The Inflation Reduction Act (IRA) is a sweeping achievement for Joe Biden and Democratic legislators. As I discussed earlier, the bill is the most consequential effort to address climate change in our history. 

It controls prescription drug prices. It strengthens the IRS to address rich tax cheats. It makes our country more equitable. It’s a huge win.

The legislation also came with a few losses, though. 

One of the biggest involved insulin. Democrats have long been trying to cap insulin prices. They finally did with the IRA – partially. 

The IRA is an achievement worth celebrating. But a Congress that can’t pass wildly popular measures to protect chronically ill people from rapacious price gouging is a Congress that remains broken.

Their failure shows again that, despite a productive session, Congress is still dysfunctional. Not least because the filibuster, touted as a spur to bipartisanship, makes bipartisan legislating almost impossible even on overwhelmingly popular imperatives.

Cartel price fixing
In the US, about 8.4 million people use insulin, according to the American Diabetes Association. Some 1 million people with type 1 diabetes need regular access to insulin or they’ll die.

Three manufacturers make insulin: Eli Lilly, Novo Nordisk and Sanofi. Efforts to bring generics to market have so far been unsuccessful. 

That means that a handful of corporations has a stranglehold on the insulin market. As a result, they’ve used their cartel power to jack up prices. Insulin costs have more than tripled over the past 20 years. 

Insulin prices in the US are 10 times higher in the US than anywhere else in the world. A RAND corporation study found that the US manufacturer price for a standard unit of insulin is $98.70. In Australia, it is $6.94. In Canada, it is $12. In the UK, $7.52.

When insulin prices are prohibitive, patients will sometimes try rationing, leading to dangerous medical complications, even death. 

In the US, nearly 26 percent of insulin users say that they have rationed or foregone insulin in the last year due to financial constraints. In comparable countries, the number was 6.5 percent.

A policy star
Capping insulin prices is very popular. 

About 87 percent of the public favors it, including 84 percent of Republicans. That is as close to unanimity as it is possible to get.

Activists and Democrats have been trying for years to cap insulin copays to take the financial burden off of diabetes patients. 

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Colorado became the first state to pass a cap (at $100) in 2019. Since then 21 other states have passed their own caps.

With the IRA, Democrats thought they’d finally gotten a federal cap. The Senate version of the bill capped insulin copays for Medicare Part D beneficiaries and private insurers at $35.

The Democrats had the votes. But the Senate parliamentarian ruled that regulating private insurers was not a budgetary measure. 

Overruling the parliamentarian required 60 votes (a filibuster), but the IRA received no Republican votes. Surprisingly, though, a number of Republicans did cross party lines to try to uphold the price cap.

Moderate Republicans Lisa Murkowski of Alaska and Susan Collins of Maine voted to keep the cap. That’s not that unusual. 

But very conservative Republicans supported the bill, too. They were Bill Cassidy and John Kennedy of Louisiana, Cynthia Hyde-Smith of Mississippi, Josh Hawley of Missouri, and Dan Sullivan of Alaska. 

Stifling bipartisanship
It’s surprising to see far-right southerners advocate for good health care policies. But their calculus is fairly straightforward. Insulin caps are very popular with Republicans. Eighty-four percent support it. In addition, many GOP voters are old. Many old people have diabetes. 

John Kennedy advocated for a cap before the IRA. About 14.3 percent of Louisianans have diabetes — the fourth-highest rate in the US. 

Mississippi’s rate, at 14.3 percent, is the third-highest. In 2020, it had the nation’s second-highest diabetes mortality rate, surpassed only by West Virginia. Hyde-Smith said that she supported the provision despite disliking the IRA as a whole.  “I strongly opposed the Democrats’ tax and spend plan, but liked the chance of capping insulin costs even if that plan may not have been a perfect fix.”

In other words, she put partisanship aside to vote for a measure that her constituents supported, because she feels accountable to them. 

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That’s how bipartisan incentives are supposed to work.

Despite substantial Republican support, though, the insulin cap for private insurers didn’t pass. Three more GOP votes were needed. 

The filibuster stifled bipartisan legislation.

Even Josh Hawley!
In theory, the filibuster encourages compromise. But the failure of legislation to cap insulin shows clearly that it does the opposite. 

Because of supermajority requirements, Democrats were able to pass only the portions of the IRA that had no Republican support. 

The commonsense, wildly popular measure that garnered support even from Josh Hawley (!) was struck down and didn’t become law.

Without the filibuster, individual senators might cross party lines on any number of issues, like insulin pricing, to make up a majority.

With the filibuster, Senators know that their votes probably won’t matter. So there’s a strong incentive to just stick with the party and let the opposition pass what they can through reconciliation.

Still broken
The Inflation Reduction Act will help an estimated 3.3 million Medicare patients afford insulin. But millions more will still struggle, despite the bipartisan consensus of Senators representing 32 of 50 states and 214 million people or roughly two-thirds of the population.

The IRA is an achievement worth celebrating. But a Congress that can’t pass wildly popular measures to protect chronically ill people from rapacious price gouging is a Congress that remains broken.

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