Insulin Rationing in US Adults With Diabetes Risks

Nearly one in five U.S. adults using insulin report rationing their medication due to cost and access barriers1 . This practice is especially common among younger adults who often lack comprehensive insurance coverage, despite the rising prevalence of diabetes with age2 3. Insulin rationing poses serious health risks, including life-threatening emergencies and long-term complications, underscoring the urgent need for improved access to affordable diabetes medications4 5.

Dangers of Insulin Rationing

Insulin is a vital hormone that regulates blood sugar by enabling cells to absorb glucose for energy. People with type 1 diabetes (T1D) depend entirely on insulin for survival, while many with type 2 diabetes (T2D) require it to maintain glycemic control and prevent complications6 5. Despite this, insulin rationing—taking less insulin than prescribed, delaying purchases, or skipping doses—is reported by approximately 17–26% of adults using insulin in the U.S. 71.

Younger adults with diabetes are more likely to ration insulin due to cost and insurance gaps, while older adults, often covered by Medicare, report lower rationing rates despite higher diabetes prevalence2 3. Black Americans with diabetes also experience higher rates of insulin underuse and rationing, reflecting racial disparities in access8 .

The consequences of insulin rationing are severe:

• Diabetic ketoacidosis (DKA): In T1D, insufficient insulin leads to DKA, a dangerous condition where blood becomes acidic, causing dehydration, coma, or death9 1011.
• Acute hyperglycemic emergencies: Insulin omission causes high blood sugar, osmotic diuresis, and dehydration, increasing emergency room visits12 7.
• Chronic complications: Poor glycemic control from insulin underuse in T2D raises risks of kidney failure, cardiovascular disease, retinopathy, neuropathy, and hyperosmolar hyperglycemic state4 13.
• Increased hospitalizations and mortality: Studies link insulin rationing to higher rates of hospitalization and death, especially among those with T1D14 1516.

A 2021 National Health Interview Survey (NHIS) study found that 17% of insulin users reported rationing, with skipping doses associated with increased emergency healthcare utilization among younger adults7 . Older adults who rationed insulin had more urgent care visits, suggesting that adverse effects may manifest gradually and in less acute settings7 .

The psychological toll of rationing is also significant. Patients face stress and anxiety from managing life-threatening conditions with inadequate medication, which can further worsen glycemic control16 . Rationing often forces individuals to choose between insulin and other basic needs, severely limiting life choices17 .

“The high cost of this lifesaving drug is causing hardship and suffering for far too many Americans — 1.3 million Americans rationing insulin last year is outrageous.”

— Lisa Murdock, American Diabetes Association (ADA) 18

Improving Access to Diabetes Medications

The U.S. insulin market is marked by high prices and complex insurance coverage, leading to substantial out-of-pocket costs (OoPEs) for many patients, especially younger adults and those without public insurance2 19. Unlike many developed countries with regulated drug pricing, the U.S. lacks comprehensive price controls, contributing to insulin rationing20 .

• Medicare beneficiaries benefit from a federal $35 monthly cap on insulin costs starting in 2023, reducing financial strain for older adults21 .
• Many non-Medicare patients, including younger adults and those with private insurance, remain vulnerable to high insulin costs due to lack of coverage caps and high deductibles2 22.
• Public insurance coverage correlates with lower rates of insulin rationing compared to private or no insurance8 .
• Rising costs of private insurance and multiple diabetes medications add to the financial burden, prompting rationing22 .

Experts advocate for systemic reforms to improve insulin access:

• Price regulation: Implementing policies to control insulin prices could reduce patient costs and prevent rationing19 .
• Expanded coverage: Broadening insurance coverage and capping out-of-pocket expenses for insulin beyond Medicare populations is critical2 5.
• Simplified access: Reducing administrative barriers such as prior authorizations and improving pharmacy supply chains can facilitate timely insulin availability8 .
• Use of biosimilars: FDA approval of interchangeable biosimilar insulins offers potential cost savings and increased access19 .
• State-level initiatives: At least 20 states have enacted insulin copayment caps for non-Medicare patients, providing partial relief18 .

Worldwide, insulin access varies widely, with many low- and middle-income countries facing severe shortages and affordability issues5 23. The World Health Organization (WHO) emphasizes coordinated policy and health system improvements to ensure equitable insulin availability globally5 . In the U.S., racial and socioeconomic disparities persist, necessitating targeted interventions to address inequities in insulin access8 .

• Regulate insulin pricing to reduce patient costs19 .
• Expand insurance coverage and cap out-of-pocket expenses for all insulin users2 .
• Promote biosimilar insulin adoption to lower prices19 .
• Simplify insurance and pharmacy processes to prevent delays8 .
• Implement state and federal policies to protect vulnerable populations18 .