Biden and Trump are fighting to claim credit for $35 insulin. It was actually a pharma giant’s idea

WASHINGTON — Both President Biden and former President Trump love to claim credit for getting more Americans $35 insulin.

But the credit should actually go to a giant pharmaceutical company — just the type that both men claim to have challenged.

Eli Lilly, an $800 billion pharma giant and one of three insulin manufacturers in the United States, first proposed an experiment allowing Medicare insurance plans to offer $35 monthly insulin in 2019, CEO David Ricks and former Medicare agency chief Seema Verma said in interviews with STAT.

“It is true. We approached CMS with that idea,” Ricks said, referring to the government Medicare agency.

Verma gave Ricks credit. “He is an unsung hero. He was actually the mastermind of all of this,” she said.

The $35 monthly cap has proliferated broadly to nearly every corner of the American health care system. The cap eventually became law in Medicare, as one of Biden’s signature legislative achievements, adding more protections for the more than three million seniors who use insulin. The $35 figure also has been reflected in multiple state laws, and is the basis for proposals in Congress to extend the cost protections to people with insurance through their jobs. Some pharmaceutical companies, including Lilly and Sanofi, have adopted similar limits in their copay assistance programs. The origin story of the amount patients are expected to pay for insulin has not been previously reported.

The policy is unusually easy to explain compared with typically complex health care reforms, and has become a favorite talking point among political candidates. It’s part of Biden’s stump speeches as well, and has made its way into campaign ads.

“I passed a law that lowers drug prices and caps insulin at $35 per month for seniors,” Biden highlighted in one ad.

Trump just this weekend blasted Biden for taking credit for cheaper insulin.

“Low INSULIN PRICING was gotten for millions of Americans by me, and the Trump administration, not by Crooked Joe Biden,” Trump posted on Truth Social.

While both administrations advanced policies to make insulin more affordable, the candidates don’t often mention that copay caps are generally favored by pharmaceutical companies — and this cap was literally proposed by one.

Neither the Trump nor Biden campaigns responded to requests to weigh in on this story.

For two years prior to its 2019 proposal, Eli Lilly had been experimenting with offering different amounts of assistance to patients to help them buy insulin, Ricks said. At around $35 per month, patients would pay the required amount, and would stay on their medication. If the costs went much higher, patients would start abandoning their prescriptions.

UnitedHealth Group joined Eli Lilly in proposing the Medicare pilot project that allowed drugmakers and plans to voluntarily offer at least one insulin at $35 per month. In January 2020, Ricks said he met with Verma, and the two, who both have deep roots in Indiana, shook hands on the idea.

Verma said the copay amount that Lilly and UnitedHealth proposed was lower than the number the government was considering at the time.

“I know the two political parties don’t like to give credit to anyone on the other side. But the reality is, this is like a great example of how government should work,” Ricks said.

UnitedHealth Group did not respond to a request for comment about the company’s role.

The Trump administration’s demonstration marked an early appearance of the $35 monthly amount for insulin copays. States had just started capping insulin costs through their state benefit plans when the Medicare pilot project was announced in March 2020. Colorado and Illinois had set their caps at $100 per month, and New Mexico set its cap at $25 per month.

Roughly 1.5 million seniors were paying more than $35 per month for insulin before the policy experiment and new law kicked in, according to data released by the Department of Health and Human Services.

Under the Trump policy experiment, patients stayed on their insulin longer, so Lilly sold more insulin, but since the company was paying part of consumers’ costs, the end result was “about a wash” for the bottom line, Ricks said.

Under the Biden administration, the policy got bigger and more permanent when Democrats in Congress codified a $35 per month insulin copay cap for Medicare patients as part of the Inflation Reduction Act passed in 2022.

Congressional aides tell different stories about exactly how the Inflation Reduction Act’s insulin copay caps, which were crafted exclusively by Democrats, ended up at the exact same $35 per month level as the Trump experiment.

Wendell Primus, former House Speaker Nancy Pelosi’s top health care policy aide and currently a visiting fellow at the Brookings Institution, said House Democrats didn’t initially support the policy because it singled out a specific disease area. But the idea was politically popular, so the policy advanced. Ultimately, he said the $35 per month copay was chosen because it was around the average out-of-pocket cost for diabetes drugs at the time, and it didn’t cost the government much money.

But another congressional Democrat involved in drafting the legislation said the amount explicitly mirrored the Trump-era pilot project.

Regardless of how it got there, $35 insulin persisted in Democrats’ drug pricing reform law. It was widely implemented starting Jan. 1, 2023.

The Inflation Reduction Act significantly expanded the protections for patients using insulin. Under the new law, offering covered insulins at $35 per month became mandatory, not optional, for more insurance plans, said Vanderbilt University health policy professor Stacie Dusetzina. The legislative cap applied to insulin delivered through a pump, too.

“It’s one part of the IRA we actually like,” Ricks quipped. Generally, the pharmaceutical industry vehemently opposed the other drug pricing policies Democrats passed.

Now that the policies have been in place for a couple years, the results of the copay caps have started coming in.

An evaluation of the Trump insulin experiment by the RAND Corporation showed that people who used insulin in plans in the pilot had decreased out-of-pocket costs, and filled one additional 30-day prescription a year.

However, the same study showed that people in the plans who didn’t use insulin paid more. And a survey showed that only about one-third of respondents actually took insulin costs into consideration when they chose their insurance plans.

Ricks’ ambitions don’t stop at insulin. He’s pushing copay caps for medicines for other chronic diseases.

“I think the success of the insulin experiment should be pointed out, and that it wasn’t that expensive, and people’s outcomes will get better,” he said.