Key drug-pricing bill capping insulin costs faces hurdles in Congress

Major drug-pricing legislation to cap the cost of insulin is in danger of slipping to the fall, where it risks getting lost amid fights over appropriations bills, abortion and a potential government shutdown. 

The legislation is a priority for Democrats, and Majority Leader Chuck Schumer (D-N.Y.) said earlier this month that he was hoping to combine the insulin bill and legislation reforming the pharmacy benefit manager (PBM) industry into a package that could get bipartisan support and a vote before the end of summer. 

In a press conference earlier this month, he said passing an insulin bill was a “very, very high priority.”

But with just a week left before lawmakers leave town for August, there’s a lot on the agenda, and time is a precious resource.

Senate lawmakers last week began taking up their version of the annual defense policy bill. The House pushed through a highly controversial and partisan version just more than a week ago, and senators intend to start negotiating with the House by the end of the month. 

The Senate must reconcile its fiscal 2024 National Defense Authorization Act (NDAA) with the House’s by the end of September.

“NDAA is going to dominate, right? Just look at the calendar,” Sen. Bill Cassidy (R-La.), the ranking member of the Senate Health, Education Labor and Pensions (HELP) Committee said recently. Getting anything else passed “seems unlikely,” he said. 

Lawmakers are also staring down a fight over appropriations bills, which are being loaded up in the House with GOP provisions regarding abortion and funding for LGBTQ projects.

Still, several committees in both chambers have different ideas to reform PBMs, and senators said they are confident there will be enough momentum when they return from the August recess.

A lot of bipartisan attention is being paid to the issue, but different measures from different committees — some with overlapping subjects — could complicate matters. 

The Health Committee cleared PBM legislation in May. A bill co-sponsored by Sens. Chuck Grassley (R-Iowa) and Maria Cantwell (D-Wash.) cleared the Commerce Committee in the spring.

Grassley introduced another bill with Sen. Tom Carper (D-Del.) in the Finance Committee, which is holding a July 26 markup.

The late markup means any action to merge the disparate bills by leadership will have to wait until September.

“Until you get the Finance Committee putting the bill out, I don’t think that you’re going to get any conversation about melding the bills together. So it’s more of a process question than it is a question of substance,” Grassley said. 

“I know this, Schumer wants to do something on drug pricing, and PBMs is a big part of that,” Grassley said. 

Despite the interest in PBM reform, a push to combine it with insulin pricing could be problematic because it’s not yet clear whether enough Republicans support the insulin measure.

“We have a PBM bill. It’s a very good bill coming out of the Health Committee. $35 insulin was not part of it,” Cassidy said.

“That’ll complicate it,” Grassley said of tying PBMs and insulin together, “but it’s something that’s going to have to be done.”

Passing legislation that caps the cost of insulin at $35 for people on private health insurance has been a key Democratic goal since last year.

Democrats tried to include a $35 cap for commercial insurance in the Inflation Reduction Act, but they were forced to strip it out when the Senate parliamentarian deemed it to be in violation of budget rules, meaning it would be subject to a 60-vote threshold. 

Still, seven Senate Republicans voted to keep the private insurance cap in the bill, meaning there could still be a deal in the closely divided Senate. 

In the interim, all three top insulin manufacturers have announced plans to lower the prices of some of their insulin products. But lawmakers want to ensure there’s legislation that will prevent the companies from backing off.

There are dueling bipartisan proposals, and neither Schumer nor Health Committee Chairman Sen. Bernie Sanders (I-Vt.) has decided which one will make the cut.

One plan is from Sens. Raphael Warnock (D-Ga.) and John Kennedy (R-La.), and the other is by Sens. Susan Collins (R-Maine) and Jeanne Shaheen (D-N.H.).

Both would cap insulin at $35 per month for the privately insured, but the similarities end there.

The bill from Shaheen and Collins would apply a cap of $35 or 25 percent of the list price, whichever is lower, to at least one insulin of each type and dosage form. It includes provisions related to PBM discounts and biosimilars. 

The Warnock and Kennedy bill would apply the $35 cap to all types of insulin. It would also extend the $35 discount to the uninsured. 

Warnock has said he intends for the bill to be fully paid for, and Schumer is “all in” with his support. 

Neither pair of senators said they see their bill in competition with the other.

“We’ve been working on this for years now,” Shaheen said when asked about timing. “I think the point is, let’s figure out how we get the votes to get it done.”

But even if an insulin cap does get through the Senate, the GOP-controlled House is unlikely to support such a measure.

Rep. Brett Guthrie (R-Ky.), chairman of the Energy and Commerce Health subcommittee, said he’s concerned insulin caps would lead to shortages. 

“We aren’t preventing people from getting access to the drugs. So we want it to be absolutely affordable; we will absolutely negotiate with anybody on that. But we also want to make sure we don’t make it a shortage either,” Guthrie said.

After President Biden called for a $35 insulin cap in his State of the Union, Energy and Commerce Committee Chairwoman Rep. Cathy McMorris Rodgers (R-Wash.) called the move “socialist” and a “federal mandate” that hurts competition.

She voted against a similar bill last year when Democrats controlled the House.