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How helping diabetics stay alive became a partisan fight in Minnesota

Nicole Smith-Holt testifying on Monday while bill sponsor Sen. Eric Pratt looks on.
MinnPost photo by Peter Callaghan
Nicole Smith-Holt testifying on Monday while bill sponsor Sen. Eric Pratt looks on.

How did insulin become yet another partisan proxy war in Minnesota? 

Two legislative hearings this week raised that question (and a few others) as part of a dispute that has placed diabetics and their families in the middle of what is, in fact, a life-or-death issue: Insulin is needed to keep type 1 diabetics alive, but price increases have made it unaffordable to the under- and uninsured.

Yet even lobbying from diabetics and their families, especially from Nicole Smith-Holt and James Holt Jr., who lost their son Alec in 2017, hasn’t been enough to shake free a plan to help the most desperate patients. 

At the center of the impasse is another question: who should pay the relatively small cost of an emergency insulin plan, taxpayers or insulin manufacturers?


It was a question that was once thought to be resolved. Near the end of the 2019 legislative session, Republicans in the Minnesota Senate approved language that would, as the DFL-controlled House had already done, assess a fee on the pharmaceutical industry to pay for an emergency insulin plan. But the agreement somehow fell away during the end-of-session, behind-closed-doors negotiations, and the blame-casting began almost immediately afterward. Even an informal bipartisan work group, which also met in private, couldn’t get around the funding impasse.

That’s why a plan recently proposed by Senate Republicans looked like it could be a breakthrough. Diabetics earning less than 400 percent of the federal poverty level — about $50,000 for an individual — could apply for the program. Once the patient’s financial eligibility was approved through MNsure, doctors would be able to order the patient a 120-day supply of insulin from the manufacturer, which would be expected to fill it without charge. Such help could last up to a year.

The same application process would steer those eligible for subsidized health insurance — either through Medicaid or the MNsure exchange — to plans that would replace the insulin program. 

“I think the hope is that if we connect people to their supply before they’re in crisis, before they start rationing it, we will save lives,” said Sen. Eric Pratt, R-Prior Lake, the proposal’s prime sponsor. “A parent should never have to bury their child.”

Two bills that ‘go hand-in-hand’

But some patients worried that the Republican plan didn’t go far enough. “This is a good start but it doesn’t erase my fears and I, along with the rest of the diabetic community, needs something that does,” said Alexis Stanley, a Concordia University student with type 1 diabetes. 

Those patients would like to see a plan that matches a DFL plan, dubbed the Alec Smith Emergency Insulin Act, that would dispense insulin in emergency situations. Talk this week was whether the House and Senate could reach a compromise that would include elements of both sides’ plans.

Concordia University student and type 1 diabetic Alexis Stanley, right, with bill sponsor state Sen. Eric Pratt.
MinnPost photo by Peter Callaghan
Concordia University student and type 1 diabetic Alexis Stanley, right, with bill sponsor state Sen. Eric Pratt.
“From my standpoint, these are two bills that will go hand in hand,” Smith-Holt said at a hearing of the Senate Health and Human Services Committee this week. “Alec’s bill will touch on the emergency situation, whereas the Pratt bill is more for once we get out of this emergency situation; it would be a secondary bill that would help.”

But that wouldn’t resolve the impasse over funding. Money would still be needed to set up the Alec Smith program and to reimburse drug stores that dispense insulin under its provisions. That means either a license fee or taxpayers dollars would be required, something Senate Republicans have resisted. Instead, GOP leaders prefer tapping funds from Minnesota’s health care provider tax, which they reluctantly agreed to reinstate at the end of the 2019 legislative session.


In a letter to the Senate committee, a representative of the pharmaceutical industry lobbying group PhRMA said the group opposed the Pratt funding plan. Yet Pratt said he has had conversations with the industry and didn’t expect pushback. Providing drugs to needy patients through coupons and other so-called Patient Assistance Programs is something drug companies already do. And the Pratt plan doesn’t create a new fee or tax on the industry, which has aggressively opposed such assessments. 

But the Republican proposal would require the drug companies to include more people in those current programs. Holt-Smith said Thursday that currently more than half of people living with diabetes who seek help from the companies are denied. 

Potential for compromise

Insulin is needed to regulate blood sugar levels in people with diabetes; without the hormone, type 1 diabetics can die, while type 2 diabetics can suffer severe health problems. Yet only three pharmaceutical companies make nearly all of the brand-name insulin sold in the United States — Eli Lilly, Novo Nordisk and Sanofi — and prices for the medicine have jumped 1,200 percent over the last 20 years, diabetics have told lawmakers. 

While there are expected to be non-brand-name suppliers soon, their products — known as biosimilars — are not yet available in Minnesota.

Rep. Mike Howard, DFL-Richfield, is the prime sponsor of the Alec Smith Act in the Minnesota House — Alec and his parents lived in his district. He said there is potential for a compromise in the Pratt plan but that there remain issues to resolve.

“At the end of last session, one of the stumbling blocks appeared to be who was going to pay for this program,” Howard said in an interview. “In the Senate proposal we see the Senate moving to the House position and agreeing with Minnesotans that those insulin manufacturers should bear the burden. They profited greatly and they should be responsible for paying for a program.”

State Reps. Mike Howard, center, and Laurie Halverson, a type 1 diabetic, speaking at a press conference on Thursday.
MinnPost photo by Peter Callaghan
State Reps. Mike Howard, center, and Laurie Halverson, a type 1 diabetic, speaking at a press conference on Thursday.
While Howard said he preferred a fee on the drug makers, he said he was open to other mechanisms, such as the one included in Pratt’s bill. Even that, however, wouldn’t resolve how to pay for emergency insulin for diabetics who lacked money to pay for it. 

The latest plan from House DFLers would let a pharmacy dispense insulin immediately while a patient is applying for assistance. That emergency supply would be paid for by the state with revenue from a manufacturers fee, and the program would be managed by a pharmacy benefit manager contracted by the state. The DFL plan would also cover more people than the Senate proposal, in that would apply to those earning up to 600 percent of federal poverty level. 


Gov. Tim Walz has repeated that he would call a special session to address the issue — but only if a deal is struck that assesses drug makers for the cost.

Howard said this week he is open to some cost sharing. “It doesn’t make sense to be so rigid, that we’re not open to ideas,” he said. “As long as the insulin manufacturers are the key responsible funding entity, I’m open to some level of other resources being included.”

‘It hits people in the gut’

While Pratt said he too was open to talking about the details with task force members, he said the issue needed to get away from politics. “What I have been really upset with is the hyper-politicization of this issue,” he said. “Forgive me if I try to step away from some of that so I can try to work through it without the noise, the rhetoric, the attacks.” 

DFLers, however, are convinced that the political pressure brought by them and diabetes advocates is what caused the Senate GOP to move toward some form of industry funding. Being tied to the pharmaceutical industry remains political poison, and Republicans have been sensitive to accusations that they are uncaring about the issue — or in bed with Big Pharma. Neither presents good political optics, and Republicans’ efforts to call attention to drug supply changes already passed — or to the idea that the insulin program needed more work — weren’t enough to change them.

This week, GOP lawmakers have been distancing themselves from a controversial video by Rep. Jeremy Munson, a Republican from Lake Crystal who is a member of the four-person New Republican Caucus. In it, he says he purchased $25-per-vial insulin at Walmart and suggested diabetics in need had that option.

But diabetics and their physicians said that product is an older formulation of insulin that doesn’t work well for many diabetics. Thursday, Munson was criticised by both DFL Rep. Laurie Halverson of Eagan — herself a type 1 diabetic — and GOP Rep. Mary Franson of Alexandria.

“Don’t pretend to understand what we live with every single day and then legislate based on that,” Halverson said.

“We should not practice medicine as a Legislature,” said Franson. “And we should never mandate a product. That should be left between the doctor and the individual in the clinic room.”

Howard said earlier this week that he has heard complaints from some Republicans about the way the issue has been made political and emotional. But he said the politics are driven by the way the issue affects diabetics and their families.“It hits people in the gut,” he said. “That is what has raised the temperature of this issue and that is what have made people uncomfortable.”

He said he thinks the Senate is responding to political pressure brought by families. “That part has been necessary and will continue to be necessary to drive us toward getting something done,” Howard said.

The Pratt plan could blunt accusations and attacks. “I want to state that I’m grateful that the Senate Republicans have made this issue a priority for your caucus,” Lija Greenseid, whose daughter has type 1 diabetes, told the Senate committee. “I’ll be honest. We didn’t always feel last session that you were listening to us and consequently some of you were the victims of the ferocity that as mama bears we will show if someone isn’t doing enough to protect our kids. 

Lija Greenseid, insulin advocate, testifying at the Senate Health and Human Services Finance and Policy Committee.
MinnPost photo by Peter Callaghan
Lija Greenseid, insulin advocate, testifying at the Senate Health and Human Services Finance and Policy Committee.
“While we might show our claws if we don’t think you’re with us, we’re also quick to embrace with bear hugs those who join us in this fight.”

At the end of a House hearing on the issue Thursday, Rep. Tina Liebling, DFL-Rochester, said there have been talks between House Speaker Melissa Hortman and Senate Majority Leader Paul Gazelka about appointing a joint committee of lawmakers “with decision-making authority” to see if an agreed-upon bill can be drafted. 

If that happens, a special session could still occur. The next regular session doesn’t begin until mid-February 2020. 

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Comments (11)

  1. Submitted by Gene Nelson on 09/27/2019 - 11:55 am.

    I wish someone could list something repubs do to help us with our unaffordable life as I see zilch from them.

    • Submitted by Henk Tobias on 09/27/2019 - 02:55 pm.

      If you go back to the 60s, they haven’t done a single thing FOR the working class, they’ve done a lot TO them, but nothing for them.

  2. Submitted by Joel Stegner on 09/27/2019 - 12:00 pm.

    Here is the real issue – price gouging. The astronomical price increases have not been related to the increased cost of manufacturing, but to pricing to make as much money for corporate executives and wealthy shareholders.

    Other states have capped the amount that can be charged. Buy your supply from Canada at a very small percentage of the price.! The most ludicrous thing is that the Canadian researcher who did the original discovery chose not to patent it, because he cared more about the life extending and saving qualities.

    Manufacturer pricing has already harmed and killed countless people. This story which focuses on local politics and doesn’t even mention prices entirely missed the point that insulin’s status quo puts profits over health. We need to do better!

    • Submitted by Sarah Nagle on 09/29/2019 - 12:18 pm.

      When it comes to sticking it to the taxpayers or sticking it to the insurance and pharmacy companies, it’s pretty obvious that the GOP will stick it to the taxpayers. So much for “lower taxes” . . . . and so much for “pro life”.

      And ““We should not practice medicine as a Legislature,” said Franson” – and then he proceeds to prescribe an older form of insulin available at Walmart.

  3. Submitted by Gerald Abrahamson on 09/27/2019 - 12:02 pm.

    The total cost of a vial of insulin is roughly $2.50 to $3.50–which sells for $25.00. Add 30% to have the same product in a disposable pen. Thus, the funding ratio needs to be about 90% manufacturer paid and 10% paid by public funding. The product is produced in Canada and elsewhere, with Canadian prices far below US pricing. Therefore, the proposed ratio allocation (90%:10%) is not unreasonable.

  4. Submitted by Barbara Skoglund on 09/27/2019 - 12:33 pm.

    The GOP knows it would take years to add eligibility rules for another program to the METS software system that supports MNsure and the public health care programs. There are already multiple programs that are no where near being moved to METS. This is just a effort to “pretend” to help people and then they will blame DHS for not getting the job done on yet another unfunded mandate. Their ultimate goal is to destroy public assistance programs and kill poor people.

  5. Submitted by ian wade on 09/27/2019 - 01:07 pm.

    It’s simple really. Republicans lack empathy. Just like those that are poor, they feel that any illness is somehow the fault of the person that gets sick. “Oh, your pancreas decided to stop producing insulin? What did you do?”

  6. Submitted by Henk Tobias on 09/27/2019 - 01:18 pm.

    Republicans always will protect taxpayers, as long as it doesn’t interfere with their Collecting Corporate Cash, which is to say Republicans rarely protect tax payers.

  7. Submitted by Paul Udstrand on 10/01/2019 - 08:48 am.

    This is perfect example why whack-a-mole health care patching is doomed to failure. These are the kinds of Obamacare “tweaks” that neoliberals claim to be more “realistic” than Medicare for All. Americans are the most price-gouged patients in the world simply because we have refused to move away from “market” models of health care.

    Listen: Any program that people have to “qualify” for also requires an application process, and all applications have to be processed and examined, and denials require a appeal process of some kind. All this does is pile more administration on top of the most overly administrated health care system in the world. It would probably take a year or more to get something like this up and running and even then is would probably be full of glitches. This is why some kind of immediate emergency relief would be necessary.

    I’m not saying these proposals should be abandoned but we need to accept the fact that a national health care system that everyone is automatically enrolled in, and is irrevocable, is the most rational solution for crises like this that permeate our health system. A national system is also the ONLY way we limit gouging because it’s the only way we can possess the necessary leverage.

    We will NEVER whack-a-mole our way out of this.

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