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KFF: $35 MONTHLY INSULIN COST CAP COULD BENEFIT 1 IN 4 AMERICANS IN INDIVIDUAL,
SMALL GROUP PLANS

By Robert King Mar 24, 2022 08:00pm
Kaiser Family FoundationChuck SchumerAffordable Care Act (ACA)Ron Wyden

A $35-a-month cap on insulin costs could benefit 1 in 4 Americans in an
individual or small group plan, according to new findings from the Kaiser Family
Foundation. ((Getty/Samara Heisz))

A $35-a-month cap on out-of-pocket insulin costs could benefit more than 1 in 4
Americans on the individual and small group markets and 1 in 5 in large
employer-sponsored plans, a new analysis found. 



The analysis, published Thursday by the Kaiser Family Foundation, comes as
Democrats are working to renew efforts to install a $35 out-of-pocket monthly
cap on insulin costs that had been a part of the stalled Build Back Better Act.

“With a $35 per month cap on out-of-pocket insulin costs per product, savings
could be substantial in some cases for people who use insulin,” the analysis
said. 



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Kaiser looked at 2018 enrollee data for all individual and small group
Affordable Care Act plans sold on and off the exchanges. It also looked at
claims data from that year from people who had large employer coverage using IBM
MarketScan data.

Overall, the analysis explored 110 million out of 160 million Americans with
private insurance. Kaiser added that about 1 million people among those studied
got an insulin prescription filled in 2018.

Researchers looked at how many enrollees paid more than $420 a year
out-of-pocket on insulin, which is the average of $35 a month.



It found that 26% in the individual market and another 31% in the small group
market paid more than $420 a year. The large employer market had only 19% of
people who paid more than that figure annually, as this group tends to have
lower deductibles and copayments.


RELATED

Class-action lawsuit alleges 4 drugmakers colluded to restrict insulin sales to
340B contract pharmacies

Low-income ACA Marketplace enrollees receiving significant cost-sharing
assistance were less likely to have out-of-pocket insulin costs averaging over
$35 per month.

Private and group plans are required to cover at least one of each dosage form
of insulin and one of each type of insulin, such as short-acting or
intermediate-acting types. 

The analysis comes as lawmakers are trying to resurrect the $35 cap, which has
gotten bipartisan support before. 



The cap, however, was included as part of the $1.75 trillion Build Back Better
Act that passed the House last year and remains mired in the Senate after
objections from Sen. Joe Manchin, D-West Virginia.

Sen. Raphael Warnock, D-Georgia, has been championing legislation to resurrect
the insulin cap, and Senate Majority Leader Chuck Schumer said during a press
conference Wednesday that making insulin more affordable was a “top priority.”

He added there is a bipartisan effort to package legislation installing a cap
with “additional policies to drive down the list price in a more comprehensive
way including having the uninsured protected.”

Schumer expects to bring the legislation up for a vote later this spring after
the Easter Senate recess.

It remains unclear whether Democrats will use the legislation to advance other,
more controversial policies such as giving Medicare the power to negotiate for
lower drug prices. Sen. Ron Wyden, D-Oregon, emphasized during a hearing in the
Senate Finance Committee last week that granting Medicare negotiation power was
a major priority.

FinanceRegulatoryPayersDrug Pricesinsulin

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