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Preventing diabetic ketoacidosis through health financing system design

May 8, 2019

Topics: Quote of the Day

By Adam Gaffney, M.D., M.P.H.
Washington Post, May 8, 2019

The blood sugar rises, and nausea and vomiting follow. The blood acidifies, the breath hastens, dehydration and then delirium ensue: That’s how ketoacidosis, a feared complication of diabetes, progresses. Diabetic ketoacidosis, which results in nearly 190,000 hospitalizations a year, is a condition I treat frequently as an ICU physician: We infuse intravenous insulin, saline and electrolytes, while carefully tracking sugar levels and blood chemistries and vital signs. If all goes well, the sugar normalizes, acid levels fall, the breath begins to slow, the appetite returns. Not always, however: Every year, hundreds of people die of the condition.

What makes this such a tragedy is that the complication is typically preventable through the regular use of insulin. Yet the soaring price of that drug has put it beyond the reach of many — and for many of the 29 million Americans without insurance, insulin might be unaffordable at any price.

But what about ketoacidosis in a country with universal health care? I joined some colleagues at Harvard Medical School, the Cambridge Health Alliance and the City University of New York to collaborate with a team of researchers at the University of Manitoba in Canada to find out.

We compared ketoacidosis hospitalization rates in the United States and Canada, focusing on the transition from adolescence to young adulthood — a vulnerable time when many young people lose or change health coverage. Our results, published in the Journal of General Internal Medicine, were striking. Based on our analysis of two large databases of hospitalized patients — one covering the United States and the other the province of Manitoba — we found that the hospitalization rate for diabetic ketoacidosis among children and adolescents was somewhat higher in the United States than in Canada. However, as teenagers became young adults, the rate soared by 90 percent in the United States, compared with a 23 percent rise in Manitoba.

At least three major differences in the way our nations finance health care could contribute to this result. First, uninsured rates rise dramatically in young adulthood in the United States. And as numerous studies have demonstrated (to say nothing of common sense), the uninsured go without all types of needed medical care, ranging from doctors’ visits to prescription drugs. In Canada, in contrast, this is not a problem; the uninsured rate is zero.

A second factor might be Americans’ exposure to onerous out-of-pocket costs for medical care. Forty-six percent of privately insured adults have “high-deductible” health plans that require them to spend substantial amounts of money out of pocket before insurance kicks in. Such plans may be dangerous for patients with diabetes. A 2017 study, for instance, found that individuals with diabetes who were pushed by their employers into a high-deductible health plan saw specialists less but wound up in the ER with acute complications more. In Canada, in contrast, physician care and hospital care is free at the time of care; co-pays and deductibles are $0.

The Canadian system does not universally cover prescription drugs as comprehensively as it does other care, unlike places such as Wales or Scotland, where everyone has drug coverage without co-pays or deductibles. Still, drugs are more affordable in Canada than the United States: In 2015, Bloomberg reported that one 3-milliliter pen of long-acting insulin cost $186 in the United States (accounting for rebates), three times the $67 it cost in Canada. Meanwhile, about 16.8 percent of older adults in the United States report not filling a drug prescription or skipping dosages of a medication because of cost — about double the proportion in Canada.

Finally, there is a related problem that researchers call “churn.” Most Americans have little stability in their insurance coverage: Your plan can change every time your boss says so, or whenever you (or maybe your partner or your parents) lose or change jobs. A recent analysis from Axios estimated that 2 million workers, together with their families, lose or change coverage every month. Churn is not merely inconvenient, though; it can be hazardous to your health. A 2016 study found that churners with low incomes frequently face dangerous disruptions in care: 20 percent change doctors, while 34 percent skip medications or stopped taking them because of discontinuities in coverage. In Canada, in contrast, there is no churn, because there is but one “single payer” that provides universal coverage seamlessly throughout the life span, without insurance networks or disruptive plan-switching.

Discontinuities in coverage don’t affect only the young. Take Meaghan Carter, a 47-year-old nurse with Type I diabetes who was found dead on her couch last Christmas, as USA Today recently reported. At the time of her death, the paper noted, she was temporarily uninsured because she was in between jobs, and she had $50 in the bank and no insulin left in her fridge, leading her family to attribute her death to ketoacidosis.

Making the American health-care system work for patients with chronic diseases such as diabetes requires rectifying not just one, but all three of these interconnected dysfunctions. Yet of the various health-care reform proposals under discussion today, only one — single-payer, “Medicare-for-all” — would do so: It would cover all the insured, basically eliminate financial barriers to care such as co-pays and deductibles, and bring to an end the dangerous disruptions of coverage that are so common in our fragmented system. This is one reason that I, like so many in the medical profession, support it.

Individuals with chronic illnesses such as diabetes deserve no less. Without such a transformative reform, it seems likely that we’ll still have patients with ketoacidosis coming through the doors of ICUs, breathing deep, dry as a bone, acid levels soaring — even when it might have been avoided had a better, more just health-care system been in place.

Dr. Adam Gaffney is an Instructor in medicine at Harvard Medical School and a pulmonary and critical care physician at the Cambridge Health Alliance and serves as president of Physicians for a National Health Program.


The Incidence of Diabetic Ketoacidosis During “Emerging Adulthood” in the USA and Canada: A Population-Based Study

Journal of General Internal Medicine, May 8, 2019



By Don McCanne, M.D.

The fact that a 3-milliliter pen of long-acting insulin costs $67 in Canada is shameful. Canadian diabetics of limited means can have difficulty affording that and may be tempted to reduce the dose or go without, risking the onset of ketoacidosis and even death.

It has often been said that no health care system is perfect, and that is true. But contrast Canada with the United States. That same dose of insulin costs $186 in the United States. Even of greater concern, the diabetic in the United States may be uninsured or has a significant chance of having inadequate coverage. For young adult diabetics going out on their own in the United States, the incidence of ketoacidosis soared 90 percent, whereas it increased 23 percent in Manitoba.

Canada can do better (pharmacare anyone?). But the United States? We certainly have no excuse either. We have the resources and the health policy know-how to do better than Canada and every other nation in the world. We should not have one single death from ketoacidosis that is due to financial barriers between the diabetic and her life-saving insulin.

We need a single payer Medicare for All system to eliminate the financial barriers to health care so that we can give more attention to reducing the other socioeconomic barriers as well.

Stay informed! Visit www.pnhp.org/qotd to sign up for daily email updates.

About the Commentator, Don McCanne

Don McCanne is a retired family practitioner who dedicated the 2nd phase of his career to speaking and writing extensively on single payer and related issues. He served as Physicians for a National Health Program president in 2002 and 2003, then as Senior Health Policy Fellow. For two decades, Don wrote "Quote of the Day", a daily health policy update which inspired HJM.

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