MONOPOLY NATION system has changed a growing number of Americans with diabetes struggle to pay for their healthcare, including medicines made by us. As a company focused on improving the lives of people with diabetes, this is not acceptable … we are focused on doing all we can so these patients can afford their medicine.” Lilly and Sanofi did not respond to a request for comment. There is one proven method for lowering prices: fomenting robust generic competition after the drug goes offpatent. Lilly’s patent on fast-acting insulin expired in 2014, but because insulin is a “biologic” drug made from human genetic material as opposed to a simple molecule, manufacturing a biosimilar version is relatively complicated and far from guaranteed to drive prices down. And drug companies fight to keep their exclusivity: When Merck tried to create a biosimilar to Sanofi’s Lantus, Sanofi sued and Merck eventually dropped the effort. (Another biosimilar was ultimately approved in 2016, but not until after a similar patent lawsuit.) But if only one generic enters the market, it typically doesn’t make a big price difference—the biosimilar version of Lantus is priced at only 15 percent below the name brand. Studies show that the market price sees a dramatic reduction only after the entry of several generic competitors into the market—begging the question of whether waiting out two decades of exclusivity, followed by the mobilization of numerous different companies to eventually compete prices down, is really the best route to humane drug pricing. Plenty of politicized diabetes patients like Laura Marston in Washington, D.C., can’t afford to wait that long, and have taken up the fight themselves. “We all live this way,” she said. “I’m scared all the time. I’m scared if I don’t keep fighting they’ll just go back to raising the prices. We’re almost being forced to fight for our lives because the government won’t do it for us, and the toll that takes on someone who already has a chronic illness is time consuming … because even though I have a stable job, even though I’m insured, god forbid my industry could go in the tank tomorrow … this is America! Anything can happen.” THOUSANDS OF DIABETES PATIENTS and their allies
have joined the #insulin4all campaign, begun by nonprofit T1International in 2014 to force a national dialogue on insulin prices. Advocates have organized rallies at Lilly’s Indianapolis headquarters, shaming the company into releasing its own licensed generic Humalog at half price. This is still over $100 per vial more than it sold for in 1996. Lilly’s generic is also only available out of pocket; insurers will only be able to get Humalog at full price, with much of that burden passed on in patient deductibles—and more broadly, into our premiums.
Advocates have also forced congressional hearings on insulin, a federal investigation from House Oversight Committee Chair Elijah Cummings (D-MD), at least two active lawsuits for price fixing, and even state legislation like the recently passed co-pay cap on insulin in Colorado. The law is a nice start, but applies only to state-regulated employer insurance plans and will thus shut out many diabetics who need it, like those in non-qualifying plans or the uninsured. Other players in the insulin supply chain are scrambling as well. Sanofi has set a fixed price of $99 per month for monthly supplies, but also only for patients paying cash. Express Scripts, one of the largest PBMs, recently created a program to lower out-of-pocket insulin costs; again, this covers only a small section of the patient population, and health plans have to affirmatively pick up the option. Walmart sells an old version of human insulin for $25, but as Lipska explained, it doesn’t work for all patients and is incompatible with many new delivery devices. Patient outrage is driving these moves, but they mostly amount to half measures. As one blogger noted, the recent Colorado legislation— along with most of the measures listed here—doesn’t pass the Alec Smith test. Removing all financial barriers to insulin to ensure that all patients have an uninterrupted supply of it would require governmental intervention, not just relying on multinational companies to devise better deals. It might even demand making moves that end our reliance on those firms to make the drugs we need most. Elizabeth Warren has written legislation providing for the public manufacturing of generic drugs, and explicitly stated in the bill that generic insulin would have to be produced within a year of passage. Even President Obama’s former head of Medicare and Medicaid, Andy Slavitt, has recommended the total nationalization of the insulin market. For her part, Nicole Smith-Holt no longer has a relative who needs insulin, but has stayed to fight for others. In early May, she joined eight members of the Minnesota chapter of #insulin4all on a so-called “Caravan to Canada”—a five-hour road trip across the border to demonstrate the pressures on diabetes patients in the United States. Once they arrived, the same vials of insulin that retail for nearly $300 here were being sold for $30 apiece. Smith-Holt didn’t need any insulin, but bought some as a memento. “If I had known that by driving five hours north that I could have saved my son’s life for a couple hundred dollars, then he would still be here,” she told me after the trip. “Because I would have crawled, I would have swam, I would have biked, I would have done whatever I had to do to get there.”
“We’re not even talking about rising prices for better products here ... there’s nothing that’s changed about Humalog. It’s the same insulin that’s just gone up in price and now costs ten times more.”
Natalie Shure is a writer and researcher whose work focuses on health, history, and politics.
SUMMER 2019 THE AMERICAN PROSPECT 33