Mick Mulvaney
The Office of Management and Budget
725 17th Street, NW
Washington, DC 20503

May 16, 2017

Dear Director Mulvaney,

The Diabetes Advocacy Alliance (DAA) is a coalition of 22 organizations representing patient, professional and trade associations, other non-profit organizations, and corporations, all united in the desire to change the way diabetes is viewed and treated in America. On behalf of the 30 million Americans living with diabetes and the 86 million Americans living with prediabetes, we write to express our concern about your statements regarding individuals with diabetes attributed to you in multiple press reports.

Diabetes is a complex disease caused by myriad factors, and it is not solely caused by excessive eating and lack of physical activity. Diabetes progression occurs for millions of people who follow all nutrition, eating, and exercise guidelines. Family history, age, high blood pressure, race, ethnicity, and a history of gestational diabetes (either during pregnancy or in a child’s mother), environmental factors, and genetics also play significant roles.

The complications of diabetes can be devastating in both human and economic terms. Diabetes can lead to increased risk for dementia, hearing loss, loss of vision, cardiovascular disease, stroke, heart disease, kidney failure, lower limb amputations, depression, gum disease, high blood pressure or LDL cholesterol, low bone density and painful peripheral neuropathy, which affects the nervous system. In the United States, nearly 30 million Americans have diabetes and an additional 86 million have prediabetes placing them at high risk of developing the disease. Not only has the number of people afflicted with this disease skyrocketed in recent years, so too have the costs. The diabetes epidemic cost our nation $322 billion in 2012 and one out of every three Medicare dollars is spent on a person with diabetes.

Fortunately, diabetes enjoys an extremely strong evidence base showing that the delay and management of diabetes can create significant cost savings. In fact, given diabetes’ prominence as a cost-driver, preventing and controlling diabetes could be one of the greatest tools at your disposal to curb the growth of health spending. For example, active prevention for those at elevated risk for type 2 diabetes has demonstrated effective clinical results, as well as return on investment. Within Medicare, the evaluation of a diabetes prevention demonstration project completed last year, and certified by the Centers for Medicare and Medicaid Services (CMS) Office of the Actuary, showed a $2,650 savings per beneficiary in just 15 months. Applied broadly, these types of interventions have the potential to reduce significant healthcare spending for both public and private payers.

There are opportunities along the entire continuum from detection, prevention, to care to rein in costs by enabling better care for those with diabetes.

  • Detection. Diabetes screening is the entry point to prevention. Evidence shows that more comprehensive screening for diabetes would help with prevention efforts—more effectively finding the undiagnosed and those at risk for developing diabetes so that they can benefit from timely and appropriate intervention to, respectively, prevent costly complications and diabetes itself.
  • Prevention. Diabetes prevention has an extremely strong evidence base. The Diabetes Prevention Program, scientific research funded by the National Institutes of Health (NIH), translated in the community, and scaled up by the Centers for Disease Control and Prevention (CDC) as the National Diabetes Prevention Program (National DPP), has demonstrated conclusively that type 2 diabetes can be prevented or delayed in adults with prediabetes through both community-based and online settings. Medicare will begin covering the National DPP for eligible beneficiaries January 1, 2018.
  • Care. Once diagnosed, patients with diabetes must self-manage healthy eating, physical activity, monitoring blood glucose levels and using the results for self-management decision making, adhering to medications, coping and problem solving with every day struggles to help reduce risks for diabetes complications. Diabetes self-management training (DSMT) is an evidence based service that teaches people with diabetes how to effectively selfmanage and cope with the disease. Studies have found that DSMT is associated with improved diabetes knowledge and self-care behaviors, lower hemoglobin A1c, lower self-reported weight, improved quality of life, healthy coping and reduced health care costs.1 The service, although covered by most private health insurance plans and Medicare Part B, is woefully underutilized in Medicare, which CMS acknowledged in its proposed CY 2017 Medicare Physician Fee Schedule rule.

We offer the Diabetes Advocacy Alliance as a resource and request a meeting to explore the ways in which you can use the better detection, prevention, and care of diabetes to find significant savings in the budget. We also welcome the opportunity to engage with you as you work on regulations that are critical to meeting the needs of people with diabetes and their families.


The undersigned DAA organizations:
Academy of Nutrition and Dietetics
American Association of Clinical Endocrinologists
American Association of Diabetes Educators
American Diabetes Association
Diabetes Hands Foundation
Endocrine Society
National Community Pharmacists Association
National Council on Aging
National Kidney Foundation
Novo Nordisk
Omada Health
Weight Watchers
YMCA of the USA