Insurance and Diabetes
I began working on diabetes related legal issues in 1994 as a result of difficulties in getting my health insurance carrier to pay for chemstrips for my blood glucose meter.
When the Diabetes Control and Complications Trial (“DCCT”) ended, there was indisputable proof that tightly controlled blood sugars would result in dramatically fewer long term complications for persons with type one diabetes. (Those results were later also proven for persons with type two diabetes.) The news was announced by the U.S. National Institutes of Health and published in the New England Journal of Medicine. Here is the article from September 30, 1993:
As a volunteer with the DCCT study I had been practicing tight control for nearly ten years when those results were announced. I understood both how to accomplish tight control and how to do so safely. And when the results were announced I learned that those efforts had been dramatically increasing my life expectancy and the quality of the life I could hope to lead.
The amazing efforts of the DCCT, and the federal and private funding that supported it, gave me the opportunity and tools I needed to make the tight control theory work in reality. When the DCCT ended and I was placed back in the normal environment of health care I quickly learned that receiving that opportunity and those tools would not be easy in the world outside the DCCT. I was self-employed and unable to purchase health care insurance at all. I applied for a California state endorsed plan open to persons unable to obtain private health insurance and, after months of waiting, was finally admitted. The California plan, known as MRMIP, is both expensive and limited. At the time I enrolled and was assigned to an HMO, my carrier refused to pay for chemstrips for blood glucose meters. The first doctor I saw in the plan did not understand why I needed to test my blood sugar so often and was unwilling to give me a prescription for the chemstrips I was requesting and the DCCT had proven were so critical to my health.
I soon changed physicians and then, with the support of my new physician, sought to convince my HMO to pay for chemstrips. It took several months, but I eventually succeeded by explaining the results of the DCCT study and pointing out the cost savings to the HMO if it paid the relatively small price of providing quality diabetes care and thus avoided the enormous expense of long term complications. Here is a 1996 article from Diabetes Health about those efforts and a talk in which I described them:
Those experiences taught me a great deal about how to convince health insurance carriers to provide payments for needed medical supplies and treatments. Over the years, I have repeated those same efforts on behalf of scores of persons with diabetes to obtain better and proper care and tried to explain to tens of thousands how they can do so for themselves.
Along the way, I testified in support of passage of legislation sponsored by the American Diabetes Association which requires that health insurance carriers provide the type of treatment proven so valuable by the DCCT. Today, similar laws have passed in 47 states. Here is the law in California:
The law regulating HMO’s is at Health and Safety Code §1367.51:
Diabetes Law for Insurers (Please scroll down to code)
Diabetes Law for Insurers (Please scroll down to code)
Based on these laws and similar ones that exist in most states in the U.S., persons with diabetes can obtain coverage of diabetes related medications, management tools, and education if they are found to be medically necessary. Over the years that I have helped persons receive coverage for such items, I have found that the key to receiving coverage is in getting a physician to support your request and being persistent in making your request for coverage. Persons who do so are more likely than not to receive coverage eventually, although it may take much effort and frustration along the way. Here is an article published in Diabetes Monitor describing my suggestions as part of a longer series of articles on dealing with managed care:
Another problem is that, often, persons most in need of urgent quality care are the least able to make the effort needed to receive it. Diabetes strikes at all levels of society, and attacks persons of all races and religions. But those of us who are less affluent, less well educated, and most ill are often the ones least able to obtain care. The failure of our country’s health care system to handle these desperate needs is all too obvious and something we will need to work to improve as best we can, in whatever way we can.