Last night, the United States Congress voted to pass the much debated healthcare bill. It was a moment likely celebrated by thousands of people just like me, whose status as Type 1 diabetics means that we are automatically disqualified from any individual plan.
I suppose I should have been cheering, too. But instead, I felt a knot of dread in my stomach. I spent this Saturday morning at a fantastic pediatric diabetes symposium put on by the UCSF Diabetes Center, and heard firsthand reports from doctors and researchers about some of the advances coming down the pipeline for people with diabetes, in this case, with Type 1. As I listened, I periodically checked the numbers on my continuous glucometer, wondering what was going to happen to my blood sugar as a result of the Symlin I’d taken that morning. And, despite the fact that I had spent literally three hours on the phone the previous week with Blue Shield, trying to figure out how to get supplies in bulk before I leave on a big trip this spring, I’ll admit: I was actually grateful to my insurance company. It took a fight, it required prior authorizations, but I have the most cutting edge diabetes gear available in the world.
So here’s my fear with the healthcare package that just passed — and I recognize that I am wading into a lion’s den by even bringing it up (I usually avoid publicly discussing anything having to do with politics). Supposedly, this will require all Americans to hold health insurance — and the millions of healthy people, like my husband, will subsidize the millions of expensive people, like me, whom insurance companies will no longer be allowed to exclude. On the surface, that is great.
But here is my fear: people like me are the ones who are going to be flocking to insurance companies’ doors. People who are young and healthy are not. I am not convinced that the universal mandate will be a success — partially because states like South Carolina, Virginia and Florida are already challenging its legality (see here), and partially because I don’t understand how anyone’s going to keep track of whether every single person in the country is holding an insurance policy. That seems like a bureaucratic nightmare — and one that would be very easy to cheat. (This is also putting aside the fact that the last penalties I read about were low enough to make it almost worthwhile to pay them.)
My point being: in one way or another, insurance companies are going to end up with a hell of a lot more expensive people like me to cover. They’re going to have to say yes to us. That is going to cost money. To prevent damage to their bottom lines, they are going to have two major options: raise premiums (likely, if politically unpopular) and/or reduce the number of products and medications that are covered. And that’s going to have a negative effect on access to care.
Think about it: is the continuous glucometer lobby large enough to prevent Blue Shield from deciding not to cover them? And what about Symlin, which has an enormously positive effect on smoothing out my blood sugar after meals, and has helped me drop my A1c by .4% since last fall? Despite these benefits, I can live without it. It’s not like it’s insulin. Wouldn’t that be easy fat to trim? And once that starts happening, why would researchers and pharmaceutical companies put resources into products that have a limited audience and are unlikely to be paid for by insurance?
You see where I’m going with this.
For the moment, it’s easy to argue that there are a lot more people whose diabetes care is going to improve as a result of this bill than there are people like me, the fortunate elite who already have access to top of the line products. But consider this: it wasn’t that long ago when insulin pumps themselves were a rarity — as were electronic glucometers before them. New technologies start with “early adopters,” and eventually, thanks in part to the positive reaction (and insistence) from the first people to use them, become widely available. I look forward to a day when insurance companies cover CGMs as often as they do pumps — or, even better, a day when CGMs replace regular glucometers as a standard in care.
My biggest concerns with the healthcare bill are actually financial — I’ve got money from my 18th birthday socked away in my underwear drawer as we speak, and I’m convinced that the United States is already about to fall (already falling?) off a financial cliff that no one seems willing to address or take steps to deal with. That alone makes me feel nauseated. But then I add in the potential ramifications for people like me — yes, we will have the immediate benefit of no longer being excluded from health plans, which is huge. But who is going to pay for us? And what will the ramifications be in terms of access to (and the development of) promising therapies down the line?
Megan McArdle at the Atlantic has interesting thoughts on this. And for another compelling take on what’s wrong with America’s healthcare/insurance system, check out this piece by the Atlantic’s Jeffrey Goldberg, called How American Healthcare Killed My Father.