Reform still needed for insulin
Executive summary
The 2026 American Diabetes Association Standards of Care accelerate access to diabetes technologies—removing C‑peptide and autoantibody prerequisites and recommending earlier use of CGM and automated insulin delivery (AID) systems—which promises clinical benefit but does not eliminate widespread affordability gaps for insulin and its delivery tools [1] [2] [3]. Federal drug law changes have capped insulin cost-sharing for many Medicare beneficiaries and Congress is debating narrower private‑plan protections for young people, yet significant populations remain exposed to high out‑of‑pocket insulin costs and documented nonadherence driven by price [4] [5] [6].
1. What actually changed: technology-first guidance, fewer clinical gatekeepers
The ADA’s 2026 Standards prioritize technology as a cornerstone of modern diabetes care, explicitly reducing administrative and biological hurdles to pumps and AID—removing requirements for minimum C‑peptide, islet autoantibody status, or fixed durations on insulin before CSII or AID initiation—and elevating CGM and AID for many people with both type 1 and type 2 diabetes [1] [2] [3]. The guidance reframes eligibility around insulin use and individualized needs rather than diabetes “type” alone and expands recommendations for CGM in pregnancy and for people on basal insulin who remain above glycemic goals [1] [2] [7].
2. The affordability reforms that exist: Medicare caps and targeted legislative proposals
On the price side, the Inflation Reduction Act established a meaningful cap on monthly insulin cost‑sharing for Medicare Part D enrollees—limiting payments to the lesser of $35, 25% of a maximum fair price, or 25% of a negotiated price for selected drugs—and kicked off Medicare drug price negotiations beginning in 2026 [4]. Separately, a House bill aims to require private group plans to cover selected insulin products with constrained cost‑sharing for enrollees 26 and younger starting in 2026, a targeted but age‑limited measure [5].
3. Why those reforms aren’t enough: coverage gaps and persistent affordability‑driven nonadherence
Even with Medicare protections and pilot private‑plan proposals, large groups remain exposed: people with commercial plans that don’t offer the capped products, the uninsured, and those on plans with high deductibles or formulary restrictions can still face crippling insulin costs—circumstances tied to 15–19% nonadherence attributed to affordability in recent analyses cited by guideline summaries [6] [4]. The ADA standards’ tech emphasis improves clinical pathways and device eligibility, but expanded device access does not by itself reduce the sticker price of insulin or the out‑of‑pocket burden that drives rationing [1] [8].
4. What reform still seems needed — policy and practice priorities supported by the reporting
The reporting makes clear two parallel reform tracks remain necessary: first, broader affordability protections beyond Medicare—such as durable limits on insulin copays across commercial plans, stronger price‑negotiation reach or pricing transparency—because IRA protections are specific to Part D and legislative proposals like H.R.2636 are narrow in population scope [4] [5]. Second, implementation reforms to pair technology access with affordability and equity supports—insurance coverage for CGM/AID and training, addressing social determinants, and aligning care teams to translate device data into actionable plans—since the ADA frames technology uptake as a core strategy but notes the need for professional support and shared decision‑making to realize benefits [2] [6] [9].
5. Trade‑offs, stakeholders, and where reporting signals friction
The ADA and allied clinical commentaries push for rapid tech adoption and fewer clinical gatekeepers to empower personalized care, which benefits patients clinically but raises fiscal questions for payers and manufacturers about who will shoulder device and drug costs [1] [3] [8]. Policymakers have enacted partial cost relief for Medicare and are examining limited private‑plan protections, but the reporting indicates a political and fiscal boundary to sweeping universal caps—leaving debates over negotiation scope, formularies, and age‑ or program‑targeted solutions unresolved [4] [5].
Conclusion: reform still needed — but more targeted now
The 2026 ADA Standards materially reduce clinical barriers to better insulin delivery and monitoring [1] [2], and federal action has capped insulin cost‑sharing for many Medicare beneficiaries [4], yet the evidence and policy briefs cited show persistent affordability‑driven nonadherence and notable coverage gaps for younger people, those outside Medicare, and the uninsured [6] [5]. The result: clinical reform has advanced; financial reform lags and must broaden beyond current, piecemeal protections if the promise of the new standards is to be fully realized across the population [1] [4] [5].