How the US healthcare system fails its diabetic citizens

We can understand the problem best through the example of diabetic ketoacidosis.


Long years of falling taxes for corporations and the ultrarich have left America’s most important services and infrastructure — from schools to roads to hospitals to airports — a shadow of what they should be.

This austerity, long a tradition of conservative thinking and more recently adopted by Democrats, fails in big ways. This was best illustrated during the pandemic, when America’s uniquely poor hospital-bed-to-citizen ratio left emergency rooms overflowing. It falls short in a thousand ways daily when families ration food to afford their kids’ medicine.

It fails continuously — as is the case with diabetes patients.

Around one in 10 Americans has diabetes, or 37.3 million people in total. One-fifth of diabetics are not aware of it. Some cases of diabetes are environmental, but many are genetic and cannot be helped. Nobody chooses to have this disease, which makes it a challenge a civilized society must take on together.

America is not doing that, though. The public is more aware than ever that poor fiscal priorities at the federal and state levels are leaving some of the most vulnerable of us behind.

How does the U.S. healthcare system fail its diabetic citizens? We can understand the problem best through the example of diabetic ketoacidosis.

Ketoacidosis Rates Reveal America’s Shortcomings

Ketoacidosis presents as a potentially deadly complication in some diabetes patients. It’s treatable, and ICUs do so almost 190,000 times per year with hospitalized patients. The condition causes blood acidification, delirium, vomiting and dehydration. Not all treatments are successful, however — and hospitals record hundreds of deaths per year as a result.

Unfortunately, the United States is in a somewhat unique situation when it comes to ketoacidosis. Taking insulin regularly prevents complications from ketoacidosis from arising in most patients. However, for many in America, that’s far from a given.

A team drawn from Harvard Medical School, the City University of New York and the University of Manitoba wanted to study the differences between Canada’s universal healthcare system and the profit-driven system in the United States. Cases of diabetic ketoacidosis turn out to be an ideal way to understand how putting profits first directly affects patient wellness and outcomes.

The team came to two conclusions when they studied hospitalization rates for ketoacidosis in Canada and the U.S.:

  • Children and young adults are hospitalized for ketoacidosis more frequently in the United States than in Canada. The differences were there, but not the most substantial part of their findings.
  • At the cutoff delineating youth and adult hospitalizations, the differences between America and Canada became much more pronounced. America’s hospitalization rate jumped by 90% for adults, compared to just a 23% rise for the Manitoba healthcare system.

This is a stark difference. Why has America fallen so far behind when it comes to medical outcomes?

Diabetes and beyond: In America, you’re on your own

It’s not just that America has more cases of diabetic ketoacidosis and more preventable deaths from the condition. One can look at data on almost any preventable medical outcome and find that the American healthcare system is brutally inefficient at treating it, despite the astronomical costs. Consider these findings from the Commonwealth Fund:

  • The U.S. healthcare budget is twice that of the average OECD (Organisation for Economic Co-operation and Development) member countries but clocks the lowest life expectancy.
  • Compared to the OECD average, Americans face the highest chronic diseases and obesity rate. The Commonwealth Fund calls this “chronic disease burden.”
  • The American healthcare system registers the highest number of preventable hospitalizations and deaths compared to any of its peers.

Researchers have observed a link between gestational diabetes and the appearance of cancer in childhood. This causal relationship may partially explain why, in the U.S., more children die from cancer than from any other disease.

America even has almost twice as many maternal deaths during childbirth as any other similarly developed country.

One of the proximate causes of high rates of diabetes and other illnesses in America is that citizens here do not visit their doctor regularly. Almost one in three Americans skip medical care outright because of the cost. The whole chain of causality looks something like this:

People aren’t visiting the doctor because we don’t have enough doctors. College education is too expensive. Capitalism is based on artificial scarcity, and a shortage of doctors means tremendous profits for people who sell treatments for disease symptoms.

Millions of Americans can’t afford or are too busy for preventive medicine, which means they’re sick before they even know it. After that, what could have been prevented by capping the price of insulin — or doing the morally correct thing and making it free — is now a full-blown disaster resulting in even higher medical bills, more medications, increased hospital stays and potentially death.

Fixing diabetes care

One of the researchers behind the ketoacidosis research mentioned earlier — Dr. Adam Gaffney — has a few suggestions for fixing diabetes care. He has identified three areas where political will must bend to medical need:

  • The uninsured rate in Canada is 0%. It’s not even a concept. In America, 9.6% of the population lacks health coverage because it’s not guaranteed to citizens. The ranks of the uninsured go without routine doctor visits and prescriptions in many cases. Universal healthcare would make a huge difference.
  • Even Americans who do have health insurance are saddled with massive deductibles, which is worse than having no insurance in the first place, considering the monthly premium payments on services they’ll never even use. Even the uninsured go without routine care too often. Diabetes patients in high-deductible health insurance plans are more likely to visit the ER with complications.
  • Insured Americans also face what health professionals call “churn” — or rapid changes to their doctors and insurance companies over time. This is most frequently due to a change in employer. Studies reveal that patients who experience high churn are at risk for care interruptions, and 34% of them skip medications due to lapses in coverage.

Short of curing the disease outright, there is no problem faced by diabetes patients in America that a universal healthcare system would not improve considerably or eliminate.

What you can do

Congress is deliberating on capping the price of insulin at $35 per month. It’s a baby step when it comes to fixing American healthcare broadly and diabetes care specifically, but it’s a welcome change. Americans should hound their representatives whenever such measures come up for a vote and harry them relentlessly on why they have not yet committed to universal healthcare.

It’s past time. Some of the more reliable left-leaning voices are renewing their calls for it. It would have made a difference in the pandemic, and it will help the millions of people who juggle diabetes alongside every other one of life’s stresses. Compared to what we all already spend on healthcare, such a system is vastly more affordable, efficient and humane.

Human beings say they’re above and separate from nature, but that status is earned. Unlike beasts, we have the means to ensure those born with — or who develop — disadvantages in life don’t have to go without the dignity the rest of us take for granted.


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