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Thomas Smith, M.D., has been an internist and endocrinologist in the Twin Cities for 30 years and currently practices for HealthEast Care System.


A middle-aged patient with diabetes is assisted onto the exam table. Short of breath and nauseated, she is also complaining of pain in her feet. This is the third time I have seen her in six months. Each time I tell her that if she would take her insulin regularly, much of her discomfort would be eased. 


"It's hard to get to the pharmacy every month and sometimes I just can't afford it," she explains. Though I am sympathetic, she was hospitalized twice last year because she failed to take her insulin. I know there is more both of us can do to stop it from happening again. 


We have a pivotal opportunity right now in Minnesota to make sure these all-too-common cases become a relic of the past. In implementing the Affordable Care Act, the state can and should require insurance companies to more actively cover the management of chronic conditions like diabetes, heart disease and hypertension. Insurance companies need to work with care systems to determine how best to manage chronic disease and completely cover those interventions and medications that are likely to promote good health and reduce expensive hospitalizations.


If insurance companies and health systems provide, without copays, a supply of insulin to every Minnesotan with diabetes, hospital admission rates would drop, quality of life would improve and the health care system would save money in the end. In addition, because diabetic patients often have other chronic diseases, the management of those would be simplified. This is not a revolutionary idea, but it is one we can implement immediately for Minnesotans who purchase individual and small group health coverage. 

Gov. Mark Dayton created the Health Care Reform Task Force

 to advise him on implementing the law. One section of the law establishes state Health Insurance Exchanges that, starting in 2014, will sell subsidized health insurance to Minnesotans who earn below 400 percent of the federal poverty level, or about $88,000 for a family of four. The state and the task force have wide authority to decide what the health plans inside and outside of our state exchange cover. 


The management of chronic diseases like diabetes must be included. 


By 2014, the number of adult Minnesotans eligible for Medicaid will more than double, and another 250,000 will be eligible for subsidies to purchase insurance in the exchange. Many cost-savings ideas would produce better results for these patients and for all Minnesotans — we just need to be open to hearing them. 


No matter the future of the Affordable Care Act, soon gone will be the days when sicker patients mean higher reimbursements for hospitals and doctors. Systems of care must and will be paid by how they keep Minnesotans healthy, not how many tests they run on them. It is no secret that 

actively managing a patient's chronic conditions

 is the cheapest and easiest way to keep him out of a hospital bed or clinic. 


In his executive order creating the task force, Dayton noted that "Minnesota is a national leader in health care innovation." As the group focuses on its three goals of better health care, lower costs and healthier communities, I hope it considers the everyday health needs of patients who require the most help. A little insulin can go a long way.

For Affordable Care Act, a prescription: Cover chronic illness

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