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Minnesota lawmakers agree on the need for an emergency insulin program. So why hasn’t a deal happened?

The explanations offered by both Democrats and Republicans have to do with the pharmaceutical industry. 

press conference
Listening to state Rep. Mike Howard, from left: Lt. Gov. Peggy Flanagan, Gov. Tim Walz and insulin advocates Nicole Smith-Holt, Jett Loewy, Alexis Stanley, and others.
MinnPost photo by Peter Callaghan

It was a press conference similar to so many that had come before. 

Last week, Gov. Tim Walz and DFL lawmakers gathered with people who depend on insulin to manage their Type 1 diabetes. They talked about rapid price increases for the medicine, and the threats to health and life when the hormone becomes unaffordable. They accused the drug companies of greed, and they accused Senate Republican leadership of stubbornness and complicity.

For more than a year, many of the same people had said many of the same things. During that time, diabetics and their supporters had been teased with news of deals to address the issue only to be disappointed. Every deadline has been missed. Every hope for an agreement has been dashed.

Watching the issue play out in St. Paul was especially frustrating for those affected. Negotiators from both parties said they agreed on the need for an emergency insulin program: that costs should be shared by the state and the insulin manufacturers; that there should be an emergency program where diabetics without the ability to pay could obtain insulin at the pharmacy immediately; and that there should be a longer-term program for those without insurance or with high-deductible policies.

And yet, there is still no deal. Why? 

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At the heart of the debate: Who should pay? 

The explanation offered by the two sides have to do with Big Pharma — from different perspectives.

“In every one of these areas where we face a divide, Republicans are siding with insulin manufacturers instead of Minnesotans,” said Rep. Mike Howard, the Richfield DFLer and prime sponsor of the Alec Smith Emergency Insulin Act, a bill named for the 26-year-old who died in 2017 while rationing insulin. 

State Sen. Eric Pratt
MinnPost photo by Peter Callaghan
State Sen. Eric Pratt
Added Nicole Smith-Holt, Alec’s mother: “We thought we were getting somewhere after the many months of positive negotiations. But then Pharma got involved and derailed all of the progress that we made.”

In response, Sen. Eric Pratt, the Prior Lake Republican and lead negotiator for Senate Republicans, said the lack of a deal is due to a desire by DFLers and advocates to get revenge on the three main manufacturers of the hormone. 

“We can get this done if there wasn’t this desire to punish the manufacturers,” Pratt said.

Such rhetoric was more apt a year ago, when advocates and DFL leaders took the position that the cost spikes were caused by an industry exploiting a captive and desperate customer base. Because of a doubling and tripling of prices of insulin and supplies, people like Alec Smith — who had just aged off of his parent’s health insurance — took to rationing the medicine. 

Initial DFL plans imposed fees on the industry to pay for an emergency insulin program, something they termed holding Big Pharma accountable rather than punishing them.

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Some Republicans in the Senate (though not all) thought the costs should come from state sources. That echoed industry arguments that fees would only increase costs and ultimately hurt diabetics.

Those two viewpoints — briefly muddled when the state Senate unanimously approved fees last spring, only to back away during conference committee — were at least easy to enunciate. But that ended over the summer when Republican Pratt proposed requiring the industry to provide insulin through their existing patient assistance programs and Howard agreed to use state funds for part of the response, especially the emergency program.

Those two significant concessions produced optimism — but still no deal. The fall was spent in public arguments over private meetings, in disputes over deadlines and the size and membership of each chamber’s negotiating teams.

Without a deal in place, House DFLers released a plan last week that absorbs previous agreements on the big points and layers in the DFL position on the details. About a million dollars of state money would go to set up the program, for both the need-it-now emergency plan and the longer-term regular supply. The plan would require the companies to supply insulin to all diabetics deemed economically eligible — up to 400 percent of federal poverty levels or $50,000 for individuals and $100,000 for a family of four. It also would impose fees on the industry for the emergency program supply that could be lessened if the companies provided insulin in those cases as well.

Under the DFL plan, the state would also determine eligibility for the long-term plan, and the companies would be required to fill the supply. Currently, companies make the decision as to who gets help, and advocates have complained that many who seem eligible are turned away. 

Some Republicans have argued that the manufacturers and insurance companies are feeling the heat of public opinion and reducing costs, negating the need for state intervention. The DFL says that should only serve to reduce the number of people who need the programs, not eliminate the need.

The Senate Republican’s last offer was similar to the DFL’s in many of the broader points, though it has higher copays for patients and provides emergency insulin for less time. GOP leaders also oppose fees and think the state should pay for the emergency program from out of the Health Care Access Fund, which is funded with the state’s provider tax. They would also sunset the program at the end of 2023.

DFL to introduce new insulin bill early in 2020 session

“They have a bill drafted. They’re ready to drop it,” Pratt said of the DFL. “We didn’t have a bill drafted because we were still trying to reach consensus. We’ll have a bill drafted and run that through the Senate and we’ll be talking at each other instead of to each other for the next couple of months.”

Pratt said he does think a bill is needed, even if the industry has begun to take steps to reduce costs on patients.

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“If they can get on a pharmaceutical assistance plan, that’s awesome,” he said of diabetics with no or inadequate health insurance. 

But some might not, and a state program would have value even if it is just to facilitate the program, he said. And if drug makers try to roll back their programs in the future, the state would still require they fill insulin orders from those eligible for the program.

House Speaker Melissa Hortman
MinnPost photo by Peter Callaghan
House Speaker Melissa Hortman
House Speaker Melissa Hortman said she expects the DFL’s insulin bill, House File 3100, to be among the first that will be taken up by the House after it convenes Feb. 11. She said she thinks the Senate Republicans are interested in reaching a deal.

“It is a convenient story line to say people don’t want a deal. And there are a few people who value combat over resolution,” Hortman said. She also disputes allegations that DFLers would rather take the issue to voters in the fall as a way to portray the GOP as doing the bidding of big drug companies. (A press release sent last week by the DFL-supporting Alliance for a Better Minnesota was headlined: “Senate Conservatives Cave to Big Pharma.”)

“I think Eric Pratt at times has felt like we don’t want a deal. I don’t know how many ways I can say it. There’s nothing more that I want than to stand next to you and announce our deal,” she said. 

But there are limits to how far she will compromise. “Not every deal fails because both sides are being unreasonable. Sometimes one side is being more unreasonable than the other,” Hortman said.