Dueling With Diabetes

Lawmakers Look to Rein in Illness and Costs From Diabetes

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Legislative Affairs Feature -- October 2004

By  Ken Ortolon
Senior Editor

Laredo family physician Leonides G. Cigarroa Jr., MD, conducted only a half-day clinic in his office on Aug. 10. But among the handful of patients he saw that day were four newly diagnosed with diabetes. They are part of a disturbing trend of increasing diabetes across the state.

"We're getting used to that, unfortunately," Dr. Cigarroa, chair of Texas Medical Association's Council on Scientific Affairs, testified at a legislative hearing in Austin the following day.

Because of lifestyles heavy on fattening foods and light on exercise, diabetes is reaching epidemic proportions in Texas. Minority populations here are at the highest risk of contracting the disease. And, frighteningly, the typical victim is getting younger and younger.

Eduardo Sanchez, MD, commissioner of the Texas Department of State Health Services, told a House Public Health Committee subcommittee that when he graduated from medical school in 1988, "type 2 diabetes was referred to as adult-onset diabetes. Children did not develop type 2 diabetes. Now, in the year 2004, children as young as 6 years of age are being diagnosed with type 2 diabetes."

The Texas Pediatric Diabetes Research Advisory Committee says up to 47,000 Texas children will have type 1 or type 2 diabetes by 2025. At an average cost of $1,000 per month per person, the direct and indirect cost of treating them will total $23.5 billion over their lifetimes, Dr. Sanchez says.

Lawmakers say the state can't shoulder that burden. They are looking for solutions to lessen suffering from diabetes and reduce the impact on the state's budget and economy.

Don't Go There

The house committee is examining the demographics and costs of diabetes in Texas and assessing its impact on the population, budget, and health care system. Subcommittee member Rep. Jaime Capelo (D-Corpus Christi) was instrumental in convincing House Speaker Tom Craddick to authorize the study because his South Texas district has been hard-hit by diabetes.

If projections are correct, says subcommittee member Rep. Jim McReynolds (D-Lufkin), the state must act now before diabetes devastates the quality of life for tens of thousands of Texans and wrecks the economy.

"If we leave things alone, we're $23 billion in the hole by 2025," said Representative McReynolds, who has diabetes. "We can't go there because we don't have $23 billion to spend toward this single issue."

The rampant rates of type 2 diabetes, particularly in children, are entirely due to lifestyle factors that will be hard to change in a society hooked on "supersized" meals and sitting in front of television or computer screens instead of exercising.

Dr. Sanchez says the number of overweight children in Texas has tripled in a single generation. About 35 percent of Texas kids are now overweight or obese.

Meeting the Challenge

Lawmakers and public health officials say prevention and education are the obvious starting points to reduce diabetes in Texas.

"Education and other activities associated with physical activity and fitness, proper nutrition, and lifestyle and cultural implications are paramount to reducing the incidence and prevalence of diabetes," said Dr. Cigarroa. He testified on behalf of TMA and the Primary Care Coalition. "Aggressively managing the growing obesity problem in the state, through efforts such as SB 19, is essential." Senate Bill 19, passed in 2001, mandates a minimum amount of physical activity for children in Texas elementary schools.

"Appropriate and adequate insurance coverage must continue for diabetes medical services, equipment, and supplies," Dr. Cigarroa added. He urged lawmakers to maintain the primary care case management model for Medicaid managed care and reject the state's proposal to transfer the vast majority of Medicaid patients into HMOs.

"This decision is shortsighted as it will further deter physician subspecialists from participating in Medicaid," Dr. Cigarroa said. "Without access to timely care from endocrinologists and other specialists, diabetic Medicaid patients will have more complications and hospitalizations, driving up Medicaid costs, not lowering them, not to mention the human toll."

Representative McReynolds says lawmakers may need to expand physical activity requirements to the state's middle schools. Legislators also may take another look at restricting the types of foods being sold in vending machines on school campuses. That may be unpopular among school officials who viewed SB 19 as an unfunded mandate and who rely heavily on vending machine contracts for revenue.

"Do I want to go in and tell the schools they must have three hours of physical education?" committee Chair Rep. Jodie Laubenberg (R-Parker) asked. "Do we tell them the state's going to create the menu for their nutrition programs? Do we set up a universal nutrition program? Do we have the money to do that? These are questions I am asking and the legislature will be looking at."

Representative Capelo says spending money to prevent diabetes could lessen the burden of illness on patients and save money in programs such as Medicaid and the Children's Health Insurance Program (CHIP).

But finding the dollars to put into prevention and education could be tough. In 2003, the legislature faced a $10 billion budget deficit and cut programs that directly impact diabetics, including podiatric care under Medicaid and vision care under CHIP.

Also, House Bill 2292 mandated a preferred drug list for Medicaid. While TMA and other groups supported the preferred drug list to control costs, advocates for diabetes patients have been disappointed that Lantus, a type of insulin that they say most closely mocks naturally produced insulin in the body, was excluded. Lantus was excluded solely because its maker would not offer the state a rebate.

Representatives Capelo and McReynolds say those decisions may have been penny-wise and pound-foolish.

"There's no doubt that some of the cost savings have had a particularly devastating impact on our current Medicaid diabetes community," Representative Capelo said. "That has harmed doctors' ability to effectively treat diabetes."

Ken Ortolon can be reached by telephone at (800) 880-1300, ext. 1392, or (512) 370-1392; by fax at (512) 370-1629; or by email at Ken Ortolon.

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