Winners and Losers in the Battle over Copay Caps
Copay caps on state regulated plans have now passed in more than a dozen states. More are making their way through state capitols in Georgia, Kentucky, Michigan, and Oklahoma this week. Most of these bills cap copays on insulin for those with state-regulated plans somewhere between $30 and $100 per month. But by now the limitations of these bills should be abundantly clear: they cover very few people, leave the most vulnerable behind, and let legislators and patient advocacy organizations off the hook for a crisis they hear about constantly.
Last week the editorial board of the Des Moines Register said what many #Insulin4All advocates have been saying for some time: copay caps are not enough.
“We’re sick of copay cap bills,” Hannah Crabtree said on an episode of the Beta Cell Podcast this week. Host Craig Stubing had Hannah on to talk about her data work re: copay caps, the American Diabetes Association’s conflicts of interest, and how to piss off an embattled red state Dem on Twitter. It’s a really important conversation about how copay caps threaten to take the wind from the sails of more substantive actions that states could take, and why state reps need to listen to patients rather than patient advocate orgs.
But there are other long term consequences to copay caps that I worry about. What does it mean to codify a copay cap of $100? Copay caps (intentionally or not) may work to expand a practice that shouldn’t exist in the first place— copayment (AKA prescription cost sharing) itself.
The logic of copays is antithetical to the purpose of insulin, which is to keep people with diabetes alive and prevent the complications caused by high blood sugar. In the world of health economics, copays are sometimes described as giving patients “skin in the game” of health costs. In theory, they exist to deter wasteful overuse of one’s health insurance plan and keep premiums down. In practice, copays are a punishment for needing medicine — a little penalty each time you cost your insurance plan money for being sick. Copay caps further codify their existence into law, and leave open the possibility that plans could increase their toll. Plans that may have offered copays on the level of $15 or $20 can now charge more (even up to $100) and still be on the right side of these “caps.”
In stories about copay caps, health insurance companies are sometimes cast as the losers, because the bills are viewed as a limitation on cost sharing. In Montana, Blue Cross Blue Shield stood in opposition to the bill. But in reality, copay caps are a kind of victory for them in that one of their cruelest practices is rhetorically and legally reinforced. Unwittingly, state legislators, the American Diabetes Association, and even some #Insulin4All activists who celebrated these bills in the early days, have legitimized copays for insulin as high as $100. (Meanwhile, pharmaceutical companies skate by without having to lower list prices.)
A health system that made sense would never deter us from picking up our insulin from the pharmacy. It would make it as easy as possible to adhere to our prescribed regimen, one designed to keep us out of the intensive care unit and off the dialysis ward. But we don’t have a health system in the U.S., let alone a logical one. We have a patchwork of little coverage islands, each a fortress of political and financial capital, strengthened year after year by toothless reforms like copay caps.
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Small doses
An Arm and a Leg reran their podcast episode on insulin from last year, with some updates at the end of the episode. It’s a great backgrounder on the history of insulin, plus an informative look at the Open Insulin Project. Host Dan Weissmann:
“I’m starting to catch on here that folks with Type 1 diabetes have been doing this for a long time, and on every level. Advocating. Sharing knowledge. Sharing insulin. And even building tech. And so much of it is self-organized. Because of course: If you’ve got Type 1 diabetes, you’re up against everything that’s wrong with our health care system-- literally every day, and it’s literally life or death.”
In the Hill, a rundown of what drug pricing legislation could bubble up this year, including a rehash of H.R. 3, which could allow the federal government to negotiate prices with pharmaceutical manufacturers for Medicare and federally-regulated private plans.
Eli Lilly will partner with Welldoc, a digital health platform, on its “smart” insulin pen product. Per Fierce Biotech:
"Today, less than half of people who use insulins are achieving their target A1C goals,” said Marie Schiller, Lilly’s vice president of product development for connected care and insulins. “We want to simplify the experience of using insulin by integrating our medicines with the most innovative technology available."
Something tells me it’s not a lack of innovation keeping some people who use insulin away from their target A1C, Marie.
To end on a more optimistic note, Business Insider covered the groundbreaking study on insulin efficacy in high temperature climates I mentioned last time.
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That’s all for this week. My inbox is open. Just reply to this email or send stuff to theshotnewsletter@gmail.com.
With apologies for missing another week,
-harried freelancer Emily Pisacreta