Policy influences practice. Without advocacy, we would not have Diabetes Self-Management Training as a Medicare benefit, RDNs would not be able to bill as providers, Medicare would not have a $35 insulin copay cap, and we would not have as strong of CGM coverage as we do today.
—ADCES Director of Advocacy Hannah Martin, MPH, RDN
State advocacy is critical for advancing access to DSMES and other cardiometabolic treatments, technologies, and medications. ADCES members working together through their State Coordinating Body (CB) are the lifeblood for this work within the association, with training and support from staff and national leadership to identify priority issues and fruitful partnerships within the state.
To increase the acumen of members on state advocacy, ADCES hosted its first ever State Policy Forum in September 2024. Over 200 advocates attended, with registrants hailing from 49 states, Washington, D.C., and the U.S. Virgin Islands.
The event focused on Medicaid and covered 3 areas of care where many states need improvements in their Medicaid coverage policies:
Diabetes self-management education and support (DSMES)
Continuous glucose monitors (CGMs)
Obesity medications
While ADCES continues to advocate for expanded access to Medicare Diabetes Self-Management Training (DSMT) benefits at the federal level, parallel efforts are essential across state Medicaid programs. Coverage of DSMES across state Medicaid programs is highly variable. Although current data are not readily available on the percentage of Medicaid beneficiaries with diabetes who access DSMES in the first year after diagnosis, rates among people with Medicare or private insurance range from 5% to 6.8%.
The critical first step in developing an effective DSMES benefit begins with assessing current coverage and examining whether it allows DSMES access for all beneficiaries with diagnosed diabetes at the 4 critical times without lifetime limits. All accredited and recognized programs should be eligible to participate as Medicaid providers, including via telehealth. Additionally, barriers such as group-only care and narrow referral criteria should be minimized.
CBs and their Grassroots Coordinators are poised to be leaders in this space, with DCESs being the ultimate experts in how DSMES coverage criteria translate into access to care. Connecting with tenured volunteers to help gain insight into what has been previously tried in your state and fostering partnerships with other CBs that have pursued similar changes in their state are also important for developing an effective advocacy strategy. Advocates will also want to identify other organizations in the state who can join forces to create a coalition of voices.
CGM technology has revolutionized diabetes management and is now included as part of evidence-based guidelines. However, access remains limited for many Medicaid beneficiaries. And across states that do cover CGMs to some extent, coverage policies can be highly variable.
Although coverage has improved in recent years, some states still limit CGM access to certain populations based on the type of diabetes they have or whether they are using insulin. There are also differences in how CGM benefits are administered, such as whether CGMs are covered as durable medical equipment, under the pharmacy benefit, or both. At this year’s forum, resources (table format or map and coverage details) were provided that showed the current state of CGM coverage, as of August 2024, across state Medicaid programs.
Coverage variability remains high due to the unique ways in which each state determines its Medicaid coverage policies. A wealth of advocacy strategies were outlined for CBs who want to pursue improvements to their state’s Medicaid CGM benefit. These practical strategies included an overview of the different policy consideration processes that states typically use and what it looks like for advocates to interface with those systems, what level of preparation is recommended, recommendations for organizations to partner with, and opportunities to work directly with managed care organizations.
Recognizing the close link between obesity and diabetes, advocates discussed efforts to improve Medicaid coverage for obesity treatments. Over 85% of adults with diabetes have overweight or obesity. The American Diabetes Association’s Standards of Care recommend person-centered treatment for obesity that includes intensive behavioral therapy, obesity medications, and bariatric/metabolic surgery. Unfortunately, access to comprehensive obesity treatment, especially to the most effective obesity medications, is lacking across state Medicaid programs.
Unique barriers affect access to obesity treatment, including low rates of formal diagnosis, limited provider knowledge on treatments, and weight-related stigma and bias. These factors and more contribute to poor coverage across many public and private insurers and low utilization even when coverage is available.
Unlike other Medicaid benefit determinations that often default to occurring through a regulatory or administrative process, states are more commonly relying on state legislatures to authorize the coverage of obesity medications. Therefore, the strategies outlined were significantly different from the strategies most likely to be employed for DSMES or CGM coverage advocacy. Due to the shortcomings of coverage across the continuum of care for obesity, advocacy in this area uniquely addresses counseling, medication, and surgical coverage simultaneously rather than the siloed, benefitspecific advocacy that is common when addressing other coverage policies. Coalition efforts are anticipated in 2025 in New York, Maryland, Virginia, Florida, Texas, Colorado, Tennessee, West Virginia, Washington, and Oregon.
The top theme of the policy forum was the importance of partnerships. DCESs bring a unique perspective, and a diversity of advocates are needed to impress upon policymakers the importance of good coverage for Medicaid beneficiaries. The different experiences of these grassroots advocates also underscored that sometimes advocacy looks like taking up the helm and convening a group of like-minded individuals and organizations, whereas other times, it means contributing at key moments while others lead the way. Identifying how individual DCESs and CBs can be most effective is a key first step in any state advocacy work.
The ADCES advocacy state policy forum provided a wealth of information and strategies for improving diabetes and obesity care through policy changes and underscored that DCESs play an important role in this work. By understanding the policy landscape, building coalitions, and sharing personal stories and expertise, advocates can help ensure that everyone with diabetes and obesity has access to the care and tools they need to live healthy, fulfilling lives.
Whether you’re new to advocacy or a seasoned veteran, there are always opportunities to make a difference. Your voice and experience could be the key to unlocking better diabetes care for millions of people with or at risk of diabetes. Readers are invited to view the full recording of the ADCES 2024 State Policy Forum for free and to stay updated on future advocacy training opportunities via the Advocacy Forum on ADCES Connect.
The 2025 State Policy Forum will focus on Medicaid coverage of the Diabetes Prevention Program and automated insulin delivery systems, among other issues. Keep an eye on ADCES communication channels for announcements about the fall 2025 date and registration information.
This year’s state policy forum highlighted a few of the ways DCESs across the country can advocate and make their voices heard on these critical issues:
State Coordinating Bodies (CBs) are poised to be leaders in advocating for increased access to DSMES. Contact your CB’s Grassroots Coordinator or Chair to get involved.
Partnerships are crucial in advancing Medicaid advocacy to support diabetes prevention and treatment. Identify other local organizations who you can join forces with to create a coalition of voices.
Stay informed on what’s new and moving in the space by attending events like the ADCES State Policy Forum and keeping up with reputable news sources.
Subscribe to the Advocacy Forum on ADCES Connect to hear about registration for the 2025 State Policy Forum.
Teresa Martin, MS, RDN, LD, CDCES, is the clinical educator for the DM Education Program at Novo Nordisk based in Bend, Oregon. Hannah Martin, MPH, RDN, is the director of advocacy with ADCES based in Washington, DC.
The authors declare having no professional or financial association or interest in an entity, product, or service related to the content or development of this article.
The authors declare having received no specific grant from a funding agency in the public, commercial, or not-for-profit sectors related to the content or development of this article.