Diabetes in the United States: Examining Growth Trends, State Funding Sources and Economic Impact by The Council of State Governments

Diabetes in the United States Examining Growth Trends, State Funding Sources and Economic Impact

Diabetes Prevention Program, or National DPP, in 2010. The long-term health burden on citizens, along with rising health care costs, have spurred action at the state and local levels to tackle the specific needs in their state regarding diabetes.1 Not only is diabetes a long-term health concern if not managed properly, it is also extremely costly. In a report by the University of Washington’s Institute for Health Metrics and Evaluation, health care spending on diabetes diagnosis and treatment totaled $101 billion in 2013, and has grown 36 times faster than spending on heart disease, the number one cause of death in the United States. The total indirect cost of diabetes is estimated at $68.6 billion, according to 2012 American Diabetes Association research. These costs result from lost productivity from absenteeism, reduced productivity at work and at home, unemployment due to chronic disability, and premature mortality.2

OVERVIEW The Council of State Governments, in partnership with the National Association of Chronic Disease Directors, or NACDD, issued a survey to the 50 states to gain a better understanding of state funds that are appropriated toward diabetes prevention and management. Additionally, the survey inquired about successful state programs developed to assist with diabetes treatment and management. CSG received responses from all 50 states. Half of the states reported appropriated state funds in fiscal year 2017 for diabetes programs or public health purposes that include diabetes. In 16 states, funds were specifically earmarked for diabetes prevention and management, with six of

these states dedicating over $1 million dollars to support diabetes programs in fiscal year 2017. The number of adults with diagnosed diabetes has increased by more than 20 million cases in the U.S. from 1980 to 2015—from 5.5 million to 25.8 million— as reported by the Centers for Disease Control and Prevention, or CDC. The chart below shows the climbing number of diabetes cases from 1980 to 2015 in the United States. Due to the dramatic increase in cases over the years, the U.S. has taken action to combat the disease, including Congress authorizing CDC to establish the introduction of the National

This report summarizes the current state of diabetes in the United States by examining several federal and state initiatives to prevent and manage diabetes. In addition, the report provides data on the growth of diabetes and major funding sources for diabetes programs by state. The goal of this report is to bring awareness to the diabetes epidemic and the need for ongoing funding and policy solutions.

Adult Diagnosed Diabetes Cases 1980 to 2015

30 25 Number in millions

20 15 10 5

1 9 8 0

1 9 8 1

1 9 8 2

1 9 8 3

1 9 8 4

1 9 8 5

1 9 8 6

1 9 8 7

1 9 8 8

1 9 8 9

1 9 9 0

1 9 9 1

1 9 9 2

1 9 9 3

1 9 9 4

1 9 9 5

1 9 9 6

1 9 9 7

1 9 9 8

1 9 9 9

Source: Centers for Disease Control and Prevention, https://www.cdc.gov/diabetes/statistics/prev/national/figadults.htm

2 0 0 0

2 0 0 1

2 0 0 2

2 0 0 3

2 0 0 4

2 0 0 5

2 0 0 6

2 0 0 7

2 0 0 8

2 0 0 9

2 0 1 0

2 0 1 1

2 0 1 2

2 0 1 3

2 0 1 4

2 0 1 5

WHAT IS DIABETES? Diabetes is a chronic disease resulting from either a lack of insulin production by the pancreas (Type 1 diabetes) or the body’s ineffectiveness in using the insulin produced (Type 2 diabetes, gestational diabetes and prediabetes). Insulin is a hormone produced naturally in the body that regulates blood glucose to maintain normal levels. Over time, increased levels of blood glucose can build up and cause a loss of energy and serious damage to the heart, blood vessels, eyes, kidneys and nerves.3 Type 1 diabetes is typically diagnosed in children and young adults. In Type 1 diabetes, the pancreas is not able to produce enough insulin. A daily injection of insulin

is required to regulate the amount of glucose in the bloodstream. Only five percent of people with diabetes have Type 1 diabetes. Individuals with Type 2 diabetes are unable to use insulin effectively, which is often referred to as insulin resistance. Initially, the pancreas will compensate by making extra insulin, but over time this will not be sufficient to maintain normal blood glucose levels.4 While Type 1 diabetes is not preventable, Type 2 diabetes is generally thought to be caused by a combination of genetics and risk factors such as obesity, diet and physical inactivity. And although Type 2 diabetes was previously limited to adult

populations, the number of cases among children is on the rise. Many health experts believe that the increase in childhood Type 2 diabetes correlates with the increase of obesity among children.5 In addition to Type 1 and Type 2, there are two additional classifications of diabetes called gestational diabetes and prediabetes. Gestational diabetes is a condition that can happen during pregnancy to women who did not previously have diabetes. Typically blood sugar levels are above normal, but still below regular diagnostic levels for diabetes. Women who experience gestational diabetes are at increased risk of developing Type 2 diabetes later in life and can face additional complications during their pregnancy. Children born to mothers with gestational diabetes are six times more likely to develop diabetes or prediabetes later in life. People diagnosed with prediabetes exhibit blood glucose levels higher than normal, but not yet high enough to be clinically diagnosed as diabetes. Prediabetes is sometimes referred to as “impaired glucose tolerance” or “impaired fasting glucose,” depending on the type of test used by the physician.6 Prediabetes also increases a person’s risk of developing Type 2 diabetes. Individuals with prediabetes are typically not aware of their condition, consequently they are unlikely to engage in measures to prevent the onset of diabetes.

ECONOMIC IMPACT OF DIABETES IN THE U.S. More than 30 million Americans were living with diabetes and 84 million were living with prediabetes in 2015, according to the latest CDC diabetes statistics.7 Not only is diabetes a long-term health concern if not managed properly, it is extremely costly as well. In a report by the University of Washington’s Institute for Health Metrics and Evaluation, health care spending on diabetes diagnosis and treatment totaled $101 billion in 2013, and has grown 36 times faster than spending on heart disease, the number one cause of death in the United States. The large

majority of the direct medical costs stem from inpatient hospital care, which accounts for 43 percent of all expenditures related to diabetes. Other costs include prescription medications, anti-diabetic agents, diabetes supplies, physician office visits, as well as nursing home or other residential facility stays.8 The total indirect cost of diabetes is estimated at $68.6 billion, according to 2012 American Diabetes Association research. These costs include lost productivity from absenteeism, reduced productivity at

work and at home, unemployment due to chronic disability, and premature mortality. The majority of this burden comes from unemployment due to permanent disability ($21.6 billion), lost productivity while at work ($20.8 billion), and premature mortality ($18.5 billion). Absenteeism due to diabetes ($5 billion) and reduced productivity for those not in the workforce ($2.7 billion) represent a relatively small portion of the total burden.9

Percent of U.S. Adults 18 or Older with Diagnosed Diabetes by State, 1999 to 2015

1999

3-4.9%

2004

5-6.9%

7-8.9%

9-10.9%

FEDERAL DIABETES PREVENTION INITIATIVES National Diabetes Prevention Program

After multiple studies demonstrated that structured lifestyle changes are effective in preventing Type 2 diabetes, the U.S. acted on this research to implement community prevention programs. In 2010, Congress authorized the CDC to establish and lead the National Diabetes Prevention Program, or National DPP. The program relies on a multi-level solution that includes community-based organizations, health insurers, employers, health care systems, academia and government agencies to focus on implementing low-cost interventions. Participants in this program are directed by a trained coach on how to

make healthy lifestyle changes to prevent or delay the progression of prediabetes to diabetes. Evidence shows that the program can reduce risk for diabetes by up to 58 percent.10 The National DPP programs are administered by a variety of local organizations, including YMCAs and local health departments. As the evidence of the effectiveness mounted, some state governments have added National DPP to employee health care benefits. According to the National Association of Chronic Disease Directors, 10 states offer coverage of a National DPP lifestyle change program including California, Colorado, Kentucky, Louisiana, Minnesota, New Hampshire, New Mexico, Oregon, Rhode Island and Washington.11

11%+

NACDD compiled a report in 2016 that outlined the steps taken by Colorado, Kentucky, Minnesota and Washington to establish coverage for state employees. Colorado, Kentucky and Washington cover face-to-face delivery of National DPP intervention programs, while only virtual delivery of the program is supported by Minnesota and Colorado.12 Medicaid programs in Minnesota and Montana—on a pilot basis—reimburse state-licensed DPP providers, with California becoming the largest state to include National DPP as a statewide Medicaid benefit beginning in July 2018. California appropriated $5 million to its Medicaid program, expecting $8 million of federal matching funds. The state expects to enroll 25,000 individuals each year. California’s Medicaid program expects to save over $45 million each year in reduced medical costs—more than three times the cost of the program—because of those who do not develop diabetes and require less medical treatment.13 In addition, Maryland and Oregon received CDC funding in 2016 to develop a sustainable coverage model of the

2009

2015

Source: Centers for Disease Control and Prevention, using the actual number of diagnosed cases. Age adjusted rates available through the CDC website, from https://gis.cdc.gov/grasp/diabetes/DiabetesAtlas.html

National DPP for Medicaid beneficiaries with prediabetes through managed care organizations and accountable care organizations. Findings from this study will be used to help NACDD develop a National DPP Diabetes Toolkit to help states map out similar coverage programs.14 The Employee Retirement System of Texas released a detailed report in 2016, estimating that 13 percent of its state employees have diabetes and that diabetes-related expenditures for this group make up 30 percent of the state’s health plan costs. The prediabetes population is estimated to be 124,000. Without intervention, which averages $251 per enrollee, it was projected that 2,900 people would develop diabetes in 2016 and cost the state employee health plan $12 million.15

Changes in Medicare Reimbursement for Diabetes Intervention

The Centers for Medicare & Medicaid Services, or CMS, proposes to expand the Medicare Diabetes Prevention Program, or MDPP, and provide reimbursement for eligible Medicare enrollees starting sometime in 2018. Diabetes dispropor-

tionally impacts older Americans and, as a result, accounts for a large portion of their health care costs. Approximately 1 in 4 Americans aged 65 or older has diabetes. The new expansion will enable organizations, including those new to Medicare, to prepare for enrollment into Medicare as MDPP providers. The core benefit of MDPP proposes a 12-month intervention that consists of at least 16 weekly hour-long sessions with approved MDPP coaches, and at least six monthly maintenance sessions. Beneficiaries have access to three-month intervals of ongoing maintenance sessions after the core 12-month intervention if they achieve and maintain the minimum weight loss of 5 percent in the preceding three months. This marks the first time that a preventive service model from CMS has been expanded.16 While the federal Medicare program has added DPP to its list of benefits because its effectiveness is proven, only three states—California, Minnesota and Montana—have added National DPP as a Medicaid-reimbursed benefit.

CALIFORNIA appropriated $5 million to its Medicaid program for diabetes prevention, expecting $8 million of federal matching funds. The state projects enrolling 25,000 individuals each year in a National DPP program. California’s Medicaid program expects to save over $45 million each year in reduced medical costs.

CDC GRANTS PROVIDED TO THE STATES FOR DIABETES CONTROL For more than 25 years, the CDC has funded diabetes programs in the states to monitor diabetes prevalence, implement and evaluate interventions, increase access to diabetes management programs, and promote public awareness. The backbone of CDC’s diabetes funding is support for state and local programs that strive to prevent diabetes and its complications. Through these grants, states can implement public health approaches that address a variety of diabetes risk factors. The CDC’s Division of Diabetes Translation provides a majority of the CDC funding to states under two large multi-program cooperative agreements. The main grant is titled “DP-1305 State Public Health Actions to Prevent and Control Diabetes, Heart Disease, Obesity and Associated Risk Factors, and Promote School Health

Cooperative Agreement.” This grant was established to help the states carry out work on diabetes, heart disease and stroke, nutrition, physical activity, obesity, and school health. All 50 states received DP-1305 grants in fiscal year 2016. The second grant is titled “DP-1422 State and Local Public Health Actions to Prevent Obesity, Diabetes, and Heart Disease and Stroke.” The second grant builds on and complements activities initiated under DP-1305 grants to fund state and large city health departments to help reduce or prevent obesity, Type 2 diabetes, heart disease, stroke and general health disparities. In fiscal year 2016, 17 states and four large cities received DP-1422 grants. Each state distributes half of the funds they receive under DP-1422 grants to support prevention in high-burden priority

populations with the largest disparities in high blood pressure and prediabetes. The CDC funding is the base for most states’ public health activities related to diabetes, although state legislators may choose to appropriate state funds directly for diabetes awareness, prevention and treatment programs.17 In addition to the DP-1305 and DP-1422 grants, CDC offers a variety of other competitive grants to states throughout the year. Grants include: DP-1421 A Comprehensive Approach to Good Health and Wellness in Indian Country; DP-1417 Partnerships to Improve Community Health, or PICH; and DP-1513 Behavioral Risk Factor Surveillance System, or BRFSS. A full list of grants is available on the CDC website.

STATE PROGRAMS SUPPORTING DIABETES PREVENTION AND MANAGEMENT Diabetes Action Plans

One way that states have drawn attention to diabetes challenges is through state legislation to require a Diabetes Action Plan. The fundamental intent is to require state officials from the department of health, the Medicaid agency and the state agency responsible for purchasing state employee health insurance benefits to come together to develop a report for the state legislature that reflects the financial and health impact of diabetes in their state. The legislation is designed to encourage different agencies within state government to collaborate on designing the report in a way that highlights the costs and burden of diabetes; documents current state activities that address the burden; and makes recommendations to legislators on evidence-based strategies that can be implemented to decrease the costs and burden. Currently, 14 states have developed diabetes action plans, and an additional four states have passed legislation requiring the development of a diabetes action plan for their state.18 Usually the state legislation requires an annual or biannual review of the plan and report to the legislature. In 1988, North Carolina created a special Diabetes Advisory Council to serve as an advisory group to the state’s Diabetes Prevention and Control program. This group helped to draft the Diabetes Action Plan for North Carolina, which establishes very specific measurements for success. In terms of prevention, they established a goal to increase the number of people enrolled in diabetes prevention programs from 740 (as of July 2015) to 5,000 and increase the number of public employees and retirees who can utilize diabetes prevention programs as a covered benefit from zero to 680,000 by 2020. For diabetes prevention and management, the Diabetes Action Plan is focused on at-

tracting people to diabetes self-management programs. North Carolina intends to increase the number of people with Type 2 diabetes enrolled in a diabetes self-management program from 36,000 to 50,000 and increase the number of people with Type 2 diabetes who have taken a diabetes class from 484,000 to 533,000 by 2020.19 For full details on North Carolina’s Diabetes Action Plan, visit http://www. diabetesnc.com.

Diabetes Funding Under the Medicaid Program

Medicaid—jointly funded by the states and the federal government—is the primary insurance program for low-income individuals in the United States, as well as a major source of funding for diabetes care in the U.S. Medicaid expenditures for care related to diabetes is not readily available data reported by states to the federal government, therefore CSG did not ask states to provide Medicaid spending data on diabetes. It is reasonable to assume that increases in clinical diagnoses of diabetes drive up Medicaid expenditures and some research studies confirm recent increased spending. A study completed by the American Diabetes Association, after the implementation of the Affordable Care Act, or ACA, found that Medicaid diabetes-related expenditures have increased. In the 31 states and the District of Columbia that expanded Medicaid eligibility under the ACA, there was a 23 percent increase in patients newly identified with diabetes as compared to only a .04 percent increase in the non-expansion states. The surge of new cases is likely a result of increased access to care for these Medicaid patients, resulting in earlier diagnosis of the disease.22

A 2015 report by the Office of the New York State Comptroller found that approximately 460,000 Medicaid recipients in New York diagnosed with diabetes received services costing more than $1.2 billion in state fiscal year 2014. This reflects a 31 percent—or $293.7 million increase—in diabetes-related expenditures for Medicaid patients over the five-year period ending in 2014.23 Maryland reported that the state’s Medicaid program covered on average twice as much in health care costs for people with diabetes than those without the disease. Maryland’s Medicaid program covered an average of $24,387 annually for each diabetes patient, compared to $10,880 for an individual without diabetes. Health Choice, who manages a large majority of the treatment for the state’s Medicaid population, covered $471 million for diabetes expenditures in 2014. These costs are a result of hospitalizations, physician visits and prescriptions.24

states have developed Diabetes Action Plans (Florida, Illinois, Kentucky, Louisiana, Mississippi, Missouri, New Jersey, North Carolina, North Dakota, Oklahoma, Oregon, Texas, Washington and Wyoming)20

states have passed legislation requiring development of a Diabetes Action Plan (Arkansas, Kansas, Ohio and Tennessee)21

STATE APPROPRIATIONS FOR DIABETES The Council of State Governments, in partnership with the National Association of Chronic Disease Directors, or NACDD, conducted a survey of all 50 states to learn whether states appropriated state funds toward diabetes prevention and management. The survey questions were limited to public health programs targeting the prevention and management of diabetes. The survey did not request data on the amount of Medicaid spending related to enrollees with diabetes nor the spending for active state employees or retired state employees. These last two categories of state spending are not specifically appropriated by state legislatures and would only be available if states specially aggregated expenditures for those with a diabetes diagnosis. Additionally, the survey gathered information from the states on innovative and successful programs developed to assist with diabetes treatment and management. CSG received responses from all 50 states. Half of the states reported appropriated state funds in fiscal year 2017 for diabetes programs or public health purposes that include diabetes. In 16 states, state funds were appropriated specifically to diabetes prevention and management, while 14 states allocated state funds for public health purposes that include diabetes. Five states had appropriations in both categories. The amount of appropriated state funds varied greatly, from $6.6 million in Colorado to $5,000 in South Dakota. In the states that designated money specifically for diabetes programming, six of them topped $1 million: Colorado at $6.6 million; Maryland at $3.2 million; Michigan at just over $1 million; New York at $5.9 million; North Carolina at $2.3 million; and Tennessee at $2.8 million. Among states appropriating funds for related public health purposes including diabetes, two states had funds over $1 million: Texas at $1.2 million and Kentucky at $2.3 million.

MAJOR FUNDING SOURCES FOR DIABETES PREVENTION & MANAGEMENT State

State Funds SPECIFICALLY Designated for Diabetes, Fiscal Year 2017

State Funds for Public Health Purposes that Include Diabetes, Fiscal Year 2017

Alaska

$170,000

$50,000

Arizona

$150,000

Colorado

$6,608,000a

Delaware

$284,000

$67,000

Georgia

$401,000

$30,000

Hawaii

$441,767

Kentucky

$2,270,000

Maine

$607,302

Maryland

$3,250,773

Massachusetts

$219,373

Michigan

$1,000,600

Missouri

$50,356

Montana

$768,725

$26,000

New Mexico

$977,505b

New York

$0 c

$5,970,000

North Carolina

$2,300,000

Pennsylvania

$100,000

Rhode Island

$60,000e

South Dakota

$5,000

Tennessee

$2,850,000

Texas

$505,227

$1,216,840

Vermont

$382,500f

Washington

$31,000g

West Virginia

$97,000

Wisconsin

$71,547

See page 15 for footnotes a-g.

SPOTLIGHT ON STATE DIABETES PROGRAMS

DELAWARE Creating Diabetes Support Groups

In 2016, 10.6 percent of adults in Delaware reported a diabetes diagnosis, according to the Delaware Behavioral Risk Factor Survey. To increase the number of people receiving formal education for their diabetes, the state offers free workshops through their Diabetes Self-Management Program, or DSMP, to caregivers and people with diabetes to manage the disease more effectively. Developed by Stanford University, the DSMP is evidence-based and workshops are held for two-and-a-half hours once a week for six weeks in both community and clinical settings. Caregivers or people with Type 2 diabetes attend the program in groups of 12 to 16. Workshops are facilitated from a highly-detailed manual by two lay trainers, one or both of whom have diabetes themselves. A completer certification is provided to those attending at least four of the six workshops. The program is designed to help people gain self-confidence with their ability to control

their symptoms and learn how their health problems affect their lives. Participants make individual action plans, share experiences and help each other solve problems encountered in creating and carrying out their diabetes self-management plan.25 Nearly half of all adults in Delaware diagnosed with diabetes took a class on how to manage diabetes in 2016, according to the survey response. From the DSMP program, there were 498 participants who completed four out of the six sessions and 726 that attended one to three sessions. Annual cost to operate this program was $136,900 in fiscal year 2016. Funding and support services were provided by the state of Delaware (both general funds and Health Funds/Tobacco Settlement Funds), Centers for Disease Control and Prevention, Delaware Medical Reserve Corp and the Delaware Division of Aging and Adults with Physical Disabilities.

KENTUCKY

Educating People on Diabetes Self-Management One unique intervention in Kentucky has been the creation of the Healthy Living with Diabetes, or HLWD, program which received accreditation status through the American Association of Diabetes Educators, or AADE, in January 2016. This program was developed through collaboration of many partners through the Kentucky Diabetes Prevention and Control Program, or KDPCP. The purpose of the HLWD program is to help people with diabetes make lifestyle changes to better manage their disease by focusing on the AADE7™ self-care behaviors, which include healthy eating, being active, monitoring blood sugar levels, taking medications, problem-solving for high and low blood sugars and sick days, healthy coping, and reducing risks for long-term complications. There are currently 14 fully accredited branches of the HLWD program in local or district health departments in Kentucky and more are in process. Since the inception of the program, HLWD has educated 744 Kentuckians with diabetes. Program outcomes measured include the A1C test (measures average blood glucose levels over the past three months), blood pressure, as well

as individual learning goals and behavior change goals. According to the American Diabetes Association Clinical Practice Recommendations, the A1C goal for most people with diabetes is less than 7 percent. Prior to participation only 47 percent of participants had an A1C less than 7 percent. After participating, the number at goal increased to 65 percent. Blood pressure levels also showed positive changes. HLWD participants are also asked to identify self-care behaviors they would like to improve and set at least one goal aimed at changing that behavior. On follow-up, it was demonstrated that 93 percent of all goals set were either achieved or showed some progress toward achievement. This is important, as positive self-care behavior changes lead to improved clinical outcomes and health status. HLWD is supported by both federal and state funds. Though support from both sources are important for program success, state funding is key to the program infrastructure as this offers support to local health departments to provide diabetes services within their communities.26

NEW YORK

Creating Healthy Schools and Communities Increasing physical activity and having access to healthy food can help prevent obesity and diabetes. The state of New York designed the Creating Healthy Schools and Communities program, or CHSC, to increase access to healthy, affordable foods and opportunities for daily physical activity in high-need school districts and their surrounding communities. The state awards grants to organizations that help schools establish nutritional standards and access to healthy food and improve access to physical activity. Grantees develop solutions that mobilize communities to increase access to healthy foods through healthy food retail, mobile produce sales, cooperative buying groups and food hubs. The Clinton County Health Department created the Better Choice Retailer program to increase access to healthy foods for their residents. They partnered with 10 retailers to change the mix of food and beverage offered, as well as the promotion of healthy items in the store. Retailers have

reported an increase in sales on healthy items and community members who are happy to have these healthier options available within their county. In addition, grantees develop plans that support the Complete Streets Act signed into legislation in 2011 requiring state, county and local agencies to consider the convenience and mobility of all users when developing transportation projects that receive state and federal funding. A “Complete Street” is a roadway planned and designed for better access and mobility of all roadway users of all ages and abilities. This includes pedestrians, bicyclists, public transportation riders and motorists. The incorporation of sidewalks, lane striping, bicycle lanes and paved shoulders makes it easier for people to get outside and increase their physical activity. CHSC awarded 25 grants funded by the state of New York, totaling over $5.9 million in 2017.

TENNESSEE Tackling Obesity to Prevent Diabetes

Obesity is a major risk factor for diabetes, so many states target obesity as a way to prevent diabetes. Project Diabetes, which began in 2007, is a state-funded initiative administered by the Tennessee Department of Health. Grants are awarded to community partners with a focus on reducing obesity to help prevent the development of diabetes. In the first year, $2.5 million was awarded, with plans to award $7.5 million over a three-year cycle. Tennessee currently has 36 community partners participating in the Project Diabetes program through these grants, reaching over 300,000 people in 2017.27 Projects follow the prevention goals and strategies identified in the report Accelerating Progress in Obesity Prevention: Solving the Weight of the Nation, issued by the National Academy of Medicine, formally known as the Institute of Med-

icine. To determine which projects are funded, Project Diabetes focuses on the first two goals of the report: 1) Make physical activity an integral and routine part of life; and 2) Create food and beverage environments that ensure healthy food and beverage options are the routine, easy choice. Murfreesboro City Schools received a grant for their Farm to School program, which gives students access to healthy, locally-sourced foods as well as education opportunities such as school gardens, tower gardens, cooking lessons and farm field trips. The Farm to School approach is part of a nationwide movement that helps children understand where their food comes from and the impact food has on their bodies, the environment and the community.

WEST VIRGINIA Teaching Children to Manage Diabetes

The SEARCH for Diabetes in Youth Study found that the rate of new diagnosed cases of Type 1 diabetes in youth increased by about 1.8 percent each year, and Type 2 diabetes increased even more quickly at 4.8 percent between 2002 and 2012.28 Diabetes must be managed on a daily basis, which can be challenging for children. Camp Kno-Koma was introduced in West Virginia to provide a safe environment for diabetic children ages six through 14 years old to teach them about managing their diabetes. The mission of the diabetes camp is to provide these children with a fun summer camping experience that also promotes self-confidence and important life skills needed to manage diabetes. The camp has physicians, nurses, dieticians, and other support staff on hand to provide medical supervision at all times. Campers take an active role in making decisions about their care under the supervision of the medical staff. Teachable moments intro-

duce campers to new diabetes skills or simply fine tune their existing skills.29 The camp continues to grow, with 135 children from six different states attending the camp last year. In 2016, 97 percent of campers said they learned something new and that camp helped them manage their diabetes. The funding for Camp Kno-Koma comes from a combination of business and personal contributions and state-funded grants. Major contributors include the Grand Encampment of West Virginia, The Health Plan, Lions Club of West Virginia, and West Virginia Delta Kappa. The camp also received in-kind supplies of over $50,000 in value from Eli Lilly, Sanofi, BD, and Novo Nordisk. With over $98,000 in operating costs annually, the camp relies heavily on donations to keep the camp running.

MAJOR FUNDING SOURCES FOR DIABETES PREVENTION AND MANAGEMENT State

State Funds SPECIFICALLY Designated for Diabetes, Fiscal Year 20171

State Funds for Public Health Purposes that Include Diabetes, Fiscal Year 20171

CDC DP-1422 Grants, State/Local Level, Fiscal Year 20162

CDC DP-1305 Grants, State Level Only, Fiscal Year 20162

Alabama

$521,771

Alaska

$170,000

$50,000

$331,812

Arizona

$150,000

$903,588

Arkansas

$826,793

California

$5,280,000

$1,422,661

Colorado

$6,608,000a

$811,530

Connecticut

$701,088

Delaware

$284,000

$67,000

$362,677

District of Columbia

$436,751

Florida

$1,116,458

Georgia

$401,000

$30,000

$442,080

Hawaii

$441,767

$1,375,406

$385,449

Idaho

$822,404

Illinois

$512,084

Indiana

$815,662

Iowa

$780,868

Kansas

$1,627,160

$701,088

Kentucky

$2,270,000

$794,763

Louisiana

$350,830

Maine

$607,302

$738,458

Maryland

$3,250,773

$1,760,000

$768,900

Massachusetts

$219,373

$1,760,000

$840,214

Michigan

$1,000,600

$1,760,000

$910,056

Minnesota

$1,760,000

$806,604

Mississippi

$780,239

Missouri

$50,356

$794,983

State

State Funds SPECIFICALLY Designated for Diabetes, Fiscal Year 20171

State Funds for Public Health Purposes that Include Diabetes, Fiscal Year 20171

CDC DP-1422 Grants, State/Local Level, Fiscal Year 20162

CDC DP-1305 Grants, State Level Only, Fiscal Year 20162

Montana

$768,725

$26,000

$718,095

Nebraska

$1,320,000

$708,506

Nevada

$401,463

New Hampshire

$310,180

New Jersey

$1,024,811

New Mexico

$977,505b

$359,293

New York

$5,970,000c

$3,519,286

$1,122,147

North Carolina

$2,300,000d

$1,760,000

$838,789

North Dakota

$412,281

Ohio

$1,758,559

$419,064

Oklahoma

$1,320,000

$404,042

Oregon

$856,806

Pennsylvania

$100,000

$1,392,796

$1,003,188

Rhode Island

$60,000e

$1,760,000

$736,752

South Carolina

$1,760,000

$936,854

South Dakota

$5,000

$313,987

Tennessee

$2,850,000

$874,737

Texas

$505,227

$1,216,840

$483,646

Utah

$1,760,000

$719,579

Vermont

$382,500f

$380,866

Virginia

$1,332,060

$779,900

Washington

$31,000g

$1,216,191

$859,436

West Virginia

$97,000

$365,866

Wisconsin

$71,547

$816,985

Wyoming

$316,271

Cash fund is from tobacco taxes collected under Amendment 35 to support grant programs to improve the health of people in Colorado. Amount is for 2016-2017 and varies year to year. A portion of this money each year supports implementation of the National Diabetes Prevention Program, Diabetes Self-Management Education, Medication Therapy Management, and other health systems changes related to diabetes. b

Appropriation comes from Tobacco Settlement funds.

Appropriation is used for both diabetes and obesity programs.

Fund was established several years ago to address a variety of health issues, and altered in 2016/2017 to support Diabetes Prevention Programs.

Appropriation is used for heart disease prevention, including diabetes as a risk factor.

Appropriation is used to fund the YMCA Diabetes Prevention Program, Stanford University’s Diabetes, chronic disease, chronic pain self-management programs, tobacco cessation and the Copeland Centers Wellness Recovery Action Planning. g

Appropriation is used to fund the creation of the Diabetes Action Plan, a biennial report that addresses the state of diabetes in Washington.

SOURCES: 1 CSG survey of statea diabetes programs, 2017 2 CDC’s Funded State & Local Programs to Address Diabetes. (2016, June 02), from https://www.cdc.gov/diabetes/programs/stateandlocal/cdcfunded.html.

METHODOLOGY This report was compiled from a combination of survey responses, online research and the assistance of many state government officials. The Council of State Governments worked in partnership with the National Association of Chronic Disease Directors, or NACDD, to disseminate and collect survey responses on state diabetes funding appropriations. NACDD members were asked to provide information on state general and nongeneral funds allocated for diabetes prevention and management in their state. The Council of State Governments obtained survey responses from the 50 states and the District of Columbia. Information was typically provided by diabetes program managers or chronic disease directors within each state’s health department. It is important to note that

some allocations include footnotes that provide additional details as to public health appropriations in the states and other purposes for which they may be used in addition to diabetes. Historical data regarding the number of adult diabetes cases in the United States through 2015 was obtained from the CDC website at cdc.gov/diabetes. Background information, diabetes definitions and associated risk factors were obtained from the American Diabetes Association website at diabetes.org. Any other program highlights or state level data were found online or obtained through the survey of the states. Additional resources are listed in the footnotes section.

ACKNOWLEDGEMENTS AUTHORS: Debra Miller, CSG director of health policy Emily McCarthy, CSG graduate fellow Daniel Ficker, CSG graduate fellow

The Council of State Governments would like to thank Novo Nordisk and Boehringer Ingelheim for providing support to prepare this report. We would also like to thank the National Association of Chronic Disease Directors, or NACDD, for their assistance in developing and distributing the state diabetes funding survey. Special thanks to Zarina Fershteyn, director of program evaluation at NACDD, and Ann Forburger, senior diabetes team consultant at NACDD, for their

partnership and technical expertise. We would also like to thank the community of state health officials that provided state budgetary information on diabetes programs within their states.

ABOUT CSG Founded in 1933, The Council of State Governments is our nation’s only organization serving all three branches of state government. CSG is a region-based forum that fosters the exchange of insights and ideas to help state officials shape public policy. This offers unparalleled regional, national and international opportunities to network, develop leaders, collaborate and create problem-solving partnerships. Gov. Kate Brown

OREGON CSG National President

Sen. Janet Petersen IOWA CSG Midwest Chair

Sen. Kelvin Atkinson NEVADA CSG National Chair

Senate Pres. Pro Tem Ron Richard MISSOURI CSG South Chair

Sen. Theresa Gerratana

Deputy Speaker Kevin Ryan

Sen. Sam Hunt

David Adkins

CONNECTICUT CSG East Co-Chair

WASHINGTON CSG West Chair

CONNECTICUT CSG East Co-Chair

CSG EXECUTIVE DIRECTOR/CEO

FOOTNOTES Centers for Disease Control and Prevention. National Diabetes Statistics Report: Estimates of Diabetes and Its Burden in the United States, 2015. Atlanta, GA: U.S. Department of Health and Human Services; 2015. 2 Dieleman JL, Baral R, Birger M, Bui AL, Bulchis A, Chapin A, Hamavid H, Horst C, Johnson EK, Joseph J, Lavado R, Lomsadze L, Reynolds A, Squires E, Campbell M, DeCenso B, Dicker D, Flaxman AD, Gabert R, Highfill T, Naghavi M, Nightingale N, Templin T, Tobias MI, Vos T, Murray CJL. U.S. Spending on Personal Health Care and Public Health, 1996-2013. JAMA. 2016;316(24):2627-2646. doi:10.1001/jama.2016.16885. 3 American Diabetes Association, from http://www.diabetes.org/diabetes-basics 4 Ibid 5 Prevalence of Type 1 and Type 2 Diabetes Among Children and Adolescents From 2001 to 2009, JAMA. 2014;311(17):1778-1786. doi:10.1001. 6 American Diabetes Association, from http://www.diabetes.org/are-you-at-risk/prediabetes. 7 Centers for Disease Control and Prevention, National Diabetes Statistics Report, 2017: Estimates of Diabetes and Its Burden in the United States, from https://www.cdc.gov/diabetes/pdfs/data/statistics/national-diabetes-statistics-report.pdf 8 Dieleman JL, Baral R, Birger M, Bui AL, Bulchis A, Chapin A, Hamavid H, Horst C, Johnson EK, Joseph J, Lavado R, Lomsadze L, Reynolds A, Squires E, Campbell M, DeCenso B, Dicker D, Flaxman AD, Gabert R, Highfill T, Naghavi M, Nightingale N, Templin T, Tobias MI, Vos T, Murray CJL. U.S. Spending on Personal Health Care and Public Health, 1996-2013. JAMA. 2016;316(24):2627-2646. doi:10.1001/jama.2016.16885. 9 Peterson, M. (2013). Economic Costs of Diabetes in the U.S. in 2012. Diabetes Care, 36(4), 1033-1046. doi:10.2337/dc12-2625 10 Diabetes Prevention Program (DPP), from https://www.niddk.nih.gov/about-niddk/research-areas/diabetes/diabetes-prevention-program-dpp. 11 Employees Retirement System of Texas, Offering a Type 2 Diabetes Prevention Program to State Employees. Aug. 31, 2016. http://ers.texas. gov/About-ERS/Reports-and-Studies/Reports-and-Studies-on-ERS-administered-Benefit-Programs/Type-2-Diabetes-Prevention-Program.pdf 12 National Association of Chronic Disease Directors, CDC-Recognized Lifestyle Change Programs for Diabetes Prevention A Matrix of Steps and Key Features for State Employees, February 2016, https://c.ymcdn.com/sites/chronicdisease.site-ym.com/resource/resmgr/Diabetes_Projects/ State_LCP_Coverage_Features_.pdf 13 Karlamangla, Soumya. With diabetes rising at alarming rate, California puts money behind prevention campaign. Los Angeles Times, July 11, 2017. http://www.latimes.com/local/california/la-me-ln-diabetes-prevention-20170711-story.html 14 Correspondence to CSG from Heather Hodge, Director for Chronic Disease Prevention Programs at YMCA of the USA. 15 Employees Retirement System of Texas, Offering a Type 2 Diabetes Prevention Program to State Employees. Aug. 16, 2016. https://www.ers. state.tx.us/About_ERS/Reports. 16 Medicare Diabetes Prevention Program (MDPP) Expanded Model, from https://innovation.cms.gov/initiatives/medicare-diabetes-prevention-program. 17 CDC’s Funded State & Local Programs to Address Diabetes. (2016, June 02), from https://www.cdc.gov/diabetes/programs/stateandlocal/cdcfunded.html. 18 Provided by the National Association of Chronic Disease Directors, 2016. 19 North Carolina Diabetes Advisory Council, North Carolina’s Guide to Diabetes Prevention and Management 2015-2020, from http://www.diabetesnc.com/downloads/1215/NCsGuideToDiabetesPreventionandManagment2015-2020_FINAL.PDF 20 Ibid 21 Ibid 22 Leonard, K. (2015, March 23). Diabetes Cases Surge in States That Expanded Medicaid, from https://www.usnews.com/news/blogs/data-mine/2015/03/23/diabetes-cases-surge-in-states-that-expanded-medicaid-under-obamacare. 23 Lovett, K. (2015, October 02). Spread of Diabetes Among Medicaid recipients cost NY $1.2B. Retrieved June 13, 2017, from http://www.nydailynews.com/news/politics/spread-diabetes-medicaid-recipients-cost-ny-1-2b-article-1.2383216. 24 McDanels, A, Cohn, Meredith. (2016, October 27). Baltimore Sun, from http://www.baltimoresun.com/health/blog/bs-hs-medchi-diabetesstudy-20161027-story.html. 25 Delaware, T. S. Diabetes and Heart Disease Prevention and Control Program, from http://dhss.delaware.gov/dph/dpc/diabetes.html. 26 Hogan, D. Diabetes Self-Management Key to Healthier Living with Diabetes, from http://chfs.ky.gov/NR/rdonlyres/32C282F0-D7D3-4973-AD764ED8790A5FC1/0/nr111016diabetes.pdf 27 Tennessee Department of Health, Project Diabetes, from https://tn.gov/health/article/project-diabetes. 28 Centers for Disease Control and Prevention, Rates of new diagnosed cases of Type 1 and Type 2 diabetes on the rise among children, teens, from https://www.cdc.gov/media/releases/2017/p0412-diabtes-rates.html 29 Camp Kno-Koma, from http://campknokoma.com. 1

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