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$35 Insulin Cap for Private Sector Blocked From Budget Reconciliation Bill

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While efforts to cap monthly insulin costs for Medicare patients at $35 survived a budget reconciliation bill in the Senate, Republicans blocked the measure from extending to the private sector.

After a 15-hour amendment process, the US Senate passed a budget reconciliation bill for a long-awaited climate, tax, and health care package. However, one measure that Democrats initially pushed for was missing from the final bill: insulin caps for patients enrolled in private health insurance.

The Inflation Reduction Act of 2022 (HR 5376) passed with a 51-50 vote, with all Democrats voting in favor and every Republican dissenting. Democratic senators were able to keep the majority of changes proposed by Republicans out of the final bill. However, some changes were made to allow the full package to move forward.

The aim of the bill was to help address the ongoing issue of inflation, which has been raising prices of goods and services around the world; by increasing job creation; raising taxes for big corporations and hedge funds, investing in initiatives to address climate change; and some health care provisions. The $739 billion package will expand some health care programs under the Affordable Care Act and allow the government to have a direct role in negotiating drug prices with companies, which will hopefully lower prescription drug costs.

“This bill caps seniors’ out of pocket spending for prescription drugs at $2000 per year – no matter what their drug bills would otherwise be, seniors will not have to spend more than $2000. In addition, 13 million Americans, covered under the Affordable Care Act, will see their health insurance premiums reduced by $800,” wrote President Biden in his statement on the passage of the bill.

Democrats had pushed to have a maximum $35 out-of-pocket (OOP) co-pay per month cap on insulin for patients with diabetes enrolled in health insurance plans provided through Medicare and private companies. However, according to a report from CNN, “the Senate parliamentarian [Elizabeth MacDonough, JD] decided that extending the cap to the private market was not compliant with the rules of the reconciliation process, which Democrats used to pass the legislation with a simple majority vote.”

The provision remained in the bill until Republican senators raised a point of order, resulting in a 57-43 vote that limited the cap to beneficiaries enrolled in a Medicare plan only, with 7 Republicans joining all 50 Democrats. Alas, a 60-vote threshold was needed to enable the cap to extend to patients with private health insurance.

A $35 cap was originally proposed by CMS in March 2020 as part of the Part D Senior Savings Model, which then-President Trump signed an executive order to establish. The model was designed to save beneficiaries who take insulin an average $446 in annual OOP costs for insulin, representing a 66% reduction in the average cost sharing for insulin. The model was projected to generate $250 million in savings for the federal government over a 5-year period.

The hope was that the cap could also be applied to biosimilar insulins, of which the FDA has approved 2. Both are insulin glargine products and 1 has received an interchangeable designation (Semglee).

Additionally, during his first State of the Union address in March 2022, President Biden urged congressional leaders to “cap the cost of insulin at $35 a month so everyone can afford it.” Biden had originally intended to have the measure passed as part of his Build Back Better initiative but it was removed from that bill as well.

In late March 2022, HR 6833, also known as the Affordable Insulin Now Act, was voted on by the House of Representatives and passed with a 232-193 vote. However, since then, the bill has been read twice by the Senate and was “placed on Senate Legislative Calendar under General Orders. Calendar No. 389” in May 2022, signaling that it may be a long time before Senators will have the opportunity to vote on it.

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