Key takeaways:

• In 2026, many patients with diabetes have been hit with financial and access challenges.
• Healthcare professionals must be prepared for when a patient loses insurance coverage or can no longer afford care.

Patients with diabetes, especially type 1 diabetes or insulin-dependent type 2 diabetes, need regular access to care, and in 2026, that has become challenging for many.

Changes to Medicaid caused many patients to lose their insurance coverage, rising costs of goods such as food and gasoline have led some patients to reduce their spending on healthcare, and crackdowns related to immigration status have led some patients to stop coming to public places such as doctors’ offices.

Healio | Endocrine Today Editorial Board Member Anne L. Peters, MD, professor of medicine at Keck School of Medicine of University of Southern California, runs a diabetes clinic in East Los Angeles that serves many socioeconomically disadvantaged patients. She spoke to Healio about the work that must be done to enable high-risk patients with diabetes to survive if they are no longer able to afford healthcare.

“It’s as important to go backward safely as it is to go forward,” Peters told Healio. “We need survival skills for our patients, particularly for our most vulnerable patients, because I think everybody needs to say, OK, if you can’t be on the [advanced technology] system, here’s how we convert you back to fingersticks.”

Healio: To what extent are you seeing patients whose health insurance has been changed, worsened or lost recently?

Peters: Well, that’s a complicated question, because if they’ve lost their health insurance or changed their health insurance, I don’t get to see them. So, I don’t know they lost it, because there’s a lack of follow-up.

However, since January, there are people who had Medi-Cal, which is Medicaid elsewhere, who had their classification changed, so they no longer have their Medi-Cal, and they have something called Ability to Pay. These changes are just starting and will become worse over the next 6 to 10 months. On the new plan, only devices and treatments on the formulary are provided, which includes insulin, meters and strips, but not continuous glucose monitors or pumps.

In addition, people are having more trouble affording healthcare because the exchange policies for the people who were on the California state programs have changed so that they have to pay more or have a higher deductible. So, I’ve seen people struggle because insurance has either been lost or has become more expensive.

Healio: To what extent are you seeing patients who have financial concerns for other reasons, and what are some of those reasons?

Peters: I have seen people who have lost jobs. There has been a lot of job turnover. It kind of divides along the environment in which people work.

I’m a doctor and I don’t ask about immigration status. I just see people who need me, and they all need me because they have type 1 diabetes or complicated type 2 diabetes. But people have lost their incomes because they can’t go to the workplace because they’re afraid of U.S. Immigration and Customs Enforcement (ICE). So there’s been a lot of fear, and people therefore aren’t working like they once did, and that’s been hard.

In general, if you are of a higher income status, it hasn’t been as difficult, although in some cases insurance premiums are still higher, which can be limiting. But the cost of living has gone up — the price of gas and other goods are making people have to penny-pinch more. There are a lot more people that I see who seem to have less.

Healio: What kind of concerns are patients having about their treatments?

Peters: Well, they just simply can’t afford them. My problem, in a nutshell, is people with type 1 diabetes need insulin, otherwise they die. So they are worried about not being able to afford the kind of treatment they were on before — maybe an automated insulin delivery system — or they are afraid to come into clinic because they are afraid of being in a public place because they are afraid of ICE.

We have ICE agents near our clinic; they’re in the neighborhood. People often have to come into clinic to get the supplies they need. We try very hard to make sure people can get insulin. And I must say that the county of Los Angeles is doing a really good job at ensuring it. It may not be the kind of insulin they were on before. If they were on, say, degludec, a very long-acting insulin, they may have to take glargine. They may not be on what they were, but they may be on a less expensive version, or they may not be able to use a CGM or a pump.

But there are workarounds. We give them meters, and we’re trying to make sure everybody stays safe. Because you can’t not take your insulin. It’s not right.

However, we are seeing more people who end up, due to lack of insulin, or insulin rationing, in ketoacidosis in the hospital, which is problematic because obviously that has a human and a financial cost to it. And our emergency departments are filled to the brim due to people foregoing their usual care. We don’t want people to go into DKA to get their insulin from the hospital.

It is ironic that my wealthiest patients are paying up to $80,000 per year for high-end concierge care when others can’t afford basic health resources. For many others, as healthcare premiums go up, patients purchase plans with fewer benefits, which often limits affordable access to the diabetes supplies they need. So we are doing a lot of scrambling to make sure people can get the insulin and supplies they need.

Healio: How often are you having to adjust treatments based on insurance issues and/or affordability?

Peters: It is almost daily that I have to adjust based on access. But it is not the same for everyone.

I don’t want to say that everybody needs an adjustment, but there are increasing numbers of adjustments.

For the population of people with diabetes, there is more than glucose to focus on. I look at lipids and blood pressure and renal and cardiac function. Statins and aspirin are cheap. Many of the blood pressure medicines are inexpensive. So there are those medicines that I may be able to keep people on even if they can’t afford diabetes technology or the insulin they are used to. I am careful to make sure we are always giving people what they need for hypertension, dyslipidemia and the other nonglycemic modifiable risk factors.

Which means I don’t feel like patient care is a complete loss in the sense that I can do something. But what we are dealing with is constricting choices for the more expensive treatments.

Healio: How well have patients responded to these adjustments?

Peters: If you can’t afford continuous glucose monitoring, and you have to go back to finger sticks, it’s a big change. I think CGM makes you feel safe at night. When I started using CGM a lot in patients with type 1 diabetes and insulin-dependent type 2 diabetes, it gave people this feeling of relief because they were going to get an alarm if they went low. If you take that away, and they’re just doing finger sticks, it’s a harder ask of a patient, and it brings back the fear of nocturnal hypoglycemia.

However, you don’t sit around and talk about what you’ve lost. You talk about what you can do. This is very important.

I think people are adjusting, but, again, I don’t think it’s their first choice. And not everybody has to change. At the moment, there are people who are still on Medi-Cal who we can keep on their devices, even with prior authorization challenges. That’s an ongoing issue. It’s simply incumbent on us as healthcare professionals to make, at the very least, survival possible and to make it the best survival we can. Hopefully things will get better and we can make it easier for people to get healthcare and devices.

Healio: How much do you think endocrinology practices will change going forward in response to these trends?

Peters: Many of the people who lose or have less health insurance will lose access to specialists, and endocrinologists may not be able to see them. Which will result in more care for diabetes occurring in primary care or in urgent care clinics. The more we, as endocrinologists, can help create simple workarounds for blood glucose monitor use, insulin adjustments and even remote monitoring, the more we can help. Diabetes educators and community health workers can play an important role in keeping patients healthy. There are patient-facing organizations that can assist patients as well.

Healio: How mindful have you had to be of cost?

Peters: We have to be very mindful of cost. I have had a lot more pushback about concerning the costs of various supplies. It seems endless because of the way plans have changed and the way people get coverage. We have to focus now on what can we do more basically, and figure out where patients can get the treatments they need less expensively. For example, analog insulin still requires a prescription from a doctor, which can be difficult if someone doesn’t have a doctor. But there are a lot of ways to try to figure out more affordable insulins. And there are organizations and services that offer prescription savings coupons and discounts. We can help our patients find ways to get insulin for less.

Device companies are also becoming more aware of the problem associated with cost. And I know that some of the CGM companies are helping people who have lost access be able to access CGM less expensively, though it is still a cost. If you have food insecurity, you’re not going to be paying for CGM. But there are organizations who are trying to make treatments like CGM more affordable for people who are in a situation where they can’t get them through their health plans. I would encourage healthcare professionals to become aware of those resources and guide people to use them.

Unfortunately, we may lose our patients when they lose their healthcare, and then we can’t follow them. Which makes it imperative that people have backup plans for any situation. I always make sure people with diabetes have a meter, unexpired test strips and lancets. I make sure they have injectable insulin and a backup plan if automated insulin delivery systems fail or are not available. This plan should be communicated both with the patient and their primary care professional. These days, it is important for many people with diabetes to be prepared for some lapse in health coverage or affordability issues. As much as it troubles me to see people with diabetes lose access to the therapeutic approaches we promote as the most effective, such as automated insulin delivery systems, it makes me happy whenever we can still help.

For more information:

Anne L. Peters, MD, is professor of medicine at Keck School of Medicine of University of Southern California and director of the USC Clinical Diabetes Programs and runs diabetes centers in Beverly Hills and East Los Angeles, California. Peters can be reached at endocrinology@healio.com.