NR 506 Week 8 Health Policy Synthesis Paper Example

Policy Synthesis: Our State Nurses Association Should Stop Asking the Legislature for Insulin Caps and Ask Its Congressional Delegation for a Statutory Limit That Reaches Self-Funded Plans, Paired With the Rebate Reform Employers Say They Want

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College of Nursing, Chamberlain University

NR 506: Health Care Policy

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Month Day, Year

Policy Synthesis: Our State Nurses Association Should Stop Asking the Legislature for Insulin Caps and Ask Its Congressional Delegation for a Statutory Limit That Reaches Self-Funded Plans, Paired With the Rebate Reform Employers Say They Want

A Claim That Could Be Wrong

My claim is that our state nurses association should stop spending its legislative effort on state insulin cost-sharing caps and should instead ask our congressional delegation to support a federal statutory limit on insulin cost-sharing that covers employer group coverage of every kind, self-funded plans included, introduced together with reform of manufacturer rebates. The claim could be wrong in at least two ways: state caps might reach more people than I think, or a federal cap might do more harm through premiums than good through access. The sections below address both.

The claim rests on work from earlier in the term, which is cited here rather than repeated: the Week 2 brief on who current law leaves out, the Week 3 legislative history, the Week 5 rulemaking record, the Week 6 interest group analysis and the Week 7 evaluation.

Sub-Claim 1: The State Cannot Reach the People Left Out

State insulin caps, beginning with Colorado's $100 limit in 2020, apply only to plans the state regulates (Colorado General Assembly, 2019). Plans that employers fund themselves answer to ERISA rather than to state insurance law, and in 2024 they covered 63% of workers with employer coverage, including 79% of those at large firms (KFF, 2024). Many of our own members work for large hospital systems whose plans are self-funded. A further state cap, however well drafted, would not change what they pay. This is the sub-claim that most directly supports redirecting effort, and it is the one on which the evidence is firmest.

Sub-Claim 2: A Statute Holds Where a Regulation Does Not

The Week 5 record showed a regulation meant to lower patients' costs at the counter, the 2020 rebate rule, published and final but never in effect. It was delayed by court order and then by Congress, most recently until January 1, 2032, in part because each delay counted as budget savings that could pay for other spending (Department of Health and Human Services, 2023). The Medicare insulin cap sits in the Social Security Act itself, and no budget negotiator can quietly postpone it to pay for something else. The association should ask for a statute, not for agency action.

Sub-Claim 3: The Medicare Limit Suggests the Mechanism Works

The best available evaluation of the Medicare limit showed Part D enrollees in their late sixties and early seventies filling about 21,700 more insulin prescriptions a month after January 2023 than the trend in a younger comparison group would predict (Myerson et al., 2023). That is evidence from a different population, older adults in a public program, and it measures fills rather than health. It supports the mechanism, that lowering what people pay at the counter increases how much insulin they fill, without proving that the same effect would occur in employer plans.

The evidence also has a limit I should state plainly. Older adults on Medicare take insulin for type 2 diabetes far more often than for type 1, while many of the insulin users in employer plans are younger people with type 1 diabetes, for whom a skipped dose can lead to diabetic ketoacidosis within days. If anything, that makes the stakes of cost-related rationing higher in the population the claim is about, but it means the size of the effect cannot simply be carried over.

The Objection People Actually Make

The objection is not abstract. When the House voted on the 2022 insulin bill, employer groups placed letters in the Congressional Record arguing that a private-plan cap would shift costs to employers and employees and raise premiums, and citing a Congressional Budget Office estimate of about $11 billion in federal costs (Congressional Record, 2022). The ERISA Industry Committee, which represents the largest employers, went further, arguing that a cap would let manufacturers raise prices knowing patients would pay a fixed amount.

The objection is partly right. A cap moves cost from the person with diabetes to the plan and, through premiums, to everyone in it. My answer is that this is the purpose, not a side effect: spreading the cost of a life-sustaining drug across a risk pool is what insurance is for, and without it the whole cost lands on the person who cannot safely stop taking the drug. But the objection also contains the key to the strategy. The same employer letters named manufacturer and pharmacy benefit manager practices, including rebates, as the causes of high insulin costs and asked Congress to address them. Pairing a cap with rebate pass-through reform answers the employers on their own terms, and it could turn the strongest organized opponents of a cap into supporters of a combined bill.

What Else Moves

Several things are moving at the same time, and the claim should not depend on any of them standing still. Insulin list prices fell after 2023, probably because of the end of the Medicaid rebate cap in 2024 more than because of any cost-sharing limit (American Rescue Plan Act, 2021). Lower list prices reduce what people in high-deductible plans pay, which weakens the case for a cap somewhat. Manufacturer out-of-pocket programs exist, but they are company policies that can change. And from 2026, the Medicare limit itself falls below $35 for some insulins, which will widen the gap between Medicare and employer coverage. None of these closes the gap for people in self-funded plans with high deductibles, which is the gap the claim addresses.

Who Would Have to Act

The instrument is federal legislation, so the actors are specific. Our congressional delegation would have to cosponsor or introduce a bill, since the Affordable Insulin Now Act died with the 117th Congress. In the House, the bill would again go to the committees with jurisdiction over the three statutes that govern private plans: Energy and Commerce, Ways and Means, and the committee overseeing ERISA. In the Senate, it would need 60 votes unless it could be written to fit budget reconciliation rules, which the private-plan cap did not in 2022.

The association's own action is smaller and nearer. Its policy committee should adopt the position at its next meeting, ask members in self-funded plans to share their insulin costs so that the association can put real figures in front of the delegation, and write to each member of the delegation asking for a meeting. If the delegation will not move, the claim should be revisited; the fallback would be to press the state's largest self-funded employers, including our own hospital systems, to cap insulin cost-sharing voluntarily in their plans.

References

American Rescue Plan Act of 2021, Pub. L. No. 117-2, 135 Stat. 4 (2021).

Colorado General Assembly. (2019). HB19-1216: Reduce insulin prices. https://leg.colorado.gov/bills/hb19-1216

Congressional Record. (2022, March 31). Affordable Insulin Now Act (House of Representatives, Vol. 168, No. 57, pp. H4033-H4055). U.S. Government Publishing Office.

Department of Health and Human Services. (2023). Action to delay effective date consistent with congressionally enacted moratorium. Federal Register, 88, 90125-90126.

KFF. (2024). 2024 employer health benefits survey. https://www.kff.org/health-costs/report/2024-employer-health-benefits-survey/

Myerson, R., Qato, D. M., Goldman, D. P., & Romley, J. A. (2023). Insulin fills by Medicare enrollees and out-of-pocket caps under the Inflation Reduction Act. JAMA, 330(7), 660-662. https://doi.org/10.1001/jama.2023.12951