Disparities in diabetes prevalence and outcomes between non-Hispanic white people and people of color in the United States are well established. Black and Hispanic patients have higher rates of hospitalizations and emergency department use related to complications from diabetes than do other populations. They also face higher hospital charges for diabetes-related admissions. But, at the same time, Black and Hispanic people are less likely to access new diabetes medications than non-Hispanic whites. One barrier to successfully preventing and managing diabetes is the cost of care: even with insurance, diabetic patients can spend thousands of dollars out-of-pocket on medication, supplies, and health services. These costs can present a particularly significant burden on Black families.
As part of broader initiatives to prioritize health equity, several states and state-based marketplaces are seeking to mitigate the disproportionate impact diabetes has on communities of color by reducing the financial costs of diabetes and promoting better quality care for diabetic patients.
Eliminating Cost Sharing for Diabetes Care and Prevention
Skyrocketing insulin prices have led dozens of states to enact caps on the copayments private health insurers can charge enrollees for insulin — usually $25 to $100 for a 30-day supply. But several state authorities are going further to address financial barriers to care by requiring some insurance plans to eliminate cost sharing for diabetes-related items and services. Although these changes will benefit all enrollees in the plans affected, research suggests lowering cost sharing for evidence-based care can reduce racial health disparities.
Most state authorities have prioritized changes that financially relieve patients while having minimal impact on plans’ actuarial values or premiums (see table below). For instance:
- Delaware bars all state-regulated plans from imposing cost sharing for insulin pumps, at an estimated monthly premium impact of $0.47
- California’s marketplace has eliminated cost sharing for diabetes-related education
- Maryland requires a subset of marketplace plans to make their preferred brands of insulin and blood glucose meters available without cost sharing
- Colorado will have zero-dollar cost sharing for certain items and services within three key racial health disparity areas, including diabetes, as part of its new Colorado Option plans that go into effect next year.
D.C.’s marketplace currently requires standardized plans in the individual market to cover insulin at no cost to the patient. Starting next year, at the recommendation of its Social Justice and Health Disparities Working Group, D.C. also will remove cost sharing for a much broader set of items and services than other states have in both individual and small-group standardized plans. For example, these plans will cover doctor visits, eye and foot exams, lab work, and prescription and diabetic supplies at no cost to the patient. The decision to start with diabetes was based partly in the marketplace’s ability to identify relevant items and services using a claims scenario for diabetes care developed by the federal government. D.C. intends to eliminate cost sharing for the treatment of other high-disparity conditions, such as pediatric mental health, in future years. Maryland’s Commission on Health Equity has recommended following D.C’s approach to diabetes in 2024.
As part of its effort to advance health equity, Massachusetts eliminated certain diabetes-related cost sharing for ConnectorCare plans, which are available to lower-income enrollees and partially subsidized by the state. These plans will receive increased state subsidies to fully fund the benefit changes.
Diabetes-Related Quality Reporting and Improvement
California’s marketplace is also tackling diabetes disparities by including diabetes quality measures in its Quality Transformation Initiative. This initiative, launching in 2023, requires insurers to report their performance on several measures and make quality improvement payments if they do not meet specified benchmarks. In the future, the marketplace intends to stratify population benchmarks by race and ethnicity and tie payments to disparity reductions. California’s marketplace also requires insurers to report on and, if necessary, work to improve enrollees’ use of diabetes prevention programs.
The National Committee for Quality Assurance (NCQA) takes a similar, but more flexible approach in its Health Equity Accreditation (HEA), which marketplaces and other regulatory bodies can require insurers to achieve. NCQA’s HEA asks insurers to report diabetics’ hemoglobin A1C control, stratified by race and ethnicity, and use these data to identify and reduce disparities. The California and D.C. marketplaces will require insurers to achieve NCQA’s equity-related standards, with California’s requirement — in addition to its Quality Transformation Initiative — going into effect beginning in 2023. Other marketplaces, like Maryland and Pennsylvania, are actively considering requiring NCQA Health Equity Accreditation in the future.
Looking Forward
States are studying and implementing similar tactics in other areas that disproportionately affect people of color, such as maternal mortality, behavioral health, and tobacco use. Additional federal support — financial, technical, and regulatory — could enhance these efforts. For example, states may benefit from federal help identifying items and services that should be targeted for different conditions, like the claims scenarios the federal government developed for diabetes treatment. Eliminating cost sharing for care for high-disparity conditions will improve health care access and equity and can and should be prioritized by federal and state officials.
