Diabetes is a costly, chronic condition in which the body does not produce or properly use insulin. An estimated 29.1 million people in the United States—9 percent of the population—have some form of diabetes. Of those, 25 percent do not yet know that they have the condition. In addition, an estimated 86 million U.S. adults have pre-diabetes—an elevated blood sugar level that is not high enough to be classified as diabetes, but which greatly raises their risk of developing type 2 diabetes and its complications.
Insulin is necessary to covert sugar, starches and other foods into energy for living. Major types of diabetes include:
- Type 1 diabetes is usually diagnosed in children and young adults and was previously known as juvenile diabetes. Insulin shots are the only way to keep blood glucose levels down in Type 1 diabetes sufferers.
- Type 2 diabetes, which is the most common form of diabetes, causes the body to not produce enough insulin or causes the cells to ignore the insulin.
- Gestational diabetes occurs when pregnant women who have never had diabetes before have high blood sugar (glucose) levels during pregnancy. Gestational diabetes requires pregnant women to manage their condition during pregnancy to deliver a healthy child. The condition is temporary and usually reverses after the child's birth. However, women who develop the condition are at a higher risk of developing diabetes later in life.
- Pre-Diabetes occurs an individual develops type 2 diabetes, he or she almost always has "pre-diabetes." In this condition, blood glucose levels are higher than normal, but not yet high enough to be diagnosed as diabetes. Fifty-seven million people in the United States have pre-diabetes. Research shows that, when individuals with pre-diabetes take action to manage their blood glucose, they can delay or prevent type 2 diabetes from developing.
A person can develop diabetes in a number of ways. Type 1 diabetes is typically not preventable and is usually determined by one’s genes.
Type 2 diabetes usually develops over time as a person’s blood cells gradually become resistant to insulin. As the cells become more resistant, the pancreas must produce more insulin to overcome the resistance. If the condition is left untreated, the pancreas will be unable to produce sufficient insulin to allow blood cells to access sugars and other nutrients.
According to the National Institutes of Health, the following factors increase a person’s risk for developing Type 2 diabetes:
- A member or descendent of certain ethnic groups, including:
- African American
- Asian American
- Native American
- Pacific Islander
- Acanthosis nigricans (AN) diagnosis.
- Aged 45 years or older
- Certain problems with blood vessels
- Developed gestational diabetes during pregnancy
- Having a first-degree family member with Type 2 diabetes
- High cholesterol levels
- Hypertension (high blood pressure)
- Overweight or obese
- Polycystic Ovary Syndrome (PCOS)
- Sedentary lifestyle
Diabetes Prevalence: County Level. This NCSL postcard provides the latest national data released and available by the CDC in 2010 about county level diabetes prevalence (Archived--July 2010).
Focus On Populations at Higher Risk of Developing Diabetes
Focus on population groups
States Address Diabetes in Minority Populations. This LegisBrief highlights actions of states and public-private partnerships to tackle type 1 and type 2 diabetes (June 2012).
Disparities in Health by NCSL - African American, Hispanic, American Indian and Alaskan Native adults are twice as likely as white adults to have diabetes. Other diabetes risk factors include being over age 45, overweight, inactive or having had gestational diabetes. Even those at highest risk benefit from prevention and treatment. Cutting calories to lose 5 percent to 7 percent of body weight and increasing physical activity—walking for 30 minutes five days per week—reduced diabetes onset by 58 percent in a major study. Click here to learn more about diabetes health disparities.
Congress established the Special Diabetes Program for Indians (SDPI) in 1997. The SDPI provides funding for diabetes treatment and prevention services at 399 IHS, Tribal and Urban Indian health programs in the 12 IHS areas in 35 states across the United States. IHS has used these funds to establish approximately 350 new diabetes programs in AI/AN communities. In 1998, CDC and IHS established the National Diabetes Prevention Center in Gallup, New Mexico, to provide guidance and technical support to AI/AN communities throughout the United States and to develop, evaluate, and disseminate culturally appropriate interventions. More information can be found online at: http://www.ihs.gov/MedicalPrograms/diabetes/.
Women's Health - Diabetes is the fifth leading cause of death among women ages 45-54 in the United States and a major cause of disability. An estimated 9.1 million women have diabetes, but one-third of them are unaware of their illness.
Women and Diabetes. This NCSL postcard snapshot provides some brief statistics about women and diabetes, costs, and control and prevention (Archived--March 2008).
Diabetes is treatable. Although there is no "cure" various treatments allow most diabetics to live relatively stable, normal lives. Early screening, diagnosis and treatment also prevent or reduce the more serious consequences of the disease — emergency room visits, hospitalization, loss of sight, loss of limbs. Once diagnosed, diabetes requires self-management, including testing and monitoring blood glucose levels. Because treatment requires patient education, special equipment and supplies, it can become costly especially when it is not covered by health insurance.
Costs of Diabetes
Diabetes is the seventh leading cause of death in the U.S. Its complications, including heart disease, stroke, amputations, blindness and kidney disease, are both serious and expensive. The cost to treat an individual with diabetes is more than 200 percent higher than the cost to treat a patient without diabetes. According to the 2015 study by the Health Care Cost Institute, medical costs and productivity loss attributable to diabetes were estimated to be $245 billion in 2012. By comparison, the estimated total cost of diabetes in 2007 was $174 billion.
- Includes $116 billion in excess medical expenditures and $58 billion in reduced national productivity
- $27 billion for care to directly treat diabetes
- $58 billion to treat the portion of diabetes-related chronic complications that are attributed to diabetes
- $31 billion in excess general medical costs
By 2012 the total cost of diabetes increased to $245 billion, meaning that the disease’s toll on the economy has increased by more than 40 percent since 2007, according to a report from the American Diabetes Association.
The Centers for Disease Control and Prevention (CDC) estimated in 2010 that "[a]s many as 1 in 3 U.S. adults could have diabetes by 2050 if current trends continue."
Chronic Cost of Diabetes - NCSL's April 2012 issue of State Legislatures magazine highlights issues and challenges.
Insurance Coverage Mandates
States have recognized the major effects diabetes plays, both in its impact on patients and on society. As of mid-2016, 46 states and the District of Columbia have some law that requires health insurance policy coverage for diabetes treatment. Laws in Mississippi and Missouri require only that insurers offer coverage, but not necessarily include the coverage in all active policies. Most states require coverage for both direct treatment and for diabetes equipment and supplies that are often used by the patient at home. The four states that do not have a mandate or insurance requirement are Alabama, Idaho, North Dakota and Ohio. State tables include the enacted state laws passed since the first California mandates in 1981 and New York's in 1993, through early 2016.
Diabetes Health Coverage: State Laws and Programs - This report covers all state diabetes mandates and minimum coverage requirements for state-regulated health insurance policies. Online edition updated in May 2011 and 2014. [66 pages as PDF] Or Use links below to go directly to state-based information:
Alabama 2016, Alaska 2016, Arizona, Arkansas, California, Colorado, Connecticut, Delaware, Florida, Georgia2016, Hawaii, Idaho, Illinois, Indiana, Iowa, Kansas, Kentucky, Louisiana, Maine, Maryland, Massachusetts, Michigan, Minnesota, Mississippi2016, Missouri2016, Montana, Nebraska, Nevada, New Hampshire, New Jersey, New Mexico, New York, North Carolina, North Dakota, Ohio, Oklahoma, Oregon, Pennsylvania, Rhode Island, South Carolina, South Dakota, Tennessee, Texas, Utah, Vermont, Virginia, Washington, West Virginia, Wisconsin, Wyoming, District of Columbia, Puerto Rico, U.S. Virgin Islands, and Guam.
NCSL SURVEY: DIABETES DRUG COVERAGE IN INSURANCE, 2016. Read and download a survey of 2016 health insurance plans in the 50 states, examining patient access to diabetes drug treatments in the 46 states with laws mandating or offering diabetes coverage. (see map and report)
State Efforts to Prevent and Control Diabetes
States Fight Diabetes - NCSL's April 2013 issue of State Legislatures magazine highlighting state action to prevent and treat diabetes.
Diabetes State Legislative History -.An archive, 2007-2013.: Diabetes State Legislation - Many state legislatures considered diabetes related legislation between 2007 and 2012. This report contains information about legislative options to address diabetes considered or enacted during these sessions. Additionally, in 2013, there were at least 130 diabetes-related bills proposed across 20 states, territories, and D.C.
State Approaches to Prevent and Control Diabetes. Diabetes accounts for 10 percent of all U.S. health care spending and is expected to become even more prevalent. This LegisBrief shows state programs that can help prevent the disease and improve its treatment (September 2011).
Public Health Herald- Preventing and Controlling Diabetes
To address the increasing burden of diabetes and disparities in health care coverage for the condition, CDC funds state-based diabetes prevention and control programs in all states, the District of Columbia, and eight territories. Several of these programs encourage Medicaid reimbursement for patients’ education on the self-management of diabetes (November 2011).
Diabetes Appropriations in State Budgets
2014: Diabetes: Addressing the Costs - A 50-State Budget Survey for FY 2014. NCSL released its latest health report, taking a closer look at programs and budget appropriations that play a role in control and prevention of diabetes, a chronic disease affecting 29 million Americans with the disease, and another 86 million with “pre-diabetes,” a condition that still can be halted. 20 states appropriated some funding for diabetes in their budgets; while all 50-states received some CDC federal funds for chronic disease programs. The report is especially timely for the 30 plus states that begin state budget deliberations each January. Download the 12-page Diabetes Survey PDF here.
2013: States Address the Costs of Diabetes | State Budget Survey Results. For FY 2013, the analysis included a review of state budgets and related state budget documents that explicitly identified appropriations for diabetes programs. Published by NCSL Jan. 2014.
2012: States Address the Cost of Diabetes: A 50-State Budget Survey for Fiscal Year 2012. This analysis reviewed state budgets and related state budget documents that explicitly identified diabetes programmatic appropriations.
2011: Diabetes in State Budgets. This NCSL report provides a 50-state survey of diabetes funding in the states and CDC funding for Diabetes Prevention and Control Programs (Archived report--May 2011).
Medicaid and CHIP
Medicaid covers the health care needs for qualified low-income people and those who have few resources. There are special expanded eligibility terms for pregnant women. Medicaid is jointly funded by the federal and state governments; covered populations and benefits vary among states. As a condition for receipt of federal funding, states must provide certain services, such as in- and out-patient care, doctor visits and long-term care. While services such as prescription drugs are optional under federal law all states and territories have chosen to include them. Other details of benefits such as prescribed insulin, disposable needles, syringes, monitors and blood glucose strips are determined by each state's Medicaid policy and are listed by state.
The Children's Health Insurance Program (CHIP), formerly known as S-CHIP (the State Children's Health Insurance Program), has become the nation's primary source of coverage for uninsured children who do not qualify for coverage under Medicaid. In 2008, 7.4 million children received health coverage through CHIP. The Children's Health Insurance Program Reauthorization Act of 2009 (CHIPRA) both extended and expanded CHIP through September 2013. The federal government covers about 70 percent of the programs' costs nationwide, with state governments picking up the remainder. Diabetes treatment and management is available to children enrolled through the CHIP program. Diabetes treatment options are comparable to those available under Medicaid in most states, although patients may be responsible for higher payments and care defined as diabetes education services.
Federal Coverage Requirements
Medicare is the federal program that covers both the majority of those over age 65, as well as people with certain disabilities. Medicare Part B, an optional service with a monthly premium ranging from $134—$428.60, depending upon a beneficiary’s income, provides coverage for physician visits, diabetes screening, diabetes self-management training and nutrition counseling services, lab testing, diabetes glucose testing supplies, and insulin pumps and associated supplies. Medicare information describing available diabetes coverage is online at http://www.medicare.gov/Publications/Search/Results.asp?PubID=11022&Type=PubID&Language=English. For people with Medicare Part B who are at risk for getting diabetes, Medicare covers a screening blood sugar test to check for diabetes. Medicare considers an individual at risk if he or she has any of the following: high blood pressure, history of abnormal cholesterol and triglyceride levels (dyslipidemia), obesity, or a history of high blood sugar. Other risk factors may also qualify enrollees for this test and based on the results, they may be eligible for up to two screenings each year.
Medicare Part D provides optional prescription drug coverage. Begun in 2006, Part D plans provide coverage for prescription drugs, including insulin, insulin pens and syringes. Part D Prescription Drug Plans (PDPs) are provided by commercial insurers and are allowed considerable variation in their Medicare enrollee charges. The "base beneficiary premium" for 2017 is $ $35.63 per month, according to the Centers for Medicare and Medicaid Services. Premiums vary significantly from one Part D plan to another. Part D benefits may also be subject to a coverage gap or "donut hole" for any prescription drug purchases between $3,700 and $4,950 (2017). The 2017 maximum deductible for a Part D plan is $400. NCSL has a web-based report with details on the states that provide subsidies for Part D plans available at http://www.ncsl.org/default.aspx?tabid=14334.
Low-income Medicare enrollees who also are eligible for Medicaid, known as "dually eligible" beneficiaries, often are entitled to significantly smaller out-of-pocket payments. The CMS website has specific information for diabetes treatment, available here.
Federal Health Reform Provisions Related to Diabetes - This NCSL report provides an overview of the components of the Affordable Care Act that related to diabetes (Archived Report--May 2011).
Related Medical Issues
Diabetes is linked to acquired blindness, kidney disease, heart disease and amputations, claiming the lives of more than 76,000 Americans each year.
According to Healthline, of the 29 million Americans with diabetes, approximately 73,000 had a diabetes-related amputation in 2010. At least 21 states and Guam require certain insurance plans to provide coverage for prosthetics.
Amputee Coalition: Web page with information for patients with diabetes as it relates to limb loss.
Under the ACA, all plans purchased on a health insurance exchange/marketplace, Medicaid plans, and some other health insurance plans must provide coverage to children for vision screenings as a part of the required preventive care benefits.
Overweight and Obesity
Obesity in persons with diabetes is associated with poorer control of blood glucose levels, blood pressure and cholesterol, placing persons with diabetes at higher risk for both cardiovascular and microvascular disease. Weight management through healthy eating and physical activity can help reduce the number of persons at risk for diabetes and reduce the risk for complications and premature mortality among those who already have diabetes.
The ACA requires Medicaid plans, plans purchased on a health insurance marketplace/exchange, and some other insurance plans to provide coverage for obesity screening and counseling for children as part of the required preventive health services.
Related NCSL Resouces
In the News
Follow-on Biologic Basaglar Shakes Up the Diabetes Insulin Market. The FDA does not yet allow automatic "interchangeability" between originator biologics and newer "biosimilars." However, physicians and other prescribers can create a significant market without relying on a phramacist to initiate a brand or generic switch.
A year after the first follow-on biologic Basaglar (insulin glargine) from Eli Lilly and Co. and Boehringer Ingelheim Pharmaceuticals, Inc. launched in the U.S. diabetes market, access to the drug among payers is growing rapidly, with half of all U.S. formularies placing it on their first or second tier. Although Basaglar has delivered modest savings compared to the originator drug, payers may see deeper discounts once other follow-on biologics like Merck & Co., Inc.'s Lusdana hit the insulin market.... Read Full Story AIS Health Business Daily , 1/25/2018
NOTE: NCSL provides links to other web sites for information purposes only. Providing these links does not necessarily indicate NCSL's support or endorsement of the site.
- Centers for Disease Control and Prevention (CDC)
- PhRMA: Medicines in Development for Diabetes - A Report on Diabetes and Related Conditions (2016)
- “Building the Evidence Base for Evaluating Complex Drug Formulary Designs in Type 2 Diabetes Mellitus,” -National Pharmaceutical Council and University of Maryland School of Pharmacy study. 1998; presented 6/2016.
- Insulin affordability and competition, a New York Times Op Ed. "Insulin has been around for almost a century. The World Health Organization considers it an essential medicine, which means it should be available “at a price the individual and the community can afford.” So why is this product increasingly too expensive for many Americans?" Read "Break Up the Insulin Racket" - 2/22/2016
- Per Capita Health Care Spending on Diabetes: 2009-2013 - Issue brief by the Health Care Cost Institute, 2015.
- "Changes in Diabetes-Related Complications in the United States, 1990–2010" - New England Journal of Medicine, April 2014
- Diabetes Patients In PCMHs Well Served By Nonphysicians And Physicians Alike. In the first study to compare the effectiveness of physician assistant (PA) and nurse practitioner (NP) roles to physician-only care for patients with chronic disease, Christine Everett of Duke University and coauthors found that patient outcomes were generally the same in thirteen comparisons. In four comparisons, PA and NP care was found to be superior; in three, the physician-only outcomes were higher. For the Diabetes treatment study in the November issue of Health Affairs, the authors used Medicare claims and electronic health record data from a Midwestern county and identified 2,576 Medicare patients with diabetes. Results of the study support previous findings that PAs and NPs can perform a range of effective roles in primary care, yet they indicate that patient characteristics and other factors should inform precisely how these practitioners should be deployed.. The topic was discussed at a November 14, 2013 DC briefing. (audio available)
- Report: Law, Public Health, and the Diabetes Epidemic (Am. J. Prev. Med. 2013;45(4):488-495) (2013)
- American Diabetes Association - patient membership
- America's Diabetes Challenge - a program developed in partnership with Merck and the American Diabetes Association
* Latest available population figures are from CDC "National Diabetes Statistics Report, 2014." The official federal costs statistics are from 2007 data, All other figures are more recent, as noted.
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