Lawmakers eye lame duck for unfinished business on insulin

WASHINGTON – A bipartisan Senate duo is still working to pass a bill to overhaul insulin prices, but the outlook is complicated by the messy drug pricing system, politics and a busy congressional calendar.

Sens. Jeanne Shaheen, D-N.H., and Susan Collins, R-Maine, are working to update a draft bill that would cap consumer copays for insulin in the commercial market and incentivize drugmakers to lower list prices. One of the bill’s provisions capping Medicare copays at $35 a month was enacted as part of the Democrats’ budget bill in August.

But the hurdles that previously stalled the bill remain the same. The policy is complicated. The official cost is expensive. And Republican support is thin.

The bill would extend the $35 Medicare copay cap to the commercial market. It would also ban health plans from requiring doctors’ approval before prescribing a drug and prohibit manufacturer rebates when drugmakers freeze their list prices at 2021 Medicare net rates. Drugmakers negotiate the rebates with health plans and their pharmacy benefit managers – the middlemen who manage a health plan’s drug benefit – in part for preferential coverage, but also say the rebates encourage higher list prices.

The bill’s goal is to lower insulin list prices, which shot up in recent years even though net prices after rebates largely remained flat. Research has shown that the additional profits mostly go to pharmacy benefit managers, pharmacies and wholesalers.

Limiting pharmacy benefit manager profits, however, is projected to raise both net prices and insurance premiums. The Congressional Budget Office projects the bill would cost $23.3 billion over a decade – a number that Collins has argued doesn’t capture the true savings of keeping diabetic patients healthy and out of the hospital. The bill’s updated price tag will likely be lower since it won’t include the Medicare provision.

Senate Majority Leader Charles Schumer has repeatedly voiced plans to bring the bill to the floor since the spring, but the timeline keeps slipping. A vote was most recently expected in September, but Schumer instead pivoted to a bill aimed at increasing transparency in campaign finances. The Senate rejected cloture on that bill earlier this month.

Bipartisan work is also tough in the wake of the reconciliation fight and ahead of the midterms.

“I don’t think we’re going to see anything now before the elections,” Shaheen said.

“There’s still a need for our bill,” Collins said. “I think our path is more difficult because of Sen. Schumer’s decision – which was contrary to what he told me – to break off parts of the bill and put it in reconciliation.”

Schumer’s office did not respond to requests for comment.

Lame-duck potential

Proponents are hopeful there might be a window for passage during the lame duck session, after the election dust has settled and the political pressure has lifted for outgoing lawmakers. Republicans traditionally dislike imposing restrictions in the private market, but a number of red state laws show that insulin is a special case.

But Margarida Jorge, campaign director for the advocacy group Lower Drug Prices Now, said bringing it to the floor before the election would benefit voters.

“I would probably err on the side of having the debate now as opposed to later,” she said. “Because this is one of the issues that is really sharp and really clear in terms of helping voters understand which side of the issue their members are on.”

Jorge still expects that, if the legislation comes to the floor, it will receive a standalone vote instead of hitching a ride on a must-pass spending bill. But a Senate aide said the outlook is dim given Congress’ lengthy to-do list.

Ironically, the Senate plans to use the shell of a House-passed bill capping insulin copays as the vehicle for the short-term spending bill. The bill’s provision capping Medicare copays became law as part of the reconciliation bill, although a cap in commercial plans was ultimately nixed.