Changing diabetes care: an opportunity for the feds.

If you could have a private half-hour with each major presidential candidate, what would you say about repairing our broken health care system? It is an intriguing question, and I bet each of our readers would give the candidates an earful. Where would you start? Reform the present system of re imbursements? Improve access for the uninsured? Create a national program to promote evidence-based care and to reduce waste? Shift the burden from corporate coffers to union trust funds? After reading a report from Mathematica Policy Research, Inc.,1 I have a newfound respect for a strategy to improve health care at the federal level. My approach would involve a renewed focus on the care of patients with diabetes. Perhaps some of the principal findings from this report might sway our readers to inform our political leaders about the way in which funds are spent on this widespread disease. The goal of the Mathematica report, which was commissioned by Novo Nordisk’s National Changing Diabetes Program, was to identify the kinds of federal programs, authority, and funding that might influence the incidence, treatment, and progression of diabetes. Surely, as one of the largest global suppliers of products for diabetic patients, the company has a key stake in this conversation; however, I trust that Mathematica did a rigorous independent analysis, as I am familiar with much of its other work. Skepticism aside, what were the study’s main methods and findings? Because the percentage of Americans with diabetes has more than doubled since 1980 (to a current figure of more than 20.8 million patients), the methods used by the Mathematica researchers are significant. They created an economic model using traditional “costofillness” methods to estimate the additional amount that the federal government spends to treat diabetic patients, compared with nondiabetic persons. They also used budget-analysis techniques to estimate the total amount of federal spending for other diabetesrelated purposes, including prevention and research. I was surprised by a core component of the report: almost every federal department—except the Department of State, the Department of Energy, and the General Services Administration—was responsible in some way for a policy or program that could help achieve national diabetes goals. The extent of responsibility varied, ranging from significant programs in the Department of Health and Human Services (DHHS) and the Department of Agriculture (USDA), for example, to programs with more modest implications for diabetes in other departments. So far, so good. The researchers concluded that the federal government spent nearly $80 billion in fiscal year 2005 in additional treatment costs for diabetic patients, compared with those without diabetes— about 61% of total U.S. medical spending for all payers. Thus, the amount paid by the federal government to treat diabetic patients, compared with nondiabetic persons, was more than Department of Edu cation’s entire budget in fiscal year 2005. This amount was also 12% of federal health care spending nationwide (or almost one-eighth of all federal dollars going toward diabetes treatment). This news was a staggering revelation to me; I feel that a significant share of this spending is probably avoidable, especially because we know that many complications of diabetes can be prevented and even reversed. It is apparent that the government plays a large role in treating diabetic complications, primarily because Medicare, Medicaid, the Veterans Administration, and other programs disproportionately serve elderly or ill individuals. In contrast, the amount that the government spends for prevention of illness suggests that it is not doing enough to limit the burden of diabetes or to decrease spending to treat preventable complications. “Simply put, Uncle Sam has a huge opportunity” to save money by spending more for disease prevention and by spending less for treating complications. So what would you tell those presidential contenders and the policy wonks who advise them? The Mathematica report recommends that the federal government: