Public Health Strategies for Diabetes Policy Brief

Key points

  • About 38 million people in the United States have diabetes.
  • Diabetes is the eighth leading cause of death in the U.S. (and may be underreported).
  • Diabetes Self-Management Education and Support (DSMES) provides evidence-based education to teach patients the knowledge and skills they need to manage their diabetes.
Woman Various Ages Stretching before Workout


Diabetes Self-Management Education and Support (DSMES) provides evidence-based education to teach patients the knowledge and skills they need to manage their diabetes. DSMES may reduce health care costs associated with hospital admissions, readmissions, and complications while improving health outcomes for participants.1

Diabetes is about 17% more prevalent in rural areas than urban ones. Despite this higher prevalence, CDC researchers found that 62% of rural counties do not have a DSMES program.

A variety of individual, provider, and environmental factors influence access to and use of DSMES by people who live in rural areas. These factors may include:2

  • Cost of DSMES to providers and patients.
  • Lack of access due to low availability or uneven distribution of DSMES programs, or insufficient staffing.
  • Patient barriers including lack of transportation and lower income.

These challenges may be different than those faced by people who live in urban areas.

Policy Options

These are some potential policies and practices that may help rural residents access DSMES.

Private and Public Insurance Coverage

Forty-one states and the District of Columbia require some level of private insurance coverage of DSMES. Providing coverage through private insurance may improve access to DSMES, but some state laws allow insurers to put in place requirements such as preauthorization and cost-sharing, which may limit access for patients.3

Research has shown that expanding Medicaid coverage for DSMES may create financial benefits for states. For example, New York State compiled cost savings estimates for reimbursing DSMES based on the evidence that Medicaid beneficiaries who take part in DSMES are better able to control their blood sugar.

Medicare covers DSMES when delivered by programs recognized by the American Diabetes Association (ADA) or accredited by the American Association of Diabetes Educators. Some of the requirements for recognition or accreditation, such as having a certified diabetes educator (CDE) on staff, may be more challenging in rural areas and could limit the number of DSMES programs that are eligible for Medicare coverage.

Nontraditional Delivery Methods and Venues


Telehealth may offer one way to help more patients benefit from DSMES as an option for the traditional outpatient service conducted at a hospital/health facility. One study found that both telehealth and face-to-face interventions may be effective for rural DSMES participants.4

There are barriers to widespread adoption of DSMES telehealth interventions. For example, in order to qualify for Medicare reimbursement, there are limitations on where patients can receive telehealth services. In addition, states have substantial flexibility in determining which telehealth services Medicaid covers.

Community-based Settings

Providers can also consider creating in-person programs that take place outside of the typical health care setting. The Community Guide recommends that adults with type 2 diabetes receive DSMES interventions in community gathering places, such as community centers and libraries. It is recommended that the care is coordinated with the patient's primary care physician and along with education provided in a clinical setting.

Addressing Patient Challenges and Barriers

Lack of Transportation

People who live in rural areas often report that lack of transportation "one of the major concerns that limit their access to health care or their participation in health programs." Telehealth programs may help with this challenge, but individual DSMES programs can also consider other options to help patients. Some diabetes management programs have found that coordinating patient travel and putting in place flexible scheduling may help with transportation challenges.

Lower Income

The overall cost of managing diabetes could make individuals with lower incomes less likely to participate in DSMES. Some patients who have diabetes may already struggle to cover the equipment and supplies necessary to manage their diabetes.5 The added cost of paying for DSMES out of pocket, either because the patient does not have insurance or due to insurance cost-sharing requirements, could be a barrier to participation. Some research suggests that reducing or eliminating the costs to DSMES patients could improve patient access while also producing cost savings for insurers.6

Case Studies

Montana Quality Diabetes Education Initiative

With the goal of increasing the number of CDEs and accredited programs, the Montana Diabetes Control Program and the Montana chapter of the ADA created a mentorship program for CDEs, as well as a technical assistance program for facilities interested in becoming recognized or accredited in order to receive Medicare reimbursement. From 2000-2016 over 130 health care professionals have signed up for the self-study and peer-mentoring program. As of March 2016, Montana has 37 recognized or accredited DSMES programs, as well as 87 CDEs, with almost half practicing in rural or areas of the state.7

Arkansas Diabetes Prevention and Control Program

Funded by CDC, the Arkansas Diabetes Prevention and Control Program is intended to "reduce and prevent the burden of diabetes in Arkansas." In 2001, the program brought together public and private partners to establish 12 DSMES programs in underserved counties with a high prevalence of diabetes. The program recruited facilities to participate and provided resources for the programs to begin seeing patients and eventually obtain ADA recognition. As a result of the project, 11 DSMES programs received ADA recognition. From February 2003 to March 2004, DSMES participation increased 138%, and program participants improved both their preventive care practices and health outcomes.8

  1. Powers, M. A., Bardsley, J., Cypress, M., Duker, P., Funnell, M., Fischl, A. H., .Maryniuk, M., Siminerio, L., & Vivian, E. (2015). Diabetes Self-Management Education and Support in Type 2 Diabetes: A Joint Position Statement of the American Diabetes Association, the American Association of Diabetes Educators, and the Academy of Nutrition and Dietetics. Journal of the Academy of Nutrition and Dietetics, 115(8), 1323-1334. doi.
  2. Rutledge SA, Masalovich S, Blacher RJ, Saunders MM. Diabetes Self-Management Education Programs in Nonmetropolitan Counties — United States, 2016. MMWR Surveill Summ 2017;66(No. SS-10):1–6. DOI.
  3. ChangeLab Solutions. (2016). National Landscape: Background, Benefits, and Insurance Coverage of DSME/T [PDF -796 KB]
  4. Lepard, M. G., Joseph, A. L., Agne, A. A., & Cherrington, A. L. (2015). Diabetes Self-Management Interventions for Adults with Type 2 Diabetes Living in Rural Areas: A Systematic Literature Review. Current Diabetes Reports, 15(6), 608
  5. Warren, J. C., & Smalley, K. B. (Eds.). (2014). Rural Public Health: Best Practices and Preventive Models. New York: Springer Publishing Company.
  6. Garfield, K. (2015). Reconsidering Cost-Sharing for Diabetes Self-Management Education: Recommendations for Policy Reform
  7. Montana Chronic Disease Prevention & Health Promotion Bureau. (2016). Quality Diabetes Education Initiative
  8. Balamurugan, A., Rivera, M., Jack, L., Morris, S., & Allen, K. (2006). Barriers to Diabetes Self-Management Education Programs in Underserved Rural Arkansas: Implications for Program Evaluation. Preventing Chronic Disease, 3(1), A15.