It’s no secret that insulin prices in the United States are shockingly high, a situation that has outraged people both with and without diabetes. Many politicians have thrown their support behind supposedly comprehensive national solutions, but little real progress has resulted. For many of us with diabetes, the out-of-pocket cost of insulin just keeps going up.
In some parts of the country, though, it’s getting better. There are now about twenty states that have passed laws capping insulin copays.
Make no mistake — these laws, while encouraging, do not solve the insulin pricing crisis. The typical insulin copay cap only applies to a minority of people with diabetes, and misses two important groups:
People without insurance still have to pay the full sticker price.
Copay caps only affect the out-of-pocket cost of insulin for patients with the good fortune to have medical insurance.
While only a small minority of Americans with diabetes lack health insurance, that minority must include some of the most vulnerable and disadvantaged members of our community, including many of those that have been driven to ration their insulin, a dangerous and potentially deadly practice.
Some advocates have suggested that copy caps actually do more harm than good by hiding “the actual price of insulin from privileged patients with private insurance,” thereby diluting support for legislation that could meaningfully help those without insurance.
Some states, such as Minnesota, have passed laws directly addressing the plight of the uninsured, but people without insurance have mostly been left behind in the flurry of new legislation.
People with non-state insurance do not have their copays capped.
The insulin copay caps discussed in this article largely apply only to state-regulated insurance — that is, insurance purchased through a private insurer that has to follow certain rules set by the state. But about two-thirds of Americans with employer-sponsored health insurance are in a different type of plan referred to as self-insurance plans. These plans are organized by businesses themselves (especially by larger employers) and are exempt from insulin copay caps on state-regulated insurance.
Also exempt: Medicare and Medicaid recipients, who luckily already have their copays capped by the federal government.
The end result is that a small number of people actually benefit from these state copay caps. In some places, it’s a very small number. In Illinois, for example, where about 50 percent of residents are not eligible for any savings, a state report found that 97 percent of those on private insurance already spend less than $100 per month. That means that an insulin price solution touted as comprehensive may only provide benefits for something like 1.5 percent of the population. It’s better than nothing, but far from the solution that the diabetes community needs.
The States with Insulin Copay Caps
With all those warnings out of the way, here is the list of states that have passed laws capping copays for insulin and other diabetes supplies, as of this writing in late 2022:
Colorado caps insulin copays at $100 per month; some residents are eligible for a program that caps co-pays at $50 per month.
Connecticut caps insulin copays at $25 per month and caps diabetes devices and supplies at $100 per month.
Delaware caps insulin copays at $100 per month.
Illinois caps insulin copays at $100 per month.
Kentucky caps insulin copays at $35 per month.
Minnesota has not passed a copay cap for those with state-regulated insurance but has enacted a law capping copays for uninsured and underinsured patients with an emergency need of insulin.
New Hampshire caps insulin copays at $30 per month.
New Mexico caps insulin copays at $25 per month.
New York caps insulin copays at $100 per month.
Oklahoma caps insulin copays at $30 per month.
Rhode Island caps insulin copays at $40 per month.
Virginia caps insulin copays at $50 per month.
West Virginia caps insulin copays at $35 per month. It also caps cop-pays for diabetes devices and supplies at $100 per month and copays for insulin pumps at $250.
Washington caps insulin copays at $100 per month.
Washington, D.C. caps insulin copays at $100 per month and caps copays for diabetes devices at $100 per month.
Many states have similar laws in the works — for a more complete look at proposed and pending insulin legislation, check out this summary from our friends at diaTribe.
Progress Stalled on a National Solution
Although practically all Americans agree on the need for federal action to reduce insulin prices, progress is currently stalled on the issue. This summer, the Senate rejected a new law that would have limited what Americans with private insurance paid for insulin.
At the same time, the Senate approved an element of the same bill that will limit the maximum that Medicare recipients would pay for insulin. Beginning in 2023, those on Medicare will pay a maximum of $35 per month for insulin.
It’s unclear what will happen next at a federal level, especially with the House of Representatives changing hands in 2023. Prominent politicians from both parties have proposed or supported new national copay limits; some, such as Senate Majority Leader Chuck Schumer, have spoken clearly about the need for a bill that will help the uninsured as well as the insured. But the history of national efforts on this issue is not at all encouraging.