Capping insulin costs would benefit patients on individual and small group plans

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There are several legislative proposals in Congress, some stalled and some nascent, that would propose a $35-a-month cap on what insured Americans would pay out-of-pocket for insulin — and that cost cap would benefit about 25% of those in the individual and small group markets and about 20% of those in large employer-sponsored plans.

That’s according to a new analysis from the Kaiser Family Foundation, which comes as congressional Democrats renew the push for a $35 insulin cap that was included in the stalled Build Back Better Act. This bill passed the House but got bogged down in the Senate.

The measure would require insurers, including private plans and Medicare Part D plans, to charge no more than $35 per month for insulin products, which can save the lives of people with diabetes. Private group or individual plans should cover at least one dosage form of each type, such as a pen-vial, and each type of insulin, from fast-acting to ultra-long-acting and premixed. Cost sharing would be limited to a maximum of $35 per 30-day supply of each type.

Among enrollees in the individual and small group markets taking insulin, more than one in four (26% and 31%, respectively) paid more than $35 per month on average for insulin in 2018. registrants receiving cost-sharing assistance were less likely to incur insulin costs that averaged more than $35 per month.

Additionally, one in five insulin users with broad employer coverage — which tends to have lower deductibles and copayments — spends more than $35 on average per month.

With a per-product cap on insulin costs, KFF found that the savings in many cases could be substantial: more than 1 in 20 insulin users whose costs currently exceed the insurance markets cap private pays more than $150 per month per insulin product.

This means that the median monthly savings for people in the individual market would be $27, with 25% of those patients saving at least $71. In the small group market, the median savings would be $19, and a quarter would save at least $48; in the large group market, the median savings would be $19, with a quarter saving at least $42.


Cost sharing is often used in health insurance plans to encourage patients to make cost-effective choices about medical care and prescription drugs. But one of the findings from KFF is that cost sharing can be a barrier to getting needed care. In 2020, about one in six adults said they delayed or did not get medication because of cost, or skipped medication to save money.

Increasing barriers to accessing needed medications can sometimes result in decreased drug use and increased cost of hospitalizations and emergency department visits.

Reducing direct cost sharing for insulin means that payers and insurers would cover a greater share of the costs, but some of those costs could be offset by better medication adherence and lower hospitalization rates, a declared KFF.

Importantly, a cap on direct insulin costs would not address underlying insulin prices, with unit prices for the drug being seven times higher in the United States than in peer countries, according to KFF analysis.


The Build Back Better Act, although stalled, was just one of many pieces of legislation that have been proposed to tackle insulin spending. In April 2021, Sen. John Kennedy, R-La., introduced the Ending Pricey Insulin Act, and in February of this year, Sen. Raphael Warnock, D-Ga., launched the Affordable Insulin Now Act.

According to KFF, Senate Majority Leader Chuck Schumer, DN.Y., recently hinted that bipartisan talks are underway, led by Senators Susan Collins, R-Maine, and Jeanne Shaheen, DN.H., to combine Warnock’s bill with policies to lower current insulin prices. In 2019, Shaheen and Collins co-sponsored the Insulin Price Reduction Act, which proposed to limit insulin price growth.

Biden broached the topic of insulin prices during his recent State of the Union address, saying it costs about $10 per vial to produce, but typically costs 30 times that amount.

PhRMA countered that insulins are cheaper today than they were in 2007. Citing data from the Bureau of Labor Statistics, Pharmaceutical Research and Manufacturers of America said prescription drug prices rose only 1.3 % over the past year.

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