The policy is a top priority for Sens. Jeanne Shaheen (D-N.H.) and Raphael Warnock (D-Ga.), one of his party’s most vulnerable members up for reelection in November, and the push comes as many other Democratic proposals to lower health care costs — expanding Medicaid, extending Obamacare subsidies that are set to expire at the end of the year, and allowing the federal government to bargain down the price of certain drugs — remain on ice.
But while Democrats are anxious to campaign on a tangible win, the plan has drawn criticism from the right and the left, underscoring the challenges that lie ahead.
After weeks of grumbling from the health care industry, advocacy groups and fellow lawmakers that an insulin cap alone would do little to solve the underlying problem of high drug prices, Schumer said he’d combine the cap, championed by Warnock in the Senate and frontline swing district Reps. Lucy McBath (D-Ga.) and Dan Kildee (D-Mich.) in the House, with a bipartisan bill from Sens. Shaheen and Susan Collins (R-Maine).
The details of the Shaheen-Collins bill are still being negotiated, but Shaheen told POLITICO it will target pharmacy middlemen — known as pharmacy benefit managers — who negotiate the price of insulin and other drugs, and try to bring down the list price of insulin through a yet-to-be-determined mechanism.
“All you have to do is talk to people about the high cost of prescription drugs in general to know that this isn’t just an issue for people who have Type 1 and Type 2 [diabetes]. It’s an issue for anybody who is taking medications in any long-term way,” she said. “In addition to looking at out-of-pocket costs, which is very important, we also have to look at what’s really driving the price of insulin, which is really the PBMs and the way the rebate program works. We’ve got to get at that as well as looking at capping costs.”
Folding the bills together offers a sheen of bipartisanship and addresses some members’ concerns that the Warnock approach alone would simply shift the cost of insulin to insurers and taxpayers rather than lower it. But it also gives more fodder to opponents, including Republicans and powerful pharmaceutical industry players, who oppose government regulating the price of drugs.
Some lawmakers and progressive activists are also wary that focusing solely on insulin will sap momentum for the party’s broader social spending package, which the House passed last year but stalled in the Senate because of opposition from Sen. Joe Manchin (D-W.V.)
“Often, the problem we have in Washington, is that if we create a partial solution, we take away from the mission to create a complete solution,” Rep. Susan Wild (D-Penn.) told reporters on a recent call. “[The insulin bill] doesn’t help people who need other expensive medications … In general, it’s not enough.”
Democrats, who have seen many of their health care ambitions crushed over the past two years, are attempting to find a middle ground that can satisfy their base and garner at least 10 Republican votes in the Senate. A bill too narrow runs the risk of being deemed inadequate. Yet the more comprehensive it gets, the more forces are likely to mobilize against it, as Democrats recently experienced when trying to enact sweeping drug price reforms in President Joe Biden’s Build Back Better plan.
The powerful insurance industry, for instance, has already come out against capping out-of-pocket costs for insulin.
“Capping cost-sharing merely shifts costs for insulin — it doesn’t lower them,” said David Allen, a spokesperson for America’s Health Insurance Plans. “Rather than paying for their expensive drugs at the pharmacy counter, patients would pay for them through their insurance premiums and copays.”
The group did not respond to questions about the new plan to combine the out-of-pocket caps with other reforms to insulin prices.
Pharmacy benefit managers and drugmakers, who have successfully scuttled legislative attempts to enact changes, are also expected to push back against any policies that would impact their bottom line.
And many of the divisions that have stymied progress on drug pricing for years remain present. Though Shaheen and Collins insisted in a statement Monday night that “there is a bipartisan determination … to address soaring insulin prices,” some Republicans have suggested the lack of regulation has ultimately helped diabetic patients.
“Because we don’t control the price of insulin, we’ve had tremendous innovation in that space,” Sen. Pat Toomey (R-Penn.) argued during a recent Senate finance hearing. “What astonishes me is the inability of some of my colleagues to appreciate the impact that our actions today could have for the innovations 20, 30 or 40 years in the future.”
And with the 2022 midterms less than eight months away, those tracking the issue note that even Republicans open to the Warnock and Shaheen-Collins framework are shying away.
“They’re in a very uncomfortable position on it,” said Elena G. Tompkins, a lobbyist and former George W. Bush labor department appointee who focuses on health care issues. “There’s a lot of support for the issue, but there are Republicans who don’t want Democrats to see too many wins at this point.”
Some Democrats and progressive advocacy groups are hesitant as well.
Patients for Affordable Drugs, which has testified at hearings and been a key part of Democrats’ push for government negotiation of drug prices and other reforms on Capitol Hill for the past year, is worried that trying to pass a bill focused on the narrower issue will eat up time that could be spent on the party’s broader drug reform package that originally had the insulin cap as one of its key features.
“We must not take our eye off the ball,” said the group’s founder David Mitchell. “We have to focus like a laser beam on getting the bigger package through the Congress. That will require every bit of energy and effort to finish the job and we shouldn’t get distracted by a bill that’s already included in the bigger package.”
But members like Warnock, whose state has one of the highest rates of diabetes, according to the Centers for Disease Control and Prevention, argue that the uncertainty about the fate of Democrats’ more comprehensive health care reforms and the dire need for relief in the diabetic community make the case for a smaller bill first.
“Where is the need to lower the costs of prescription drugs clearer than in the case of insulin?” Warnock said on a call with reporters and advocates earlier this month.
Though the legislation could change in negotiations with Shaheen, Collins and other members in the coming weeks, Warnock’s bill would implement the out-of-pocket cap in October of this year, right before voters decide whether he should remain in office.
Advocates also point to data from the Health Care Costs Institute showing that insulin prices nearly doubled between 2012 and 2016. In fact, diabetics account for $1 of every $4 spent on health care in the U.S., according to the American Diabetes Association.
“While we work on a bigger fix, let’s make sure we don’t lose more people who are currently rationing their insulin,” Kildee said. “Because diabetes is so pervasive, because every family in America either has someone in the family or knows someone with the disease, we feel this is a moment that has arrived.”