Health care executives faced the ire of lawmakers on Capitol Hill Wednesday, amid a growing outcry from patients who’ve been forced to ration insulin because of soaring prices.
“I don’t know how you people sleep at night,” Rep. Jan Schakowsky (D-IL) told a panel of insulin manufacturers and drug industry intermediaries assembled for a House Energy and Commerce Committee hearing on insulin prices. “I just want you to know your days are numbered.”
While the executives fumbled to explain themselves over the course of two days of questioning, one “solution” to the insulin access crisis resurfaced on social media: Patients should just buy cheap insulin at Walmart.
For context, the cost of the four most popular insulins has tripled over the past decade, forcing many of the millions of Americans with Type 1 or Type 2 diabetes who rely on the drug to skimp on or skip doses.
Walmart indeed offers a relatively inexpensive choice, essentially over the counter. People can go to pharmacies in stores nationwide and, without a prescription, purchase a vial of Novo Nordisk’s Novolin ReliOn Insulin for less than $25. (People with diabetes can require between one and six vials of insulin per month.)
But there’s a problem here: This low-cost option is far from ideal for all patients. Ultimately, “Walmart-ism,” as diabetes advocates call it, reveals a lot about what the debate around the insulin drug pricing crisis has become: a big blame game, filled with distractions from what’s really driving up drug prices.
The problems with Walmart’s insulin
Doctors and diabetes advocates point out that while ReliOn may help patients in a pinch, especially those without health insurance, it’s also a formulation (known as “human” insulin) that came on the market in the 1980s, more than a decade before more refined insulins started to emerge.
The newer insulins, known as analogs, appear to be more effective at preventing dangerous blood sugar swings in people with Type 1 diabetes or those at a higher risk for severe low blood sugar. (The evidence of insulin analog’s benefits is less clear for Type 2 diabetes, but the studies are also low quality so it’s difficult to make conclusive statements.)
There’s one more problem: Because it’s available without a prescription, patients can get the drug without the supervision of a doctor, and they sometimes get into trouble as a result. So stories have surfaced about patients who required emergency care because of severe blood sugar highs and lows after self-dosing with Walmart insulin, or even dying as a result.
“Human insulins are a reasonable option for many patients with Type 2 diabetes,” said Yale endocrinologist Kasia Lipska, who often prescribes the drugs for patients who can’t afford newer formulations. “But the drug isn’t optimal for everybody. And human insulin sold at Walmart is definitely not the solution to our insulin crisis.”
For people with Type 1 diabetes, human insulins “are harder to live on, lead to worse control, make it harder to hold down a job, impact quality of life,” said James Elliott, a trustee at T1International, an independent patient advocacy group, “and not everyone lives near a Walmart.”
A Novo Nordisk spokesperson said the low-cost formulation is also available at CVS and Express Scripts, though patients have to apply for a discount program first. “We have taken numerous steps to help make insulin more affordable for people living with diabetes,” the spokesperson said. “Approximately 775,000 people in the US use our human insulin.”
So while it’s true that Walmart offers insulin at a competitive price reminiscent of the days before insulin costs tripled and that it can be helpful for some patients, it’s not great for everybody with diabetes, and it can be dangerous for some.
Walmart-ism is part of the insulin drug pricing blame game
The Walmart solution first went viral in February, after it was featured on TV in Texas and then posted to Facebook. It continues to be bandied about on social media whenever people mention rising insulin prices. According to the meme, the problem isn’t that insulin is too expensive. The problem is that patients are too picky to take advantage of an affordable insulin option.
According to the pharmacy benefit managers testifying before Congress Tuesday, it’s the insulin manufacturers’ companies that are driving up the cost of the drug. At another congressional hearing Wednesday, pharmaceutical company executives blamed pharmacy benefit managers for helping inflate prices and boasted about their financial assistance programs as solutions to the access crisis.
The blame game involves many fingers pointing in many directions, but make no mistake: What’s driving up insulin costs is that drug companies have raised prices because they can.
As I recently explained, the US is an outlier in insulin costs and spending. America represents only 15 percent of the global insulin market and generates almost half of the pharmaceutical industry’s insulin revenue.
Although insulin was discovered a century ago, manufacturers have made incremental changes to their formulations that have allowed them to extend the patents for these drugs. Even where patents have expired, the road to getting generic insulin on the market is so complicated and expensive that recent attempts have failed.
So how did we get here? Unlike other countries, America gives drug companies free rein to set prices. The result is that the cost of the four most popular types of insulin has tripled over the past decade, and the out-of-pocket prescription costs patients now face have doubled.
Let’s break that down with some dollar figures. By 2016, the average list price of insulin rose to $450 per month. Patients can wind up paying out of pocket anything from $25 per month, if they have generous health insurance coverage or buy older insulin versions at Walmart, to more than $1,000 if they don’t have insurance or have a high deductible plan, according to T1International.
One quick fix to improve insulin access
Lately there’s been more attention on the insulin pricing problem. Members of Congress have been pressuring drug companies and pharmacy benefit managers to bring insulin costs under control. Last Wednesday, the insurance behemoth Cigna, and its pharmacy benefit arm Express Scripts, announced a new program that’ll cap the 30-day cost of insulin at $25. That’s a 40 percent reduction from the $41.50-per-month fee people with Express Scripts benefits were paying in 2018.
But like the Walmart option, these programs amount to Band-Aid solutions, said Elizabeth Pfiester, the founder and executive director of T1International.
With Walmart, patients are “having to revert to an older insulin that can damage you,” she said. Meanwhile, the Sanofi and Cigna programs “can be shut down or rescinded at any time. That’s not any kind of assurance for patients.”
“Patients will not fall for these fake measures that do nothing to solve the crisis we are facing,” she added.
There’s one way the insulin drug pricing problem could be fixed, however: lowering the price of insulin, said Yale’s Lipska. “Ultimately, it’s the list price that’s hurting patients. I keep going back to that: Just fix the list price.”
Companies could decide that instead of launching one-off programs or doling out discounts, they’ll forgo profits and lower list prices once and for all. Or lawmakers could decide to regulate drug pricing.
“We have a big problem here,” Lipska said. “People are hurting and people are dying. How much more will it take for them to regulate this? Clearly what’s in place now is not working. This is a place where our legislators can step in and help protect the patients with diabetes.”
Update, April 11: We’ve updated the story with quotes from Novo Nordisk, who responded to our request for comment after the story first published.