A Pound of Treatment: Is it Better than an Ounce of Prevention?

Yesterday, I received a telephone call from the mother of a young man who will turn 19 years old in about 10 days. The boy, who we will call Rick, has type 1 diabetes mellitus, diagnosed when he was about 10 years old. For a number of reasons, he has not done particularly well with his diabetes over the years, including many missed clinic appointments. Regardless, he is a pleasant, personable, and intelligent young man. He will graduate from high school in about 3 weeks. He wants to attend college but he has made no plans so far and does not know what he wants to study. I should add that he has had some drug problems and has just gotten out of a rehabilitation center.

Why did Rick’s mother call me?

Rick’s mother told me that Rick is now very focused on doing better with his diabetes and wants to see me in the next week or so, before his Medicaid coverage runs out (in my state, Missouri, Medicaid coverage for children is terminated on their 19th birthday). Rick lives with his mother. The parents are divorced and the father plays no role in Rick’s life, including financially. Rick’s mother has a full-time job, but no health insurance. So, in about 2 weeks, Rick will have no Medicaid coverage for his diabetes. So, what are his options?

First, he could try to get health insurance through one of the insurance carriers licensed in our state (e.g., Blue Cross/Blue Shield, United Health Care). That won’t work since he has a “pre-existing condition,” and is not eligible. He could get coverage through the state “high risk insurance pool,” a way for people like Rick to get health insurance. That won’t work given the cost which is about $800/month for a high deductible plan; neither Rick nor is mother have the resources to afford such a plan. I could lay out lots of other possible solutions, but I can assure you that none will work for Rick.

What if Rick had serious diabetes complications?

Quite a few years ago, I wrote an editorial to a medical article about the high prevalence and high costs of kidney failure in patients with diabetes. My editorial was entitled (as you might guess), “Is a pound of treatment better than an ounce of prevention?” As I recall, the results of the landmark Diabetes Control and Complications Trial, or “DCCT,” had just been published. The DCCT showed that diabetes complications (including kidney disease) could be prevented if the diabetes is well-controlled (we’ll come back to the DCCT in future entries). Anyway, in my editorial I tried to make the case for promoting excellent diabetes care “up front” to prevent the costly complications.

Rick’s dilemma

So, in about 10 days, Rick will have no means to pay for his costly diabetes supplies, let alone clinic visits and laboratory studies. I’ll do the math for you- the cost for his basic diabetes care is dramatically less than if he should develop serious diabetes complications, which he surely will unless he works to do well with his diabetes. But, Rick won’t even have the means to do well. Great system we have!

What am I going to do about this situation?

In a few days, I will see Rick in my clinic. I will try to help him develop strategies that will get his diabetes on track. I will encourage him to keep in close contact with me by telephone or e-mail over the next 1-2 months. I have looked into a free health clinic where Rick could go and even get some of his medications for free. He will need to apply; to qualify his mother’s income will need to be below a certain level- it will be a close call. The next available appointent is in about a month.
He could look for a job with health insurance- typically jobs with large companies that have health insurance for all employees without exclusions for “pre-existing conditions,” governmental agencies, hospitals, etc. He may have trouble given his drug history, but maybe not. I think full-time college is out for the moment, if he wants to do well with the diabetes (some colleges offer heatlh insurance to full-time students at very reasonable rates but one must have pre-existing insurance to qualify. Bummer.

The crazy thing is that if Rick has serious complications now, such that he has serious “functional limitations,” he could get coverage and an income to boot through the U.S. Supplemental Security Income program (SSI). Of course, if we just wait a few years, that will be a good option for Rick.

What am I trying to say?

What I have tried to explain is that our health-care system is not very good at facilitating optimal medical care for people with certain chronic medical conditions, such as diabetes who cannot obtain affordable health insurance. The end result is often dramatically greater costs (borne by all citizens with health insurance) to treat disease complications than would have been required to carry out high quality basic care of the condition. Diabetes is a great example since we know that all of the complications of this disorder are preventable.

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