Anyone else catch the story yesterday about how children with Type 1 diabetes are living longer than previous generations of kids with the disease? According to a study published on July 30 in Diabetes (and summarized here), there’s been about a 15-year improvement between a cohort born between 1950 and 1964, and another born between 1965 to 1980.
This makes good sense to me — the later you were born, the more technology you had available to keep your blood glucose levels under check. I feel very grateful — in as much as one can feel grateful for such things — to have been diagnosed in 2001, soon after Humalog, right before Lantus, and within a few years of the first US continuous glucose monitor. I never had to pee on a stick, or rely on porcine insulin. Even the best-intentioned diabetic born in 1950 would have had fewer resources available for blood sugar control than someone born in 1980 — so it would make sense on average for the people born later to be doing better.
But here’s an angle I hadn’t thought of, which is pointed out by the afore-linked press release: insurance. ”[L]ife expectancy improved from the 1950-1964 to 1965-1980 type 1 diabetes diagnosis subcohorts of the Pittsburgh EDC study,” the authors wrote in the study. “These results support the need for insurance companies to update their analysis of the life expectancy of those with childhood-onset type 1 diabetes, because the current weighting of insurance premiums is based on earlier, outdated estimates.”
That last sentence jumped out at me, because up until that moment, I hadn’t given too much thought to how, exactly, insurance companies evaluated people with Type 1 diabetes. I didn’t have to think about it — because as anyone with T1D knows, up until now Type 1 diabetes has been an automatic disqualifier if you’re self-employed and are trying to get an individual plan. (My solution was to get married.) But now we’ve got the new healthcare law which supposedly is going to prevent insurers from automatically disqualifying people based on preexisting conditions. That leaves me with a big question: how are they going to set premiums?
That’s where I fear things could get screwy. In general, I actually think it makes perfect sense to charge people with diabetes more for insurance (from an economic, if not moral, standpoint) because let’s face it: we’re expensive! Either we don’t take care of ourselves and need someone to chop off a leg, or we do take care of ourselves, and require $1/strip glucose meters, $100+ per-bottle insulin, plus — if you’re like me — thousands of dollars in pump and CGM supplies. Insuring someone like me is kind of like trying to get insurance when you already know your car is broken.
But, with that said, I don’t know how much more that should be, since an investment in our current health will pay off with fewer long-term complications. It would be really screwed up if insurance companies set premiums based on statistics on complications and deaths for people born when the discovery of insulin was a mere 30 years old. Things are different now. Yes, my supplies are expensive, but at the same time I am not going to require emergency room visits because I take care of myself very well (and a couple trips to the emergency room would cost my insurer more than all my supplies — so economically, it makes sense to help me take care of myself). Even with the cost of my technological maintenance, I am likely cheaper than someone born in 1950 who now is dealing with complications.
Also interesting is that, partially because of my disease, I take care of myself better than most people WITHOUT diabetes! I exercise. I don’t smoke. I eat an obscene amount of produce. Sometimes I walk around the streets of Philadelphia and engage in a very critical and judgmental inner dialogue, in which I look around at people eating McDonald’s and smoking cigarettes and think, “What the hell are you doing to yourself?” The crazy thing is that from an insurer’s standpoint, someone who never exercises, smokes, drinks, and exists on Big Macs is probably going to look better on paper than I am.
I’m hoping that as more studies like this are published, insurance companies will take note that even though responsible modern-day diabetics are expensive to maintain, it is possible for us to be LESS expensive in the long-term than a. people who had Type 1 when technology and insulins were in their infancy, and b. irresponsible non-diabetic members of society who don’t give a crap about their health till they land in the ER with a heart attack.
So let’s rework those actuary tables.
I’m a 53-year old type 1, diagnosed in 1973, and have shopped around for life and health insurance for almost 30 years. I can report that T1s have better life insurance options than we did when I started. The improvements in technology and understanding have led some insurers to sell life insurance policies to T1s who are in good health with more affordable premiums than in the late 1980s. Some insurace companies are already using better actuarial tables, and that’s a good thing.
But I must disagree that health insurance should cost more for diabetics. I’ve had group health insurance since 1990 (when the law was changed thanks to good legislative reforms here in Texas to require group insurance to cover diabetic members of the group). I don’t have to pay more to be a member of the group, because insurance creates a risk pool where everyone’s premiums help pay for care for the ill or even the chronically ill. If the pool is large enough — as it should be under the Affordable Care Act – the premiums received will cover everyone’s expenses.
This isn’t the best way to provide healthcare, I would agree, but it has worked well enough for me since 1973.
Thanks for the comment, Jeff. I should have clarified that while I’m currently (and thankfully) on a group plan, I was thinking about this from an individual insurance-buying perspective — i.e. one where there’s not a group to spread out the increased cost. With that said, your comment reminds me of an interesting program I participated in when I lived in California, called the Major Risk Medical Insurance Pool (Mr. MIP for short). It used money from the cigarette tax to provide group coverage to people with pre-existing conditions, and allowed me to get insurance even though I was self-employed. When I saw people light up a cigarette, I was thankful!
Ah – thanks, Catherine. That’s a good question. The ACA sets up insurance exchanges in each state for people who can’t find other health insurance. It doesn’t allow price discrimination based on health status, but it does allow discrimination based on age. The devil will be in the details, but I hope it works.
I have a T1 friend in North Carolina who had to resort to the risk pool there when she was between jobs, and it was super expensive. She’s back on group health insurance now. I hope the exchanges will turn out to be more affordable.
I have had T1 diabetes for over 45 years and during that time used bio synthetic and analogue insulins for five miserable years. I now am using pork regular and beef PZI, a good combination for me. I think it is really unfortunate that manufacturers have managed to convince so many diabetes activists that a) people with diabetes are all able to use rDNA brands equally well and b) these brands are used without side effects. Everyone has to decide which risks are acceptable, and in Canada there is a recognition by Health Canada (our equivalent to the FDA) that some people are at great risk if they use rDNA and/or analogue insulins. They admit the reasons are not known, but at least they don’t deny that this is h case. It is the same in almost every country except the USA.
The risks with some of the analogues may not be acceptable to Americans either. A number of independent (eg not Pharma sponsored) studies have raised concerns that glargine (Lantus) may be linked to an elevated risk of cancer, one reason that Germany has declined coverage under the public drug plan.
There are no studies that have linked improvements in mortality and morbidity rates to bio synthetic or analogue insulins. In fact, the Cochrane Review, as well as Canada’s Common Drug Review, have criticized researchers for neglecting to measure any outcome other than blood sugar. It is interesting that mortality rates are improving but, quite frankly, it would seem difficult to ascribe such progress to new treatment protocols since longevity would be measured by decades and the protocols and insulins you are praising have been widely used only since the mid-1990s when manufacturers began withdrawing older animal insulin products.
One more point and a correction: The Gillian Booth study referenced in your blog looked at differences in mortality and non fatal heart attacks and stroke based on what are commonly referred to as social determinants of health (socio-economic status) among those over age 65. Most of these would, of course, have Type 2 diabetes. Insulin therapy as part of an intensive treatment strategy among this population is controversial, because it has been shown to contribute to increased rates of congestive heart failure and weight gain. Booth’s study is based in Ontario where there has been a lot goodwork done showing a link between poverty and higher incidence of Type 2 diabetes. In this study she has extended that focus to include rates of mortality and heart disease and stroke. Poorer people in Ontario have less access to medicine but (like their American counterparts) after age 65 access is universal. For this cohort, access would likely refer to mainly non insulin therapies. Generally in Canada, – the first oral anti-hyperglycemic treatment introduced sometime in the 1950s – is prescribed as a first-line treatment for Type 2 diabetes. So newer is not necessarily better. Finally, a correction: when the majority of animal insulins were withdrawn in the mid-90s, an estimated 30-35% of Type 1s were affected. The industry made a huge push during the late 1980s and early 1990s to push a reluctant insulin-using population towards “human” insulin. That reluctance was based mainly on two factors: 1) the cost (animal insulin cost about $10 a vial compared to about $18-$20 a vial for bio synthetic brands); and 2) for many, the newer brands were more volatile and less predictable.
This is all very interesting. Thankfully, I’m on a group insurance plan. I always have been. Anyway, from the point of view of an insurance company, the following also needs to be taken into consideration (and I am NOT a fan of insurance companies!) The most difficult thing in terms of blood glucose control and eventual complications, in terms of children, is this. Many kids have well-controlled blood glucose levels UNTIL they reach adolescence. Then all hell breaks loose – not ALWAYS, but sometimes. I was diagnosed as an adolescent (age 16, in 1972) and I have no complications. I have met many kids in the 21st century who just don’t GET IT that what they do to their bodies now can ruin their lives. Hopefully this is not the norm.
O.K. – Let me play Devil’s Advocate. I happen to be a Type I who was diagnosed over 40 years ago, and have no complications to speak of. I’m on a pump and CGM, and use a lot of test strips. I will continue to cost my insurance company a lot of money because of these items I use in order to stay healthy. If a person with Type I DOES NOT take care of him/herself, and ends up with end-stage renal disease or severe retinopathy, he/she will end up on disability and Medicare, and will no longer be the responsibility of the private insurance company. So, from the standpoint of the private insurance company, why not deny all those claims for needed medical supplies to keep one’s blood glucose levels in check. If you can’t control your blood glucose levels, you’ll become the responsibility of the U.S. government, and will likely suffer an early death anyway. So, tight control is expensive, and poor control is only costly for a few years, and then death often intervenes.