Denying Health Care to Diabetics Makes Just About Zero Sense

Last week, the Trump administration made a new enemy: the American Diabetes Association. During a panel discussion at a forum for health care luminaries at Stanford University on Thursday, Trump’s budget director Mick Mulvaney told an audience that the GOP bill to repeal the Affordable Care Act would take care of people with pre-existing conditions, but only to an extent. “It doesn’t mean we should be required to take care of the person who sits home, drinks sugary drinks, doesn’t exercise, eats poorly, and gets diabetes,” he said.

Diabetes affects nearly 30 million Americans, most of whom did not take kindly to the jab. Almost immediately, they took to Twitter to explain that both kinds of diabetes—type 1 and type 2—are the result of a both genetic and environmental factors. The ADA backed them up on Friday with a public statement decrying the notion that diabetes is a disease of choice: “Mr. Mulvaney’s comments perpetuate the stigma that one chooses to have diabetes based on his/her lifestyle. We are also deeply troubled by his assertion that access to health care should be rationed or denied to anyone.”

Even if you subscribe to the notion that denying people health care is a morally acceptable way to get them to exercise or start eating better, there are still a few big problems with Mulvaney’s assertion.

The first is an issue of biology: You don’t get diabetes by sitting around eating too much sugar. Yes, obesity is the single biggest risk factor for type 2 diabetes (the form of the disease where the body is resistant to insulin), but the research shows it takes a combination of factors to develop the condition, including, most importantly, your genes. Type 1 diabetes (the one where patients can’t make their own insulin) is caused by an autoimmune attack on the body’s insulin-producing cells. “Scientific evidence shows the disease develops from a whole set of risk factors, but first and foremost is the familial, genetic component,” says William Cefalu, the ADA’s chief scientific, medical, and mission officer. “The bottom line is that diabetes is not a choice by a patient.”

The second is about economics. Would denying any of those patients access to affordable health insurance actually save the government money? The financial burden of diabetes comes primarily from its complications: heart disease, nerve damage, kidney failure. Those conditions will send more patients to the emergency room if they can’t get coverage to manage the disease in its earlier stages. More than 40 percent of all health care expenditures attributed to diabetes come from higher rates of hospital admission and longer average lengths of stay per admission. “There’s a practical economic reason to take care of people even if they’re in some ways at fault for their disease,” says Stanford University epidemiologist Randall Stafford. He has spent years studying and testing strategies to diminish the burden of obesity, diabetes, and heart disease while decreasing health care costs. “Saving money in the short term just means paying even more down the road because of all those complications,” he says.

For the sake of argument, what might those short-term savings look like? Based on the CDC’s most recent counts, 29.1 million people in the US are living with diabetes. Of those, 5 percent, or 1.5 million Americans, have type 1. Using some Mulvaney-style math, those people get a pass for their pre-existing condition (since they didn’t do anything to deserve it). Let’s also throw in kids with diabetes—either type—which subtracts out another 208,000 people. That leaves 27,392,000 Americans with type 2 diabetes (the presumed couch-sitting, cola-guzzling kind), the majority of whom are between 45 and 64 years old. This age group only incurs about one-third of all diabetes-related health expenditures. About 60 percent are attributed to the over-65 population, most of which are borne by the Medicare program. Since Trump and Mulvaney’s budget largely leaves Medicare alone, the majority of potential savings come out of that 45 to 64 group—a figure estimated to be around $80 billion, based on the ADA’s most recent economic impact report. Those short-term savings of course, wouldn't be offset by any potential downstream costs, much harder to measure, that would accumulate in emergency rooms if you denied coverage to type 2 diabetics.

And $80 billion isn’t nothing. But it’s still $7 billion less than the Agency for Healthcare Research and Quality estimates cancer cost the US at last count (in 2014). That year, cancer killed 585,720 people, a third from tobacco use. The World Cancer Research Fund estimated that another third of cancer cases in developed countries like the US are related to obesity, physical inactivity, and poor nutrition. According to Stafford, there are relatively few conditions that affect a lot of people and cost a lot of money that are totally free of any personal responsibility. “If we made a rule for diabetes, we’d have to make it with a whole raft of other conditions,” he says.

But those numbers get ignored here. In that same address Mulvaney made last Thursday, he at one point said, “We have plenty of money to provide that safety net so that if you get cancer you don’t end up broke.” The juxtaposition is stark. Bad luck deals you cancer. You give yourself diabetes—even though many of the risk factors are the same.

This is what happens when you try to build health care policy around an idea—that some people deserve care and some don’t—without a firm scientific understanding of disease pathology. Even if you buy into its premise, the Republican health care plan doesn’t have a good, data-driven framework for culling so-called deserving sick people from all the rest. Without that scientific compass, all that’s left is a moral or cultural one. And that’s no way to make health care policy.