Rep. Michael Howard was at his desk in the rear of the House chambers at the Minnesota State Capitol building last Tuesday when his attention was drawn to events a few hundred feet away.

In the Minnesota Senate, lawmakers were debating amendments to the large health and human services finance and policy omnibus bill. Among those amendments was one being offered by Sen. Melissa Wiklund, DFL-Bloomington, seeking to place the Alec Smith Emergency Insulin Act into the bill.

That is a piece of legislation named for a young man who died while rationing insulin that he was struggling to afford. Smith was 26 and a type 1 diabetic, just off of his parent’s health insurance, when he died of ketoacidosis in 2017.

Howard, DFL-Richfield, said he wasn’t sure what would happen to the Wiklund amendment. If majority Republicans locked up against it, it would fail. But advocates like Alec’s parents, Nicole Smith-Holt and James Holt, Jr., had also been working hard in the Senate, and several GOP members had been supportive of the law change, particularly Sen. Scott Jensen, R-Chaska, who was a cosponsor of the bill.

Then Howard heard something he wasn’t expecting: an amendment offered by Sen. Michelle Benson, the Ham Lake Republican who is the chair of the Senate Health and Human Services committee. Benson was seeking to amend her own bill to include most of the language of Alec Smith Act.

The language would establish an emergency insulin assistance program under the state Department of Human Services. Low and moderate income diabetics who lack health insurance that includes pharmacy benefits — either private insurance or state programs like Medicaid or MinnesotaCare — could apply. If eligible, they would receive a card that would let them get their insulin at participating pharmacies for no charge. That eligibility would last for 30 days, which is meant to provide time for diabetics to get connected to other programs, including those offered directly by insulin makers, and could be renewed again after 12 months.

The cost would be borne by new fees on the manufacturers of brand-name insulin with Benson expecting the fees would raise between $2.5 million and $3 million. Makers of biosimilar insulin — the equivalent of a generic drug — would not pay the fees. Such products are expected to be approved by the federal government sometime next year.

Wiklund and other backers of the bill like Sen. Matt Little, DFL-Lakeville, appeared as surprised as Howard was about Benson’s move. Earlier in session, after all, Benson had drawn some anger from people urging passage of the emergency insulin act when she said she preferred legislation that addresses drug pricing in a more comprehensive way. When asked specifically about the circumstance that faced Alec Smith, she said: “Please go to an emergency room.”

Later, in response to message from a supporter of the act, Benson wrote on Facebook: “Thank you for commenting. If you are in need of emergency insulin, you can go to an emergency room. If you have high deductible insurance, the major insulin manufacturers have coupons to help with co-pays.”

She later said she only meant that someone in a dangerous situation should go to an emergency room for help and that she didn’t think it was a solution to the issues raised about pricing of insulin.

The amendment she proposed was very similar to the Howard-Wiklund language, though it had a few important differences: It exempted the makers of non-brand-name insulin; capped the benefit at 30 days instead of the 90 days; and did not cover diabetics with high deductible insurance, those with out-of-pocket requirements of $5,000 a year or higher.

It passed 67-0 to became part of the omnibus health and human services bill that is now in a House-Senate conference committee.

Part of larger effort to rein in drug prices

Benson said the measure works together with other changes to pharmacy regulation that have come in response to constituent complaints about high and rising drug prices. The Senate also has approved regulation of pharmacy benefit managers, which are a middleman between drug makers and insurance plans. And it has okayed a new requirement that drug makers provide notice to the state when drug prices are being increased substantially.

Benson also wants discounts, coupons and other assistance programs created by drug makers to be more transparent and to be made available at the drug store counter.

“We believe that ultimately both reforms will have a bigger impact than any single bill,” Benson said.

Benson complimented Wiklund for bringing the emergency insulin language to the conversation on drug pricing. She said it is modeled on an existing childhood vaccine program that helps parents who can’t afford those immunizations get them for their children.

“We wanted to make sure that for that limited population of uninsured people who didn’t have pharmacy benefit coverage that they would have an way to get insulin to get them through a short period of time until they could get enrolled in a suitable program,” Benson said.

She said she also thinks the other reforms will help bring down the cost of pharmaceuticals.

Wiklund said she was getting ready to offer her own amendment when the Benson amendment was moved. “I was surprised,” Wiklund said, and tried to figure out on the fly what differences there were between her and Howard’s language and the Benson amendment.

While she remains concerned about the 30-day expiration of the benefit and the lack of help for the underinsured, she said it was better to approve the Senate amendment and continue talking about those issues.

The matter came before the Senate without having been heard by Benson’s or other Senate committees. “I just wasn’t sure that we would get to the point of her being willing to accept a manufacturer fee structure,” Wiklund said. “It was really unexpected.”

Howard said he too was surprised, but in a good way. “It is largely similar to the Alec Smith Emergency Insulin Act in the House. It is the exact structure, in particular the funding stream in asking the companies to pay a fee to share in the solution,” Howard said.

“On a vote of 67-0, the Senate has now joined the House in saying this is a crisis and we have to do something about it,” he said, describing himself as optimistic.

Howard agrees with Wiklund that the 30-day benefit might be too short a time to get diabetics in need of help onto other programs. And he worries that someone with a $5,000 out-of-pocket requirement might be on the same footing as someone without insurance. But he said he supports exempting prospective biosimilar insulin makers so as to encourage entry into the market of a lower-cost product.

Howard said the vote is another indication of a sea change in legislative attitudes toward the pharmaceutical industry, which had used its lobbying clout to block state regulation and interventions.

Howard said he called Alec Smith’s parents to tell them of the Senate amendment. “From the get go they wanted to pass this bill and make it law so they’re excited there’s a proposal in the Senate and an opportunity to work together,” Howard said. “It was a fun conversation to have.”