Would Low-Cost Insulin Really Kill? A Magazine’s Clickbait Disaster

Last week, The Atlantic published an article on the insulin pricing crisis that outraged many in the diabetes community: Lowering the Cost of Insulin Could Be Deadly.

The clickbait hot-take headline seems to have been calculated to enrage as many people as possible. If so, it was a success. The title clearly implies that insulin costs should remain high, an opinion so aberrant as to strike most people as simply evil.

The author, Dr. Mike Rose, found himself fending off accusations of cruelty and stupidity on Twitter. It must have been a frustrating experience for him, because the article doesn’t really say anything of the sort.

What the Article Really Says

Readers who were able to stem their anger and read the article found an argument that wasn’t entirely unreasonable. I’ll summarize here:

Insulin is not the best treatment for type 2 diabetes, and is especially inferior to SGLT2 inhibitors and GLP-1 receptor agonists.
If insulin were made cheaper, it could cause more type 2 patients to use insulin and eschew those better drugs. This would lead to suboptimal outcomes in type 2 diabetes.
Because type 2 diabetes is ten times as prevalent, it’s possible that cheaper insulin would actually end more type 2 lives than it would save type 1 lives.
Insulin should be cheaper, but for the best possible public health outcomes, we also need cheaper SGLT2 inhibitors and GLP-1 receptor agonists, so that type 2 patients can choose the best possible drugs without undue financial burden.

It’s true that insulin is not the best treatment for type 2 diabetes. Although it is the most powerful correction we have for high blood sugar, insulin does nothing to address the root causes of type 2 diabetes, and can even exacerbate them by causing weight gain and increasing insulin resistance. Insulin also has an especially dangerous side effect: hypoglycemia.

But the premise of the article – that lower insulin prices would lead patients to substitute one treatment for the other – seems shakier. This idea was subjected to plenty of pointed criticism from readers that picked apart Dr. Rose’s assumptions and conclusions. Relatively few people with diabetes use SGLT2 inhibitors and GLP-1 receptor agonists, far fewer than diabetes authorities think ought to, because the price is sky high. Will even fewer use them if the cost of insulin gets capped? It’s not exactly clear that lower insulin prices will actually lead to deaths among patients with type 2 diabetes.

To be fair, the article also found plenty of praise, some of it from doctors and public health experts. And it’s tough to argue with the ultimate conclusion: that the best of all possible worlds is one in which all diabetes medications are inexpensive or free, and universally accessible to those who need them.

In the diabetes community, the callous clickbaity promotion of the article by The Atlantic still stings. Many were offended, especially those with type 1. Although the article begins with the plight of a patient with type 1 that has been forced to ration her insulin, many readers felt that the argument gave short shrift to the people that actually need insulin to live – not just people with type 1, but the minority of those with type 2 that truly require insulin to live.

Insulin affordability is an extraordinarily sensitive subject in the type 1 diabetes community – and rightfully so. Americans have died because they couldn’t afford their insulin, and a shocking one-quarter of patients that use insulin have rationed their insulin due to the high cost, a behavior that hastens the development of miserable complications and early death. And it’s not like this is a niche issue. Major politicians routinely decry the high cost of insulin. Heck, Netflix made the insulin affordability crisis the focus of a recent romance film.

Then again, the diabetes world is talking about Dr. Rose’s ideas right now, so maybe the inflammatory title did its job perfectly. Was that the idea in the first place?


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