An All-Of-Government Approach To Diabetes: The National Clinical Care Commission’s Report To Congress

While the COVID-19 pandemic has grabbed the headlines over the past two years, these headlines have told only a part of the story of health in the United States. One untold story is that the US is facing an “acute on chronic” syndemic. Both COVID-19 and type 2 diabetes are overwhelming our health system, contributing to premature morbidity and mortality, and generating significant disparities in health across race, ethnicity, income, and education. 

Adult diabetes prevalence has increased from 5.3 percent in the late 1970s to 14.3 percent in 2018, with rates now nearly two-fold higher among people of color and those living in or near poverty. More than 40 percent of Americans will develop diabetes during their lifetimes. Most concerningly, rates of type 2 diabetes—a disease previously believed to exclusively affect adults—have exploded among youth of color. Furthermore, diabetes increases individuals’ susceptibility to communicable diseases including COVID-19. Epidemiologists and clinicians have observed potent interactions between the two. For example, half of all COVID-19-related hospitalizations are attributable to diabetes and obesity, and individuals with poorly controlled diabetes have a two-to-three-fold higher risk of death from COVID-19.

In addition to this clinical synergy, there are other parallels between the two diseases related to the social and environmental conditions that facilitate disease “transmission” and generate disparities. While there is a growing recognition that one’s social position influences one’s risk of acquiring and dying of COVID-19, it is not widely appreciated that the same is true for type 2 diabetes.

In addressing the COVID-19 pandemic, it has become clear that both a biologic form of herd immunity (wherein a majority of individuals have acquired protection from infection via immune system factors) and a socioenvironmental form of herd immunity (wherein a majority of individuals live and work in protective social and environmental conditions that prevent infection or sickness) can contribute to population health. In fact, addressing unhealthy social and environmental conditions is a sine qua non for developing this kind of “societal herd immunity” that can improve population health and reduce health disparities in both communicable and non-communicable diseases. The US must develop this new kind of herd immunity, whereby resistance to the spread of poor health in the population occurs when a sufficiently high proportion of individuals, across all racial, ethnic, and social class groups, are protected from and thus “immune” to negative social determinants. This perspective on improving the public’s health, however, has not been part of the mainstream conversation among policy makers when it comes to the diabetes epidemic. To date, the US has not integrated an “all-of-government” approach to its longstanding efforts to prevent and control diabetes.

The National Clinical Care Commission

Nearly 50 years ago, the federal government commissioned its first report on diabetes. Released in 1975, “The Long-Range Plan to Combat Diabetes” was impactful, but its focus reflected the belief that diabetes was a biomedical problem requiring a biomedical solution. Indeed, the Long-Range Plan led to a number of important advances in diabetes-related science and care. For example, Congress significantly increased its support of diabetes-related biomedical research, especially at the National Institutes of Health. This support helped advance, for example: a controlled trial of glucose control in type 1 diabetes that demonstrated the effectiveness of blood sugar control for the prevention of eye, kidney, and nerve complications; the Diabetic Retinopathy Study and the Early Treatment Diabetic Retinopathy Study, which demonstrated the value of laser photocoagulation to prevent progression of diabetic eye disease; and the establishment of diabetes research and training centers across the country.

The biomedical research capacity that developed from the Long-Range Plan has also led to advances in pharmacotherapy such as newer medications that not only lower blood glucose levels but prevent costly cardiovascular and kidney complications. Finally, the Long-Range Plan helped to establish the Centers for Disease Control and Prevention’s (CDC’s) Diabetes Control Program, which has played a major role in ensuring accurate disease surveillance.

Despite clinical progress in the national battle to combat diabetes, the number of people with diabetes in the US is increasing; improvements in the management of diabetes have stalled; the number of people with diabetes experiencing life-threatening complications is growing; and disparities in prevention, treatment, complications, and survival persist. As our understanding of diabetes has increased, it has included a recognition that social and environmental conditions shape diabetes risk and disease trajectory. And yet, the national diabetes strategy has not been updated—until now.

In 2017, Congress passed Public Law 115-80, establishing the National Clinical Care Commission (NCCC) to advise Congress and the Department of Health and Human Services (HHS) regarding how to leverage and coordinate federal policies and programs to prevent and control diabetes. On September 30, 2021, the NCCC submitted its report to the Department of Health and Human Services, and on January 5, 2022, the report was submitted to Congress.

The Commission was composed of 23 members: 12 individuals from non-federal public- and private-sector organizations and 11 representing federal agencies. Members were experts in diabetes epidemiology, public health, clinical care, patient advocacy, health policy, and regulatory matters. Over the course of its three years, the NCCC conducted 12 public meetings, numerous additional sub-committee meetings and met with many key informants. The NCCC developed a novel framework to guide its recommendations, integrating elements of the socioecological and chronic care models through a health equity lens (exhibit 1).

Exhibit 1: The National Clinical Care Commission Framework for Diabetes Prevention and Control

Source: The National Clinical Care Commission.

The report makes evidence-based recommendations related to: diabetes prevention and control at a general population level, diabetes prevention among individuals at high risk, and treatment and prevention of complications among individuals with diabetes. Recommendations were endorsed by the full Commission using a consensus process. Key recommendations of the NCCC and the specific agencies to which they are directed are described below. While some recommendations are novel, others have previously been made by other entities but have not been implemented. None of the recommendations in the NCCC report have previously been made through the deliberations of a congressionally charged Commission.

Diabetes Prevention And Control At The General-Population Level

Diabetes is not simply a health condition that requires medical care but a societal problem that requires a trans-sectoral, all-of-government approach. Adverse social and environmental conditions—operating through stress-, behavior-, access-, and toxin-mediated pathways—increase the risk of type 2 diabetes and make controlling diabetes more challenging. Disproportionate exposure to such conditions results from upstream factors including poverty, structural racism, historical oppression, and marginalization. Some of these conditions and factors are within the purview of federal policies and programs. Diabetes prevention and control efforts would benefit greatly from engagement of non-health care-related federal agencies that influence food, housing, the workplace, and the built and ambient environments.

The Food Environment

The NCCC recommended that the US Department of Agriculture (USDA) enhance the Special Supplemental Nutrition Assistance Program (SNAP) by assessing and increasing SNAP benefits, providing incentives for the purchase of fruits and vegetables, and eliminating sugar-sweetened beverages (SSBs) as allowable purchases. The USDA should enhance the Special Supplemental Nutrition Program for Women, Infants, and Children and expand the summer nutrition and fresh fruit and vegetable programs for school-age children. The USDA should further harness the National School Lunch and Breakfast Programs to improve dietary quality and collaborate with the Departments of Education and the Interior, and the Environmental Protection Agency (EPA) to ensure access to safe, appealing, and free drinking water, and prohibit the sale of calorically dense and nutrient-poor foods and beverages in schools. The USDA should be provided with resources to promote the sustainable production, supply, and accessibility of “specialty crops” (fresh fruits, dried fruits, vegetables, and tree nuts).  

To influence industry practices and consumer behaviors, the NCCC recommended that the Food and Drug Administration (FDA) implement a compulsory front-of-package icon system to inform consumers of the health attributes and risks of foods and beverages, improve its nutrition facts label to enable consumers to interpret added sugar content, and update its policies and regulations to prevent health claims on foods and beverages that mislead consumers. To reduce children’s exposure to and consumption of calorie-dense, nutrient-poor foods and beverages, the Federal Trade Commission should be provided with the authority, mandate, and resources to create rules regarding the marketing and advertising of foods and beverages to children younger than 13 years of age, monitor industry practices, and enforce such rules.

The NCCC recommended that the US Surgeon General issue a scientific report that synthesizes the evidence linking SSB consumption with type 2 diabetes. The Treasury Department should impose an excise tax on SSBs to cause at least a 10 percent increase in their shelf price; revenues should be re-invested in diabetes prevention and control in communities that bear a disproportionate burden of diabetes.

The Workplace

Breastfeeding reduces the risk of diabetes in mothers and is associated with lower odds of obesity and diabetes in offspring. The Department of Labor should expand protections for breastfeeding mothers in the workplace, disseminate resources to help employers comply with federal laws, and implement a monitoring system. Congress should enact maternity leave legislation to provide mothers with at least three months of paid leave to increase breastfeeding initiation and duration.

The Built Environment

The Department of Housing and Urban Development (HUD) should expand housing opportunities for low-income individuals and families in health-promoting environments and broaden implementation of indoor smoke-free policies to prevent diabetes complications. The Department of Transportation and HUD should modify their policies, practices, regulations, and funding decisions to enhance walkability, green space, physical activity resources, and active transport opportunities. Priority should be given to projects that mitigate the effects of unhealthy built environments on diabetes-related disparities.

The Ambient Environment

The EPA should ensure that protections are in place to limit exposures to environmental pollutants associated with diabetes and its complications including air pollution, water contamination, and endocrine-disrupting chemicals. The EPA should implement abatement measures to reduce such exposures, prioritizing exposures that contribute to diabetes-related disparities. Special attention should be paid to ensuring all Americans have access to fresh and uncontaminated tap water.

Prevention Of Type 2 Diabetes In High-Risk Individuals

Intensive behavioral lifestyle interventions and medications can delay or prevent type 2 diabetes. Federal efforts should increase awareness of prediabetes, the Centers for Medicare and Medicaid Services (CMS) should reimburse hemoglobin A1c testing for prediabetes, and the FDA should approve metformin for diabetes prevention. Financial incentives should be provided to state Medicaid programs to cover the National Diabetes Prevention Program (DPP) as a benefit. CMS should make the Medicare DPP a permanent benefit, expand coverage to include virtual delivery, and remove the “once in a lifetime” limit on participation. Finally, consistent with provisions of the Affordable Care Act, private insurers should be required to cover CDC-recognized National DPPs for people with prediabetes, including in-person, on-line, and telehealth delivery methods.

Improving Diabetes Treatment And Preventing Complications

CMS and the Health Resources and Services Administration should ensure that funding for graduate medical education and workforce programs create the workforce needed to provide team-based care for people with diabetes, especially in underserved areas. CMS should use its rulemaking authority to regularly evaluate and update eligibility requirements for diabetes supplies and equipment including those for self-monitoring blood glucose, continuous glucose monitoring systems, and insulin pens and pumps. CMS determinations should consider both glycemic and non-glycemic health benefits. CMS should ensure that eligibility, documentation, and reimbursement requirements are clearly defined and consistently applied by Medicare administrative contractors and auditors.

Congress should enable negotiation of drug prices and remove cost barriers to ensure that insulin is affordable for all people with diabetes. HHS should establish a task force to review and rate the relative value of specific secondary and tertiary preventive services for diabetes. Using guidance from that task force, HHS should mandate pre-deductible coverage of high-value treatments and services without coinsurance or copayments. Such services might include diabetes self-management education and support, intensive behavioral lifestyle interventions for type 2 diabetes, supplies for self-monitoring of blood glucose, continuous glucose monitoring systems, insulin, antihyperglycemic medications with health benefits for individuals with kidney and cardiovascular disease, and retinal examinations.

Overarching Recommendations

Trans-Agency Engagement And Coordination

An Office of National Diabetes Policy (ONDP) should be established to oversee trans-agency collaboration, implement a comprehensive national diabetes strategy to prevent and control diabetes, and promote health equity. The ONDP should oversee the implementation and monitoring of the NCCC’s recommendations; ensure action, collaboration, and coordination among federal agencies; make recommendations to the executive and legislative branches to advance a health in all policies agenda with respect to diabetes; and provide resources to develop health impact assessments for relevant policies and programs across non-health-related agencies and departments.

Access To Health Care

Federal policies and programs must be designed to ensure all people at risk for and with diabetes have access to comprehensive, high-quality, and affordable health care. No one at risk for or with diabetes who needs health care should have to go without it because of cost.

Health Equity

Achieving health equity must be a component of all federal policies and programs affecting people at risk for and with diabetes. Federal agencies should consider and evaluate the impact on health disparities of all new, revised, and selected existing policies and programs that affect diabetes prevention and control. Federal agencies should collect and use data to assess the impact of their policies and programs on health disparities and modify policies and programs as needed to reduce disparities.

An Untapped Opportunity

While some nations are affirmatively addressing diabetes through trans-sectoral governmental activities, to date, the US has not. What little work has been done to facilitate trans-agency action around diabetes has been of a pilot nature and has lacked scale. The US does not have the adequate structures, policies, and practices necessary to coordinate strategic planning across health and non-health agencies. This deficit represents an untapped opportunity to leverage efforts of a range of federal agencies to achieve outcomes called for in the NCCC charter.

The NCCC’s report to Congress and HHS is the first on this topic in nearly 50 years. Its guiding socioecological framework—and the recommendations that flowed from it—represents a substantive shift in how the federal government can address the diabetes epidemic. How clinicians and public health experts understand the diabetes epidemic has evolved since the last federal diabetes report was issued in 1975. The critical importance of unhealthy social and environmental conditions is now widely acknowledged.

While adopting the report’s recommendations could significantly reduce diabetes incidence, complications, and costs in the US, such a frameshift means that substantial political resolve will be needed to translate recommendations into policy. Some of the NCCC recommendations would require new legislation; others, however, require only administrative action (for example, rulemaking) at the level of the agency or department; still others (for example, mandating front-of-package labelling) may require input from the judicial branch.

As a result of the COVID-19 pandemic, we believe that policy makers, and more and more Americans, are recognizing how social and environmental conditions shape health, and many have begun to reckon with the consequences of the nation’s failure to implement an all-of-government approach to disease prevention and control. By recommending a health in all policies and an equity-based approach to governance, the NCCC report has the potential to contribute to meaningful change across the diabetes continuum and beyond.

Authors’ Note

We acknowledge with gratitude other members of the National Clinical Care Commission who helped develop and author the 2021 Report to Congress on Leveraging Federal Programs to Prevent and Control Diabetes and Its Complications.

Drs. Schillinger and Bullock served as co-chairs of The National Clinical Care Commission and Dr. Herman served as chair.  The authors received no financial support to participate in the Commission. Drs. Schillinger and Bullock report no conflicts of interest. Dr. Herman serves on a Data Safety and Monitoring Board for Merck Sharp & Dohme. He is an Advisor to the National Committee for Quality Assurance HEDIS Diabetes Measurement Advisory Panel.

The National Clinical Care Commission was supported through a Joint Funding Agreement of seven agencies: NIH, CDC, HRSA, OMH, AHRQ, IHS and FDA.

The funders had no role in the preparation, review, or approval of this manuscript or the decision to submit the manuscript for publication. This paper does not represent the official views of HHS or the federal government.