Running head: PAYING TO LIVE 1

Paying to Live: The Struggle of Affording Diabetes Supplies

Taylor M. McOrmond

Legal Studies Academy

First Colonial High School

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Abstract

This paper goes over the struggles of affording diabetes supplies. First, an overview of the issue

is mentioned and why this topic is important. Covered next is explaining the role of insurance

companies in the process of setting the price of prescriptions. After that, the paper goes into

detail on the most expensive diabetes supplies that diabetics pay for, along with some laws, court

cases, and case studies about each one. These supplies discussed in the paper include emergency

Glucagon, glucose test strips for glucometers, and insulin pumps. Finally, the paper includes a

detailed comparison of the expenses of diabetes between Canada and the United States.
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Paying To Live: The Struggle of Affording Diabetes Supplies

It’s common knowledge that there is a nation-wide issue of patients with diabetes

rationing their insulin to survive because they cannot afford this necessary drug. What people

don’t realize when they see these headlines in the news is that diabetics need more than just

insulin to manage their disease. There are plenty of accompanying supplies that go along with

insulin that are just as necessary and just as expensive, adding on to the cost a diabetic needs to

pay to live. Diabetes, specifically type one, is an auto-immune disease where the pancreas no

longer makes insulin. This results in patients who have been diagnosed with this disease needing

to take artificial insulin and check their blood sugar levels frequently to stay healthy and avoid

further health complications (​Centers for Disease Control and Prevention, 2020)​. With the

increase of new technology for managing diabetes, this causes the costs of managing this disease

to also increase. Between the insulin pumps, continuous glucose monitors, emergency Glucagon,

glucometers, and test strips, it is difficult for people to afford all of these necessary prescriptions

(van den Bergh, 2020). In order to reduce the long term effects a diabetic may experience if they

cannot afford their supplies, the Endocrine Society suggests that for high costs of supplies or

high deductibles to not create hardships for patients, the state and federal governments should

create regulations, as well as insurance companies to be legally obligated to cover all types of

every prescription a diabetic needs (Endocrine society, 2007). The issue is that the prices of

essential diabetes medical equipment, such as emergency Glucagon, glucose test strips, and

insulin pumps, have become extremely costly causing diabetics to not be able to afford to

manage their disease properly.

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Insurance Companies

If someone has a high deductible insurance plan, it means that they are required to pay

out of pocket for up to a certain dollar amount before anything healthcare-related will be

covered. In a report from GoodRx (a company that helps patients find what pharmacies they can

find prescriptions at to save the most amount of money), there’s numerous graphs and charts

throughout the report, with one pie chart providing that over 81% of how much money people

spend on diabetes care goes to just medical supplies alone. The remaining 19% of costs go

towards medications and endocrinology visits. These specific graphs provide the costs people

carry who have insurance (Nguyen, 2020). In the article “Some health plans with high deductible

health plans will now cover insulin before deductible is met” from the forum MyGlu.org, a

possible solution to this problem is proposed. The article talks about how some insurance

companies decided to cover certain treatments before the patient meets their deductible. This

would help significantly to people who have high deductible plans; however, from personal

experience, most insurance companies do not have this advantage, causing people to not be able

to afford their medical supplies before they hit their deductible that have insurance (Idlebrook,

2019). What happens after the patient meets their deductible? Are there supplies necessary for

diabetics that aren’t covered by insurance at all? Durable medical equipment includes test strips,

glucose meters, insulin pumps, syringes, and similar products. Surprisingly, private insurance

companies are not legally required to cover durable medical equipment (Suh, 2019) which

contributes to this serious problem of people having to pay out of pocket expenses for their

diabetes equipment. Now, what exactly causes these prescriptions to receive such a high cost in

the first place? Pharmacy benefit managers, or PBMs, are responsible for making deals with
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insurance companies and large pharmacy companies, such as CVS or Walgreens, to work out

how much a medication will cost the patient after going through that pharmacy with how much

the insurance will cover (Dodge, J. T., 2019). This information is extremely important to the

topic of this paper because these PBM’s directly determine the price the consumer pays for these

treatments, and the reason the medical equipment prices are so astronomically high. When

speaking on the phone with Ms. Bitterman, the advocacy chair for JDRF Hampton Roads, she

explained how the biggest issue of why the prices of these treatments are so high is the lack of

transparency in the process of the cost formation. Over half of these costs go back to the PBM’s

as rebates, which creates a chain of middlemen that all need to get paid in the process of bringing

each prescription all the way to the patient (Bitterman, personal communication, October 1,

2020).

Glucagon

According to GoodRx, Glucagon is an emergency medical treatment used for diabetics to

increase severe low blood sugars. Since Medicare does not cover glucagon, people living with

diabetes with this insurance have no other option besides paying the full price of this life-saving

medication at $323 (GoodRx, n.d.). The following is a specific case of someone not being able to

afford their emergency Glucagon in the NewYorkTimes. A lady named Denise Lombard’s

daughter has type 1 diabetes. From this, all of the supplies she needs can be inferred. At the time

of the article’s publication, the insurance policy for Ms. Lombard’s daughter does not cover

glucagon, causing them to have paid the retail price of $272 (Rosenthal, 2014). The Type 1

Diabetes Defense Foundation assisted to pursue the lawsuit of ​Bewley v. CVS.​ The issue of the

case was whether or not pharmaceutical companies can charge patients with diabetes
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unconscionable prices for essential treatments, such as emergency Glucagon. The plaintiff,

Bewley, sued the pharmacy benefit managers under CVS, in violation of the RICO Act:

Racketeer Influenced and Corrupt Organizations (Boss, 2017). This is where the knowledge of

pharmacy benefit managers comes in, because as mentioned earlier, if PBM’s were not making

deals with insurance companies and having to pay rebates to all of those middlemen, the prices

of these products would decrease significantly.

Test Strips

Each day, diabetics test their blood glucose levels to keep them in the correct range at

least 6-8 times. If test strips are overpriced, how do diabetics keep their numbers steady? The

following is a specific case of someone not being able to afford their test strips in a study done

by the American Diabetes Association. Nevole, a resident in Florida, lost his job and no longer

had insurance because of this. Since Nevole has diabetes, he has to pick up all of the different

supplies from the pharmacy and pay for them. However, Nevole only picked up the prescriptions

he could pay for, which is obviously nowhere near the amount he needs in order to manage his

diabetes (Georgetown University Health Policy Institute, & American Diabetes Association,

2005). This is extremely dangerous because a patient with diabetes cannot manage their disease

properly without their prescribed treatment. Proper diabetes care lowers the chances of having a

hospital visit from diabetic ketoacidosis, overall lowering the annual average cost of families of

children with diabetes (Malasanos, T. H, 2005).​ ​Some further complications that go along with

poorly managed diabetes include diabetic ketoacidosis, blindness, kidney disease, heart

problems, and nerve damage leading to amputations (Centers for Disease Control and

Prevention, 2019). Preventing these long-term complications is directly correlated with how
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often diabetics keep their glucose levels in the correct range. Keeping those numbers stable is

also directly dependent on how often a diabetic has access to the amount of test strips they need.

The Type 1 diabetes defense foundation also assisted in pursuing a different case similar to

Bewley, named​ Prescott v. CVS.​ Both cases have the same issue and rule of law, except the

plaintiff in this case sued for the overpricing of glucose test strips (Boss, 2017). The Protecting

Access to Diabetes Supplies Act of 2015 prohibits private insurance companies to persuade

patients to buy test strips that are non-compatible with the glucometer they already have, solely

because those test strips cost less for the insurance company to cover (Congress.gov., n.d.).

Many would argue that this bill needs to become a law because insurance companies violated the

law numerous times, including in a personal experience. When I switched to the Omni-pod

glucometer, my parent’s insurance company told the pharmacy that they will not cover omnipod

compatible test strips, but only OneTouch because that brand is cheaper to cover. This bill would

prohibit insurance companies from making that decision.

Insulin Pumps

It is mentioned earlier in the paper that insurance companies are not legally required to

cover durable medical equipment, which includes insulin pumps. This only applies to private

health insurance companies where it is not mandated by the state that the insurance company

must cover durable medical equipment. This is a problem because the insurance companies have

found a loophole to manage to not be required to cover all prescriptions. Although according to

the National Conference of State Legislatures, it is illegal to deny coverage of an insulin pump

(National Conference of State Legislatures, 2016), the UnitedHealthcare insurance company

decided to limit coverage of insulin pump choice, and now only covers Medtronic insulin pumps.
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This decision prompted the advocacy group of JDRF to launch the My Pump My Choice

campaign. My Pump My Choice basically advocates for patients with diabetes to be able to

choose the insulin pump of their choice, whether that be Medtronics, Insulet, or Tandem

Diabetes pumps. There are multiple differences between each of these insulin pumps, which is

why it is important to allow the patient to choose which treatment they feel the most comfortable

with. JDRF is pushing out personalized letters to the UnitedHealthcare insurance company in an

attempt to persuade them to take back this decision, as well as sharing with others why the

decision made by UHC is so impactful to patients with diabetes (Young, 2019). According to the

legal team Herrman & Herrman, there are multiple injury law cases currently going on because

of the national recall on one of the Medtronics insulin pumps. Since the insulin pump was not

working correctly, it was leading to both under and over doses of insulin, which can be lethal

(Herrman & Herrman, P.L.L.C., 2020). These cases prove why it is majorly important that

insurance companies cover all brands and companies of insulin pumps. If an insulin pump were

to be recalled, as it was in this situation, those patients need access to something different so they

can receive the proper dosage of insulin without experiencing complications.

Comparison of Canada and the United States

In relation to Canada’s expenses of medical care, people have spread that Canada has a

government regulation on the prices of insulin and accompanying medical equipment for

diabetes; however, this article published only a year ago proves that they are having the same

problems as in the U.S. The article mentions “Canadians without any coverage report spending

up to $15,000 annually in out-of-pocket costs” (Berna, 2019). The scholarly journal Chronic

Diseases and Injuries in Canada mentions that Canadians with diabetes in total spend over two
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billion dollars on everything each diabetic needs to manage their disease. This includes the

supplies needed, specialist visits, and emergency room visits for every diabetic in Canada totaled

together (Bilandzic & Rosella, Feb 2017). It is a widely known issue that diabetics in the United

States pay an extreme amount for diabetes supplies, even being brought up in at least one of the

2020 presidential debates. How much exactly do they pay though?​ ​“The average person

diagnosed with diabetes will spend $16,752.00 per year on medical costs; 60% of that is spent on

treatment” (Kleinman, 2019). This direct quote of how much American’s spend on diabetes care

has been included to compare to Canada’s almost identical annual average out of pocket cost of

diabetes medical supplies. Mentioned in the American Diabetes Association’s scholarly journal

“diabetes care”, the annual medical cost of diabetics would decrease with less hospital visits of

ketoacidosis or urgent low blood sugars if there was an increase in accessibility, expense wise, to

the supplies needed to manage the disease correctly (Riddle & Herman, 2018). The cost of

diabetes care is a never-ending cycle that only legislation will be able to break. Finding the

solution of decreasing the overall costs diabetics spend on their treatment can be looked at

legislatively. According to Rick Lessard, the Connecticut Senate passed House Bill 6003, which

will not only put an affordable price cap on insulin but also accompanying supplies. This

includes emergency glucagon and glucose test strips. (Lessard, 2020). Since the Virginia state

government passed a bill for an insulin cap, why can't they include all of the other supplies a

diabetic needs to manage their disease the same way as Connecticut?

Conclusion

The issue of diabetic patients being put in the difficult situation of not being able to

afford their treatment prescriptions, such as emergency Glucagon, test strips, and insulin pumps
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comes from the role of insurance companies, and the lack of specific legislation which would

regulate these prices. The inflation of prescription drug expenses will only continue to increase,

putting more patients at risk of long-term health complications from rationing their supplies if

something is not done about this problem. Multiple possible solutions have been proposed, such

as more flexibility by insurance companies on what and when they cover prescriptions, and

legislative regulation of the supplies’s prices on a federal or state level. If this issue could be

fixed, not only nationally, but globally as well, we could save the lives of millions of people,

since the United States is not the only place that has this issue. All that is needed is a little bit of

recognition and advocacy to get the attention of others on this issue to create the essential

change.

References

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Bilandzic, A., & Rosella, L. (Feb 2017). The cost of diabetes in Canada over 10 years: Applying

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Bitterman, C. (2020, October 1). [Telephone interview by the author].

Boss, J. (2017, June 15). ​The Type 1 Diabetes Defense Foundation files new lawsuits alleging

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