How COVID-19 is affecting diabetics and their access to insulin in America
Diabetic patients face daily challenges of treatment access and treatment management, so 2020 has been a particularly challenging year. Conor Kavanagh analyses what specific factors are making the COVID-19 pandemic particularly deadly for diabetics.
Over 30% of coronavirus deaths occur in people with diabetes, according to a Lancet Diabetes & Endocrinology study in the UK. This risk was almost three times as high for people with type 1 compared to type 2. In the US, the Centers for Disease Control and Prevention found that four in ten patients who died from COVID-19 with pre-existing conditions had diabetes. It is clear that diabetics are one of the worst hit groups by the pandemic.
For diabetics to best defend against the virus they must stick to their insulin regime, but in countries like the US this has been problematic for decades due to pharmaceutical companies constantly raising the price of insulin. Most Americans rely on medical insurance, and even this can sometimes have little effect on the high costs. Coronavirus has created a global economic crisis which has made access to insulin even harder financially.
In this feature, Conor Kavanagh analyses what specific factors are making the pandemic particularly deadly for diabetics.
Why diabetics are vulnerable to the coronavirus
People with type 1 diabetes have had their pancreatic islet cells, which are used to produce insulin, destroyed. This means that they cannot process the glucose their body needs and sugar accumulates in the blood. In terms of type 2 diabetics, sufferers cannot make enough insulin to convert glucose into energy or they will grow insensitive to the insulin they do make.
This poses several long-term problems. Too much or little glucose can inflict lasting damage to the heart, kidney, liver, and the nerves. Poor glucose control can cause stroke, heart attack, kidney failure, eye disease and, later down the line, possible limb amputation. The linings of blood vessels throughout a diabetic’s body become fragile and cannot ferry nutrients as well as they should. This can cause inflammation, reducing the effectiveness of the immune system.
The organs that COVID-19 targets are generally the same organs that are often compromised in diabetics, which means the virus will automatically have a chance of creating more severe symptoms. The consistent inflammation that diabetics suffer from also comes into play. It makes it more likely they will suffer a life-threatening cytokine storm that can often put them more at risk than the virus attacking their weakened organs. Diabetics may also be more at risk of actually catching the virus, especially those who suffer from the type 2 version of the disease. This is because these patients having more ACE2 receptors in their tissues, including those which line the blood vessels, making it easier for the COVID-19 spike protein to enter cells.
Type 2 diabetes is also linked to obesity, another factor that influences the mortality rate of coronavirus. Not only are obese people more likely to have the type 2 form of the disease but often have lung or heart disease. They are also more prone to metabolic syndrome, in which blood sugar levels, fat levels or both may be high. Generally, obese people will have fat in their abdomen that pushes up on the diaphragm. This causes the large muscles which lie below the chest cavity to put pressure on the lungs, reducing the airflow. This leads to the collapse of airways in the lung’s lower lobes where more oxygen usually arrives. The blood of obese people also has a higher risk of clotting, which has been seen as the cause of death in multiple COVID-19 patients.
How COVID-19 is making insulin harder to access
Diabetics need to follow a strict regime of taking insulin to ensure their body functions correctly. Although type 2 diabetics may have to be treated with insulin, it is essential for those with type 1. The Juvenile Diabetes Research Foundation has warned that the pandemic has compromised insulin production and access. For type 1 diabetics, the risk of a shortage or a delay could be life threatening. Health professionals are recommending diabetics stock up on a 30-day supply of insulin to deal with any issues.
Pharmafocus spoke to Josh, a social worker from Portland, Oregon, who is a type 1 diabetic, and has experienced issues accessing his insulin. Before the pandemic, Josh would get his insulin mailed to him, which gave him a discount on his medical insulin. He describes his insurance as “really good” meaning that he spends $150 a month on his insulin and supplies that includes syringes, flex pens, cap needles for the flex pens, two types of insulin, and CGM supplies.
However, after the pandemic started to hit the United States hard, it significantly impinged Josh’s access to insulin and his supplies. He said: “In July, I noticed I was on my last insulin pen so I placed an order for more. I live approximately four miles from the pharmacy that my insulin comes from. Pre-COVID, it would take two to four days to arrive. But in July, it took over three weeks from the time I placed the order. Nobody knew what was going on.
“The pharmacy said it should have been there so I should call USPS (United States Postal Service). But the number she gave me was constantly unreachable. Luckily, I have some old Humalog vials stockpiled. My friend’s father was a diabetic and when he died she sent me all his old insulin. It’s kind of morbid but insulin isn’t cheap.
“The worst part was just thinking about people who don’t have extra insulin lying around. If I hadn’t had the extra insulin I would’ve had to go to a free clinic here in Portland – and then I’m exposing myself to the virus.”
Despite Josh’s relatively affordable insurance and sufficient access to insulin, the pandemic has impacted his ability to source the substance he needs to survive. Josh was fortunate to have access to a stockpile, and other diabetics may be able to afford to create their own, but the unfortunate reality is many cannot. Without insurance, insulin can cost $275 per vial, with the three major companies who produce it selling it at about $300. Even before the pandemic, many diabetics rationed insulin because it was so unaffordable. This cab often leads to death. One of the most notorious cases in recent times was the death of Alec Smith, a 26-year-old diabetic earning minimum wage who could not afford the $1,300 cost of the treatment which led him to ration insulin.
The coronavirus pandemic has put many countries across the world into a recession, including the US. From March to October, 60 million claims had been filed for unemployment insurance. In terms of general assistance from the federal government, private citizens have only been granted a one-time $1,200 check as part of the Coronavirus Aid, Relief, and Economic Security Act (CARES Act). In the US, between 50-78% of citizens earn just enough money from their monthly salary to cover their bills, according to Nielsen, the American Payroll Association, CareerBuilder, and the National Endowment for Financial Education. Good quality health insurance is also primarily tied to unemployment. As the coronavirus pandemic puts millions out of work for the foreseeable future, it also kicks them off their insurance. This makes stockpiling insulin unrealistic and being able to afford the required amount a struggle. Many diabetics already shared the fate of Alec Smith before the pandemic, and this will only be exacerbated as COVID-19 continues to cause economic crises worldwide.
The mental impact of COVID-19 on diabetics
Like many diabetics, Josh gets his insulin delivered. But, during a pandemic where delivery services are under greater strain, it is sometimes inevitable that diabetics will have to physically retrieve their insulin from clinics. If they are also facing issues from diabetes they will have to go to the doctors. While there has been investment in phone and online doctors’ appointments, this won’t be possible for all patients due to the complexities of the condition. The threat to diabetics is severe, so most do not have the luxury of returning to any semblance of pre-COVID-19 normality – this includes Josh. Commenting on how he takes extra precautions due to the pandemic, he said: “I take precautions by wearing a mask and limiting where I go. My wife and I only send one person into the grocery store at a time. I wash my hands until they are raw when I am around people. I haven’t hung out with anyone besides my wife and dog indoors since March.
“I went on two camping trips with friends, but even that is hard because they’ve been living their lives like normal while I live like a hermit. So, for two weeks after those camping trips I was a nervous wreck.”
Josh touches on the emotional distress COVID-19 causes, and this has affected many people across the world, with the demand for clinical therapy skyrocketing. Oregon has implemented coronavirus restrictions, like rules on public meetings and stay-at-home orders, but the state’s cases are still rapidly rising. The US is by far the worst hit country in terms of coronavirus, and at the time of writing have had over 10.6 million cases and 243,000 deaths. Some states like Florida have little in the way of coronavirus restrictions and in September removed fines for not wearing face masks in public places in September.
Due to the COVID-19 pandemic and its spread in the US, diabetics like Josh have had to isolate at home for months. This has a direct mental impact, which has affected Josh. He said he is “now getting therapy for the first time,” adding: “My wife and I share a 380 sq ft apartment – she is getting her PhD – and us working from home has been stressful on both of us and our marriage. I’ve noticed I’m eating more, which means I use insulin more, which means I spend more money. I’ve just started a diet which hopefully will help in conjunction with therapy.”
Diabetics are already at higher risk of mental health related issues than the average population. A meta-analysis from the American Diabetes Association found that having diabetes doubled the risk of depression compared with the general population. Anxiety is another common side effect, with another study published in the National Library of Medicine finding that 14% of people with diabetes had a generalised anxiety disorder while 40% experienced elevated symptoms of anxiety. Coronavirus restrictions have had a great impact on the mental health of many around the world, but diabetics also have to worry about access to the right food, insulin, and other supplies during a time of great economic uncertainty. In the case of Josh and other American diabetics, they also have to worry about the extortionate cost of insulin and health insurance.
Has the US Government forgotten diabetics?
The CARES Act was a wide-ranging bill that provided economic relief to millions of businesses and workplaces, but as previously mentioned, only gave each private citizen a $1,200 check. While Donald Trump’s administration has continually spoken about reducing the price of drugs, little has been done, and there has been minimal action to address insulin prices.
Josh feels diabetics have been continually overlooked by the government, especially during the pandemic. He said: “Diabetics have always been a fringe group, and the common conception of Americans is that if you have diabetes and avoid sugar and workout you’ll be fine. I know this because I was 27 when I was diagnosed with type 1 out of nowhere. People look at it as preventable or something that only affects a certain age group. The fact that insulin costs like $3 to make and they charge such wild markups is insane. And the worst part is that Trump lauds a victory over big pharma and says insulin will be cheaper, but the vast majority of diabetics have seen no change. But since Trump said it, a lot of people assume it’s true.”
Some insulin manufacturers and state legislatures have attempted to bring some relief to diabetics. In April, Eli Lilly introduced the Lilly Insulin Value $35 co-pay card to help diabetics who are struggling financially. The co-pay will cover both insured and the uninsured individuals but will not extend to Medicaid, Medicare or Medicare Part D patients. In January 2021, people enrolled in participating Medicare Part D plans will be able to access this discount to Lilly insulin as part of the Senior Savings Model. It will also include the Humalog injection. However, Eli Lilly currently charges $275 per vial of insulin, which is a $150 increase from 2011.
Some states have taken local action to help diabetics. The Democratic legislature in Virginia passed a bill that forces insurers to cap insulin prices at $50 a month and New Mexico signed legislation capping insulin co-payments at $25. While these are welcome steps for diabetics, it is still not enough to ensure those worst off have access to affordable treatment.
Unlike most developed countries, millions of Americans do not have access to healthcare – due to the lack of a socialised system. Josh believes that diabetics suffering disproportionately is the “failure of the United States government” adding: “Nobody asked for this disease, and I am so lucky and blessed to be able to afford the costs that come with it usually, but as a social worker my heart bleeds for people who just have to come up with $150-300 a month to survive.”