $35.
• Minnesota created safety net programs for eligible residents to receive an emergency 30-day supply, and depending on insurance, a patient's copayment might be waived.
• Ohio permits a pharmacist to dispense a seven-day supply of medication for a chronic condition once during a 12-month period.

Public-Private Partnerships

Other states are exploring public-private partnerships (PPPs) to manufacture insulin. Non-profit generic drug companies emerged in recent years as hospitals were increasingly experiencing drug shortages. Lawmakers are now considering entering into agreements with these suppliers to address rising costs by producing affordable insulin. Below is a list of states that are collaborating with manufacturers.

• California has recently entered into a (PPP) and the state's CalRx Biosimilar Insulin Initiative will then distribute insulin to Californians living with diabetes at lower rate than current market prices.
• Maine formed a commission to assess the feasibility of producing insulin through the University of Maine system.
• Michigan is working toward a partnership to produce the state's insulin supply. This would allow the state to develop its own state facility, capable of manufacturing insulin.
• Texas requires insulin manufacturers to report to the state Health and Human Services Commission if a generic or biosimilar equivalent is unavailable due to a pay-for-delay contract.

Coverage for Diabetic Supplies

In addition to insulin, several states have pursued copayment limitations on diabetic supplies. Comprehensive diabetes care can include the usage of diabetic supplies such as blood glucose meters, test strips, insulin pumps and continuous glucose monitors (CGMs). Depending on the type of diabetes and medical care provided, some patients need to check their blood glucose levels 1 to 4 times a day. Glucose levels are typically tracked using blood glucose meters that require single-use test strips, or with a CGM which continuously tracks levels throughout the day.

While important, these tools may pose financial challenges for some patients. Coverage for CGMs varies by state, particularly under Medicaid and state-regulated private insurance plans. In Florida, Medicaid covers CGMs for eligible individuals. Similarly, all health policies in Illinois must cover CGMs for persons requiring insulin for diabetic management. Below are examples of states that have passed legislation addressing diabetic supply costs.

• Delaware caps the amount an insured person is required to pay for diabetes equipment and supplies at no more than $35 per month, regardless of the amount or types of diabetes supplies needed.
• New Mexico requires insurers to provide enrollees adequate networks of suppliers for diabetic equipment and to maintain that network throughout the contract.
• West Virginia caps the copayment for certain diabetic devices, such as continuous glucose monitors, at $100 per month.

Glucagon-Like Peptide-1 Receptor Agonists (GLP-1s)

Glucagon-like peptide-1 receptor agonists-or GLP-1 drugs for short are a class of pharmaceuticals used primarily to treat people who have type 2 diabetes and, in some cases, obesity. These drugs are among several pharmacological options that providers have for endocrine diseases and may play an integral role in obesity-related disease management in conjunction with longstanding options like diet, lifestyle modification and bariatric surgery. According to a KFF poll, 62% of all adults surveyed taking GLP-1 drugs reported using them to manage a chronic condition like diabetes or heart disease, while about four in ten said they were prescribed GLP-1s primarily to lose weight.

Generally, these are injectable therapies and are recommended by the American Diabetes Association to lower the chance of heart attack and stroke in certain people. However, they also delay the stomach from emptying, creating a feeling of fullness, thereby having an increased effect on weight loss. The positive or negative health effects of taking these medications long-term for weight loss are unknown and still in clinical trials.

The average annual list price of these medications is $12,000 and, as Milliman reports, most large employer health plans restrict coverage. In the above KFF poll, about half of all adults who took a GLP-1 drug said it was hard for them to afford it, and while most insured adults said their plan covered at least some of the cost, more than half of this group (53%) said the cost of the drug was beyond what they could pay for it. Medicaid spend in 2022 due to GLP-1 drugs was $4.1 billion, according to Milliman, and between 2019-2022, prescription volume for GLP1s rose between 200-500% when these treatments were first FDA approved.

State Action

About a dozen states addressed the coverage of GLP-1 drugs during 2024 sessions, but most failed. It is important to note that state legislation applies only to state regulated health insurance plans such as state employee plans or those sold on the Affordable Care Act's individual and small group marketplaces.

Last year Illinois adopted a bill to cover weight loss and obesity under the state employee health plan which included coverage of medications like GLP-1s. Earlier this year, citing cost constraints, the State Health Plan in North Carolina opted to restrict coverage of GLP-1 drugs to members with particular health conditions - and weight loss would no longer qualify. The state treasurer has issued a request for information looking for ways to lower the cost of GLP-1 drugs to treat obesity.

In KFF's 2024 annual budget survey, 13 states under Medicaid fee-for-service contracts cover GLP-1s for obesity treatment, and most require prior authorization before the patient may have their prescription approved. Both public and private payers use cost containment policies to control the amount and mix of drugs included under the prescription drug benefit which may be administered by a pharmacy benefit manager (PBM). States have the option of imposing stricter requirements on these policies or loosening them.