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WASHINGTON (AP) — Congress has so far struggled to rein in soaring insulin prices, even as Democrats say they will try again — as part of their economic plan to focus on health and the climate.

The price of the 100-year-old drug has more than tripled in the past 20 years, forcing Americans with diabetes to pay thousands of dollars a year for the life-saving drug. Democrats are considering capping the drug’s cost for at least some people, though it’s unclear what the final proposal would look like and how many insulin users would get the price cut.

Here’s a look at how insulin has become so expensive, and why it’s so hard to lower the price of the drug.

How many people in the US use insulin? for what?

About 8.4 million Americans use insulin, according to the American Diabetes Association. Not everyone with diabetes needs insulin, but for those who do, it is an important medication. Regular medication is necessary for the more than 1 million people with type 1 diabetes, without which they would die.

“People need insulin, it’s not a choice, and no one should be deciding between life-sustaining medication or food and rent,” said Dr. Robert Gabe, chief scientific and medical officer of the American Diabetes Association.

Insulin also helps control blood sugar levels in people with other forms of diabetes. Some insulin users ration the drug because of its expense, and risk many health complications as a result.

How expensive is insulin?

Prices vary.

Some people with private insurance pay hundreds of dollars a month for the drug. For most Medicare beneficiaries, the average out-of-pocket cost per insulin prescription in 2020 was $54 — an increase of nearly 40% since 2007, A study published last month Discovered by the Kaiser Family Foundation. Others live in one of the 22 states, and copays for 30-day supplies are capped at $25 to $100.

The cost has led some people to use less insulin than their doctor prescribed or delay paying for other medical bills.

Why is insulin so expensive?

Only three manufacturers — Eli Lilly, Novo Nordisk and Sanofi — make insulin, allowing these companies to control most of the market.

“Historically, they have been raising the price of their respective products in tandem,” said Dr. Jing Luo, a professor of medicine at the University of Pittsburgh. “There isn’t a lot of pricing pressure.”

Manufacturing insulin generics is no easy task, Luo added, and new manufacturers must clear regulatory hurdles and questions about how generics should be classified. A generic version of insulin is scheduled to hit the market in 2024 for no more than $30 a vial, which could reduce some of the price.

How are Democrats planning to cap insulin prices?

It remains to be seen.

Senate Majority Leader Chuck Schumer says language to limit insulin prices will be added to economic billbut it’s unclear what that price point will be and who will be protected by that price cap.

As part of a larger package that has derailed in the Senate, Democrats had proposed a $35-a-month cap for people who get their drugs through Medicare or private insurers. But it was excluded from the scaled-back package now poised for a congressional vote.

Why is the cost of insulin so hard to control?

Restricting insulin will be very expensive.

Not only is insulin becoming more expensive, but the number of people using it is also increasing.

A bipartisan bill introduced earlier this year to cap insulin prices could cost about $23 billion over the next decade, according to estimates from the Congressional Budget Office. While the bill would lower insulin costs for many consumers, it would drive up government costs and premiums charged by Medicare and private insurers, according to the office’s analysis.

This is one reason why price caps can be controversial.

“If your health insurance company voluntarily says that anyone who buys insulin on our plan has to pay more than $25, the question is who’s going to pay the balance?” Low said. “That means their costs will go up, which means they’ll raise everyone’s premiums.”

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