All About State-Based Insulin Price Cap Laws
Though the 2020 election season has passed, pressing issues like the importance of insulin price caps remains more relevant than ever as many states have yet to sign their own into law. Many people in and outside of the type 1 diabetes community beg the question—why has a nationwide insulin price cap not yet happened? While it is typically the overall goal of insulin price cap advocates to have the United States federal government take action, for now it is simpler to achieve at the state level.
This page covers the importance of insulin price caps state by state, where they stand today, and what you can do to help push the movement forward.
US states with existing insulin price caps
Within the US system, advocates and politicians alike have found more success at passing insulin-pricing bills into law at the state level than at the federal level. This strategy aims to create a groundswell at a state level, hopefully setting a precedent for a national price cap policy.
Since January 2020, ten states have implemented or passed various versions of insulin price cap legislation. Most of these price caps only apply to residents with certain kinds of private health insurance and each applies to those with healthcare plans renewed on or after January 1, 2021.
Very important to note is that NOT all private health insurance plans will be required to institute these price caps. These laws only apply to specific kinds of single-state healthcare plans, meaning if you work for a national or multi-state company that covers employees in multiple states, these single state price cap laws will not apply to you. Similarly, even if your company only operates in a single state, if they have created a self-funded healthcare plan, these price cap laws do not apply either. There are a lot of loopholes, but state-based price cap laws are still seen as a potential first step.
Colorado was the first state to pass an insulin price-cap bill, with a $100 monthly out of pocket copay maximum for those with insurance. Illinois, New York, Washington, and West Virginia’s legislation also caps out of pocket costs at $100 per month. Virginia caps out of pocket costs at $50 per month, Maine and Minnesota at $35, Utah at $30, and New Mexico at $25.
In Minnesota, where a price cap bill was signed into law in April, waves were made when pharmaceutical trade association PhRMA filed a lawsuit against the state to block the emergency access portion of the price cap legislation, which the state’s attorney general then struck down. In Tennessee, where price cap legislation has not yet been passed, the original proposed bill would cap out of pocket costs for insulin at $100 regardless of insurance coverage, but lobbying groups have approached legislators to constrict the price cap to those with commercial insurance.
Additional state-based insulin price cap bills are championed by local advocates and many have made their way onto Change.org’s Affordable Insulin movement page, which features more than one million signatures across 34 insulin-focused petitions. Official legislation is being discussed in more than 30 other states.
Will any other laws impact insulin costs?
For seniors on Medicare, yes! As of January 1, 2021, the Medicare Part D Senior Savings Model kicked in, capping some seniors’ monthly insulin copay at $35 per month. The program is opt-in and primarily applies to those who take insulin using pens or needles (insulin taken via insulin pumps is covered under Medicare Part B)—those who would like to be covered by a policy with the Savings Model in place are able to select an eligible plan during enrollment—either once one qualifies for Medicare or during open enrollment in the Fall.
For those not on Medicare, questions remain. Under the Trump administration, multiple Executive Orders were signed aimed at impacting drug pricing, but did not create any immediate or actionable change to insulin prices. In January 2021, the Biden Administration announced an intention to review the former administration’s actions to ensure they positively impacted patients, including a misunderstood freeze on 340B program drug pricing. Over the next few years, we can expect to see a variety of federal and state actions aimed at improving healthcare and lowering drug prices.
How far away are we from a national insulin price cap?
The real answer? It’s hard to say. Whether or not insulin pricing will be approached at the federal level in an actionable way is still unclear. But with many states working to cap the price of insulin, insulin price cap petitioners and advocates across the country have a clear goal in mind: get America on board.
Meanwhile, while broad systemic change is vital, insulin manufacturers have instituted a variety of stop-gap cost savings programs for people who rely on insulin. Each offers low- or no- cost insulin programs to people who earn less than 400 percent of the federal poverty rate (currently $51,040 for an individual or $104,800 for a family of four) as well as copay cards for those who do not qualify for other patient assistance programs.
How can I help?
The simple acts of being an advocate, spreading awareness and speaking about the issues that matter to you makes a big difference. Add your voice to current actions and sign up for updates from Beyond Type 1’s advocacy team. Keep the conversation alive. Participate in your local elections. Speak to your local government. Play an active role in your community. It only takes one person to set the foundation for change.