$35 Insulin Cap Under Build Back Better Plan Faces Challenges

Democrats in the Senate are primed this month to make their first attempt at salvaging one of the most popular elements of President Joe Biden’s stalled Build Back Better plan—the proposal to cap insulin costs at $35 a month.

It might not go well.

That’s true even though the idea of helping millions of Americans with diabetes afford a crucial medicine has immense public support and even bipartisan adherents. But then, there is politics—between Democrats and Republicans, of course, but also among Democrats.

Sen Raphael Warnock (D-Ga) is sponsoring a bill, expected to come up in March or early April, that would cap the price. But pursuing Warnock’s bill would remove that provision now in the Build Back Better bill.

Drug companies have dramatically jacked up prices in the United States, leaving Americans to pay more than 10 times as much as people in other developed countries, according to the most recent detailed survey by the federal government.

Senate Majority Leader Chuck Schumer highlighted the obvious selling points of bringing down insulin costs when he announced before Congress’ Presidents Day break that the issue would be a priority. “It is just preposterous—beyond preposterous—that Americans with diabetes sometimes pay more than $600 just for a 40-day supply of insulin,” Schumer said.

“There’s enormous interest in our caucus to pursue this proposal, so it will be a priority for Democrats in the weeks ahead,” he said, inviting Republicans to get involved. “This has long been a bipartisan issue: As many as 20 states across the country—many with Republican legislatures and governors—have passed state-level insulin caps. There is no reason this shouldn’t be bipartisan in this body.”

Still, the complications start on the Democratic side, even if they appear entirely surmountable.

The first is that Biden and many of the more progressive Democrats in Congress still would like to pass a stripped-down version of the Build Back Better plan. They would like to take another shot at building a package of the popular tax, climate, and health provisions that could pass muster with West Virginia Sen Joe Manchin, a conservative Democrat who blocked the more ambitious bill. Democrats could speed the new version through Congress with 51 votes under the expedited budget reconciliation rules they’ve already passed.

Biden was talking up Build Back Better and capping insulin costs as recently as last month—just days before Schumer announced Warnock’s insulin plan—and brought up insulin again in his State of the Union address, pointing to Shannon Davis and her 13-year-old son, Joshua, who lives with type 1 diabetes, like his father.

“Imagine what it’s like to look at your child who needs insulin and have no idea how you’re going to pay for it. What it does to your dignity,” Biden said, reaffirming his plan to cap insulin at $35 a month.

Pulling the insulin measure from Build Back Better removes that powerful talking point and means that an insulin-only bill would need 60 votes to pass in the Senate, instead of a simple majority.

The president did not mention his larger spending plan in his March 1 speech. And Schumer’s embrace of Warnock’s bill suggests that Democrats see the value of Warnock taking the lead on a popular issue as he faces a tough reelection battle in Georgia this year.

“I’m a pastor; I’m on the ground, and so I know that everybody knows somebody with diabetes,” Warnock said in a video in which he noted that 12% of Georgians have the disease. “I’ve seen up close how diabetes impacts Georgians.”

According to background information provided by Warnock’s office, the senator has been working with Schumer and the chairs of the Finance and Health committees on how best to bring the measure forward. He’s also been working with Biden’s Centers for Medicare & Medicaid Services on technical details, suggesting at least tacit support from the White House.

Staffers of Hill Democrats, speaking candidly about Build Back Better’s prospects, described it as less a race car that’s just pulled into a pit stop and more a clunker on cinder blocks. Some senators have declared that it doesn’t exist anymore.

Other Democratic staffers say pulling prescription reforms out of the Build Back Better package might be useful. Items included in the reconciliation process are supposed to directly affect the federal budget. The insulin provision would affect the finances of insurers and drugmakers much more than the federal government’s, leaving the provisions open to a parliamentary challenge from Republicans.

By starting the salvage operation with a popular piece, and attracting enough Republicans to succeed, Democrats could use the insulin cap as a model for getting a few other chunks of Build Back Better through Congress.

There is no clear signal, though, that Republican senators will cooperate, even though around 20 of them have previously expressed support for measures to control insulin prices. Warnock’s staffers said the senator has gotten positive feedback on the proposal from both Democratic and Republican colleagues.

Asked about Warnock’s bill, several key Republicans, including Minority Leader Mitch McConnell and the cochair of the Senate Diabetes Caucus, Sen Susan Collins of Maine—did not respond.

Jess Andrews, a spokesperson for Sen John Kennedy (R-La), who has offered three bills to lower insulin costs, one as recently as September that included caps, said the politician had nothing to say at this point.

Sen Chuck Grassley (R-Iowa), who has worked extensively with Finance Committee Chairman Ron Wyden (D-Ore) on investigations and legislation dealing with insulin costs, offered no opinion on Warnock’s bill.

A spokesperson did note that Grassley prefers a broader approach. “There’s no doubt that insulin is one of many essential medications that has become less and less affordable,” said Grassley spokesperson Taylor Foy. “Bipartisan proposals in Congress, such as the Grassley-Wyden Prescription Drug Pricing Reduction Act, would address the root causes of price increases for not just insulin, but many other medications as well.”

Indeed, nearly every group of advocates who work on a particular disease would like Congress to control the price of an essential drug to treat or cure that disease. But Congress so far has lacked the will or means to approach the problem that way.

McConnell torpedoed Grassley’s broader bill in 2019, when Republicans held the majority in the Senate. But now Schumer controls which bills make it to the floor.

If 10 of the Republicans who want to control insulin costs are willing to align themselves with a vulnerable Democrat facing a close contest, the bill could pass this time around. If they are not, Democrats will take the consolation prize of highlighting how the GOP blocked a popular reform demanded by millions.