The Massachusetts health reform initiative enacted into law in 2006 continued to fare well in 2010, with uninsurance rates remaining quite low and employer-sponsored insurance still strong. Access to health care also remained strong, and first-time reductions in emergency department visits and hospital inpatient stays suggested improvements in the effectiveness of health care delivery in the state. There were also improvements in self-reported health status. The affordability of health care, however, remains an issue for many people, as the state, like the nation, continues to struggle with the problem of rising health care costs. And although nearly two-thirds of adults continue to support reform, among nonsupporters there has been a marked shift from a neutral position toward opposition (17.0 percent opposed to reform in 2006 compared with 26.9 percent in 2010). Taken together, Massachusetts’s experience under the 2006 reform initiative, which became the template for the structure of the Affordable Care Act, highlights the potential gains and the challenges the nation now faces under federal health reform.

Justices could leave the Affordable Care Act intact, in shambles, or somewhere in between—and just months before the 2012 presidential election.

The rising tide of diabetes has an unacceptable human and societal toll. Rates of all major forms of diabetes are increasing at enormous individual and societal cost: 8.3 percent of the US population is afflicted today, and financial costs reached $174 billion for 2007. A major cause of blindness, renal failure, amputation, and cardiovascular disease, diabetes also increases the risk of cancer and dementia and more than doubles individual health care costs. Control of glucose, blood pressure, and lipids improves outcomes. Yet diabetes management is nonetheless suboptimal, particularly in disproportionately affected poor and minority populations. Safer, less burdensome, and more personalized approaches to therapy are needed. People at high risk for type 2 diabetes must be identified if society is to realize the benefits of therapies proven to delay or prevent the disease. We have many of the tools we need to address this challenge, and we must apply them now.

Between a fifth and a third of US adults will have diabetes by midcentury, up from one in ten now, according to a government estimate. We project that over the next decade, around 40 million adults could have diabetes and 100 million could be diagnosed with its clinical precursor, prediabetes. Related health care spending could reach $512 billion annually in 2021. Evidence-based interventions can curb diabetes and its clinical complications, but little has been done to implement them on a wide scale. What’s needed, among other measures, are new risk-assessment methods to identify subpopulations that will benefit most; the enrollment of consumers in new care models that support and encourage lifestyle change; partnerships with pharmacists, nurses, and health coaches; and new programs in Medicare and Medicaid that encourage patient engagement and lifestyle change.