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﷯ Legislation Insulin pricing A crisis and an opportunity By Sen. Scott Jensen, MD ﷯ day of reckoning has arrived for Minnesotans. Across the state this question is being asked repeatedly: “Who bears the costs of chronic medical problems able to be successfully treated with life-sustaining expensive medications?” Insulin has become the center point in this discussion regarding the inadequacies in our current health care system. While this is frustrating to some, I believe it presents an opportunity to pivot the conversation towards “who are we and what do we want our health care system to do?” History For too long, patients suffering from pre-existing conditions have been left alone to navigate the medical maze that accompanies the ownership of chronic diseases such as diabetes, epilepsy, asthma, peanut allergies, and many other maladies. Even though these illnesses can be successfully managed with medications and/or avoidance measures, the journey to find a way to obtain, afford, and manage the necessary prescriptions is an arduous one. A step back in time may be instructive. Fifty years ago, the first human landed on the moon, the Mets won the World Series, the crowds at Woodstock dispersed, and health care coverage was expanding rapidly. Four years earlier, the creation of Medicare and Medical Assistance piggybacked on an already expanding employee-based health insurance industry to give rise to a question destined to nag society for decades: “Is health care a right or a privilege?” ﷯ I believe that in the wake of Obamacare and so many other initiatives, this question now approximates irrelevance. A 30,000-foot view sees an affluent country trying to pivot around the question of responsibility: “What responsibility does society and government have for providing basic health care services to all?” Alongside this question lies a challenge to all citizens to be responsible users of health care services and to recognize that the common good is served best by a restrained appetite for medicines, tests, and professional medical attention. Currently more than 80% of Minnesotans believe that a basic package of health care should be available to all. I agree with this assessment, but I am impressed virtually every day by the challenge of gaining bipartisan consensus to support this viewpoint that society is best served through the provision of medical care for all. The vast majority of physicians agree that creating a universally accessible and affordable first-world health care system will require an underlying social contract between government and its citizens, recognizing that resources have limitations and abuse of consumption can and will undermine the best of intentions. We turn our attention now to the never-ending bickering about what to do with our health care system with all of its myriad problems—lack of access, unaffordable costs, epidemic corporate greed, excessive patient utilization of resources, physician profiteering from the use of low-value services, and so many more abuses. The last eight months may be viewed by many as a distasteful political stew of scheming and backroom machinations devised to blame the “other political party” for not being motivated to solve the insulin price crisis. The end result was predictable: “kick the can” down the road. Rising price tags A quick summary will refresh our minds with the following facts: an astronomical rise in the cost of insulin products has inflicted catastrophic effects on patients who experience an interruption in their continuous supply of insulin. A perfect storm of adverse marketplace trends has compromised access to affordable insulin, and this very real hardship has now become one of the premiere health care issues throughout America. ﷯ Rather than go into detail regarding the cost of insulin products, I share one fact: in the last couple of decades a single unit of insulin has gone from a few pennies to almost half a dollar in some circumstances. Insulin is a biologic product and, as such, generating cost-effective biosimilars does not parallel the relatively conventional process of creating inexpensive generic small molecule products. Virtually every primary care physician in Minnesota and many specialists can share numerous anecdotal stories about how their patients have suffered from the exponential rise in the cost of insulin, which has often led to devastating financial impacts, the interruption of stable health, and even the loss of life. The practice of rationing insulin is not an uncommon response on the part of patients—it has become commonplace and is quite understandable when one considers the complex intersection of needs, wants, dollars, and priorities. The pharmaceutical supply chain, with its many twists and turns, contributes mightily to the rising cost of insulin, but the blame game should not be limited to manufacturers, wholesalers, pharmacy benefit mangers (PBMs), employers, insurance payers, or pharmacists. Culpability even includes physicians and patients. When physicians prescribe insulin without specifically addressing the issue of cost and inquiring as to how the patient will be able to access and afford insulin, they are treating the patient as a mere client or chart number—we can and must do better for our patients and their families. When patients and families have a solid understanding of the disease and yet allow an emerging crisis to become a real catastrophe, they also share the blame by not being more proactive in reaching out to their pharmacist and/or physician. Pharmaceutical manufacturers have used effective marketing techniques, including samples, coupons, pharmaceutical representatives, perks, and meals to convince physicians and patients that each and every new product released on the market is better than the last. Marketing initiatives have insidiously and successfully brainwashed too many people into thinking that the use of any inexpensive old-fashioned insulin products delivered by old-fashioned syringes obtained from old-fashioned vials associated with old fashioned costs is second-class care associated with terrible prognoses and likely future loss of limbs or kidneys. Savvy physicians realize that, while insulin analogues contain glitzy bells and whistles, old-fashioned, less expensive human-based products can still do an adequate job in many situations in managing diabetes in accordance with best practice standards. Stalled legislation My perception of the recent 2019 session of the Minnesota Legislature was unfavorable, as many important topics were blocked from committee hearings by chairpersons, and a behind-the-scene triumvirate team—the governor, senate majority leader, and speaker of the house canceled out much committee policy work done during the first five months of legislative meetings. Many political pundits termed the session as a “dud” and House Republican Minority Leader Kurt Daudt said this: “This has been the least productive, least transparent session in the history of this state. Minnesotans should be ashamed of the process at the end of this legislative session.” Nevertheless, one bright spot did occur as a strong pharmacy benefit manager bill was passed and signed by the governor. (I was privileged to serve as chief author.) This legislation focused on PBM licensure, increased transparency requirements regarding manufacturer rebate trails, PBM strategies utilizing aggressive “spread pricing” and “clawbacking” tools to increase retail costs and copays in an attempt to increase revenues, and the ability of employers and insurance companies to view more financial data from PBM activities. ﷯ Despite the passage of a biennial budget, many other important initiatives fell by the wayside. One of these was the insulin bill chief-authored by Senator Melissa Wiklund (DFL) and co-authored by me. This bill had several components, one of which was authorization for emergency prescription refills of insulin in situations when a current prescription was not available—this feature was added onto the Health and Human Services omnibus bill, which passed in the special session. However, the actual insulin assistance program clause—the heart of the Alec Smith bill, named for a Minneapolis man who died because he could not afford his insulin—did not get a hearing in the Senate, nor did it get tacked on to any other bills. During a truncated and chaotic end-of-session discussion of numerous insulin proposals—two Republican and two Democratic submissions—no insulin initiatives were allowed to be vetted in the customary manner, and nothing passed in the House or Senate. In the special session, the tribunal of leaders decreed there would be no amendments allowed on any of the omnibus bills and that the session had to adjourn by 7 a.m. on May 25. This edict essentially killed the possibility of enacting any insulin assistance program legislation. In early June a bipartisan, bicameral group of legislators came together to remedy the legislative shortcoming regarding an insulin assistance program and hammered out details establishing applicant eligibility criteria, a network of participating pharmacies, and possible sustainable sources of funding. Today only the funding issue remains a point of contention and this question cannot be resolved without Gov. Tim Walz, Sen. Paul Gazelka (R), and Rep. Melissa Hortman (DFL) coming together, rolling up their sleeves, and putting forth a joint proposal. The puzzling aspect for me regarding the development of an insulin assistance program is this: if both parties care deeply about people with pre-existing conditions, why don’t the leaders in the House and Senate commit to getting a program in place? Arguably, there is no more prevalent and galvanizing chronic disease than diabetes. When diabetes care involves insulin with its punishingly inflated prices, lives become threatened. The time is now. Minnesota can lead as we have led before. A basic package of health care services for all Minnesotans is not too much to ask. Sharing the burden of pre-existing conditions and the cost associated with chronic medical problems is not too much to ask. And finally doing something now rather than later to create an insulin assistance program is not too much to ask. And, in fact, Minnesotans are asking. Scott Jensen, MD, is a family physician practicing in Watertown and Chaska, Minnesota. He is an associate professor at the University of Minnesota Medical School and a state senator (R) serving as vice-chair of the Health and Human Services committee. He was chair of the Senate Select Committee on Health Care Consumer Access and Affordability in 2017 and 2018. ﷯
﷯ Legislation Insulin pricing A crisis and an opportunity By Sen. Scott Jensen, MD ﷯ day of reckoning has arrived for Minnesotans. Across the state this question is being asked repeatedly: “Who bears the costs of chronic medical problems able to be successfully treated with life-sustaining expensive medications?” Insulin has become the center point in this discussion regarding the inadequacies in our current health care system. While this is frustrating to some, I believe it presents an opportunity to pivot the conversation towards “who are we and what do we want our health care system to do?” History For too long, patients suffering from pre-existing conditions have been left alone to navigate the medical maze that accompanies the ownership of chronic diseases such as diabetes, epilepsy, asthma, peanut allergies, and many other maladies. Even though these illnesses can be successfully managed with medications and/or avoidance measures, the journey to find a way to obtain, afford, and manage the necessary prescriptions is an arduous one. A step back in time may be instructive. Fifty years ago, the first human landed on the moon, the Mets won the World Series, the crowds at Woodstock dispersed, and health care coverage was expanding rapidly. Four years earlier, the creation of Medicare and Medical Assistance piggybacked on an already expanding employee-based health insurance industry to give rise to a question destined to nag society for decades: “Is health care a right or a privilege?” ﷯ I believe that in the wake of Obamacare and so many other initiatives, this question now approximates irrelevance. A 30,000-foot view sees an affluent country trying to pivot around the question of responsibility: “What responsibility does society and government have for providing basic health care services to all?” Alongside this question lies a challenge to all citizens to be responsible users of health care services and to recognize that the common good is served best by a restrained appetite for medicines, tests, and professional medical attention. Currently more than 80% of Minnesotans believe that a basic package of health care should be available to all. I agree with this assessment, but I am impressed virtually every day by the challenge of gaining bipartisan consensus to support this viewpoint that society is best served through the provision of medical care for all. The vast majority of physicians agree that creating a universally accessible and affordable first-world health care system will require an underlying social contract between government and its citizens, recognizing that resources have limitations and abuse of consumption can and will undermine the best of intentions. We turn our attention now to the never-ending bickering about what to do with our health care system with all of its myriad problems—lack of access, unaffordable costs, epidemic corporate greed, excessive patient utilization of resources, physician profiteering from the use of low-value services, and so many more abuses. The last eight months may be viewed by many as a distasteful political stew of scheming and backroom machinations devised to blame the “other political party” for not being motivated to solve the insulin price crisis. The end result was predictable: “kick the can” down the road. Rising price tags A quick summary will refresh our minds with the following facts: an astronomical rise in the cost of insulin products has inflicted catastrophic effects on patients who experience an interruption in their continuous supply of insulin. A perfect storm of adverse marketplace trends has compromised access to affordable insulin, and this very real hardship has now become one of the premiere health care issues throughout America. ﷯ Rather than go into detail regarding the cost of insulin products, I share one fact: in the last couple of decades a single unit of insulin has gone from a few pennies to almost half a dollar in some circumstances. Insulin is a biologic product and, as such, generating cost-effective biosimilars does not parallel the relatively conventional process of creating inexpensive generic small molecule products. Virtually every primary care physician in Minnesota and many specialists can share numerous anecdotal stories about how their patients have suffered from the exponential rise in the cost of insulin, which has often led to devastating financial impacts, the interruption of stable health, and even the loss of life. The practice of rationing insulin is not an uncommon response on the part of patients—it has become commonplace and is quite understandable when one considers the complex intersection of needs, wants, dollars, and priorities. The pharmaceutical supply chain, with its many twists and turns, contributes mightily to the rising cost of insulin, but the blame game should not be limited to manufacturers, wholesalers, pharmacy benefit mangers (PBMs), employers, insurance payers, or pharmacists. Culpability even includes physicians and patients. When physicians prescribe insulin without specifically addressing the issue of cost and inquiring as to how the patient will be able to access and afford insulin, they are treating the patient as a mere client or chart number—we can and must do better for our patients and their families. When patients and families have a solid understanding of the disease and yet allow an emerging crisis to become a real catastrophe, they also share the blame by not being more proactive in reaching out to their pharmacist and/or physician. Pharmaceutical manufacturers have used effective marketing techniques, including samples, coupons, pharmaceutical representatives, perks, and meals to convince physicians and patients that each and every new product released on the market is better than the last. Marketing initiatives have insidiously and successfully brainwashed too many people into thinking that the use of any inexpensive old-fashioned insulin products delivered by old-fashioned syringes obtained from old-fashioned vials associated with old fashioned costs is second-class care associated with terrible prognoses and likely future loss of limbs or kidneys. Savvy physicians realize that, while insulin analogues contain glitzy bells and whistles, old-fashioned, less expensive human-based products can still do an adequate job in many situations in managing diabetes in accordance with best practice standards. Stalled legislation My perception of the recent 2019 session of the Minnesota Legislature was unfavorable, as many important topics were blocked from committee hearings by chairpersons, and a behind-the-scene triumvirate team—the governor, senate majority leader, and speaker of the house canceled out much committee policy work done during the first five months of legislative meetings. Many political pundits termed the session as a “dud” and House Republican Minority Leader Kurt Daudt said this: “This has been the least productive, least transparent session in the history of this state. Minnesotans should be ashamed of the process at the end of this legislative session.” Nevertheless, one bright spot did occur as a strong pharmacy benefit manager bill was passed and signed by the governor. (I was privileged to serve as chief author.) This legislation focused on PBM licensure, increased transparency requirements regarding manufacturer rebate trails, PBM strategies utilizing aggressive “spread pricing” and “clawbacking” tools to increase retail costs and copays in an attempt to increase revenues, and the ability of employers and insurance companies to view more financial data from PBM activities. ﷯ Despite the passage of a biennial budget, many other important initiatives fell by the wayside. One of these was the insulin bill chief-authored by Senator Melissa Wiklund (DFL) and co-authored by me. This bill had several components, one of which was authorization for emergency prescription refills of insulin in situations when a current prescription was not available—this feature was added onto the Health and Human Services omnibus bill, which passed in the special session. However, the actual insulin assistance program clause—the heart of the Alec Smith bill, named for a Minneapolis man who died because he could not afford his insulin—did not get a hearing in the Senate, nor did it get tacked on to any other bills. During a truncated and chaotic end-of-session discussion of numerous insulin proposals—two Republican and two Democratic submissions—no insulin initiatives were allowed to be vetted in the customary manner, and nothing passed in the House or Senate. In the special session, the tribunal of leaders decreed there would be no amendments allowed on any of the omnibus bills and that the session had to adjourn by 7 a.m. on May 25. This edict essentially killed the possibility of enacting any insulin assistance program legislation. In early June a bipartisan, bicameral group of legislators came together to remedy the legislative shortcoming regarding an insulin assistance program and hammered out details establishing applicant eligibility criteria, a network of participating pharmacies, and possible sustainable sources of funding. Today only the funding issue remains a point of contention and this question cannot be resolved without Gov. Tim Walz, Sen. Paul Gazelka (R), and Rep. Melissa Hortman (DFL) coming together, rolling up their sleeves, and putting forth a joint proposal. The puzzling aspect for me regarding the development of an insulin assistance program is this: if both parties care deeply about people with pre-existing conditions, why don’t the leaders in the House and Senate commit to getting a program in place? Arguably, there is no more prevalent and galvanizing chronic disease than diabetes. When diabetes care involves insulin with its punishingly inflated prices, lives become threatened. The time is now. Minnesota can lead as we have led before. A basic package of health care services for all Minnesotans is not too much to ask. Sharing the burden of pre-existing conditions and the cost associated with chronic medical problems is not too much to ask. And finally doing something now rather than later to create an insulin assistance program is not too much to ask. And, in fact, Minnesotans are asking. Scott Jensen, MD, is a family physician practicing in Watertown and Chaska, Minnesota. He is an associate professor at the University of Minnesota Medical School and a state senator (R) serving as vice-chair of the Health and Human Services committee. He was chair of the Senate Select Committee on Health Care Consumer Access and Affordability in 2017 and 2018. ﷯
﷯ Legislation Insulin pricing A crisis and an opportunity By Sen. Scott Jensen, MD ﷯ day of reckoning has arrived for Minnesotans. Across the state this question is being asked repeatedly: “Who bears the costs of chronic medical problems able to be successfully treated with life-sustaining expensive medications?” Insulin has become the center point in this discussion regarding the inadequacies in our current health care system. While this is frustrating to some, I believe it presents an opportunity to pivot the conversation towards “who are we and what do we want our health care system to do?” History For too long, patients suffering from pre-existing conditions have been left alone to navigate the medical maze that accompanies the ownership of chronic diseases such as diabetes, epilepsy, asthma, peanut allergies, and many other maladies. Even though these illnesses can be successfully managed with medications and/or avoidance measures, the journey to find a way to obtain, afford, and manage the necessary prescriptions is an arduous one. A step back in time may be instructive. Fifty years ago, the first human landed on the moon, the Mets won the World Series, the crowds at Woodstock dispersed, and health care coverage was expanding rapidly. Four years earlier, the creation of Medicare and Medical Assistance piggybacked on an already expanding employee-based health insurance industry to give rise to a question destined to nag society for decades: “Is health care a right or a privilege?” ﷯ I believe that in the wake of Obamacare and so many other initiatives, this question now approximates irrelevance. A 30,000-foot view sees an affluent country trying to pivot around the question of responsibility: “What responsibility does society and government have for providing basic health care services to all?” Alongside this question lies a challenge to all citizens to be responsible users of health care services and to recognize that the common good is served best by a restrained appetite for medicines, tests, and professional medical attention. Currently more than 80% of Minnesotans believe that a basic package of health care should be available to all. I agree with this assessment, but I am impressed virtually every day by the challenge of gaining bipartisan consensus to support this viewpoint that society is best served through the provision of medical care for all. The vast majority of physicians agree that creating a universally accessible and affordable first-world health care system will require an underlying social contract between government and its citizens, recognizing that resources have limitations and abuse of consumption can and will undermine the best of intentions. We turn our attention now to the never-ending bickering about what to do with our health care system with all of its myriad problems—lack of access, unaffordable costs, epidemic corporate greed, excessive patient utilization of resources, physician profiteering from the use of low-value services, and so many more abuses. The last eight months may be viewed by many as a distasteful political stew of scheming and backroom machinations devised to blame the “other political party” for not being motivated to solve the insulin price crisis. The end result was predictable: “kick the can” down the road. Rising price tags A quick summary will refresh our minds with the following facts: an astronomical rise in the cost of insulin products has inflicted catastrophic effects on patients who experience an interruption in their continuous supply of insulin. A perfect storm of adverse marketplace trends has compromised access to affordable insulin, and this very real hardship has now become one of the premiere health care issues throughout America. ﷯ Rather than go into detail regarding the cost of insulin products, I share one fact: in the last couple of decades a single unit of insulin has gone from a few pennies to almost half a dollar in some circumstances. Insulin is a biologic product and, as such, generating cost-effective biosimilars does not parallel the relatively conventional process of creating inexpensive generic small molecule products. Virtually every primary care physician in Minnesota and many specialists can share numerous anecdotal stories about how their patients have suffered from the exponential rise in the cost of insulin, which has often led to devastating financial impacts, the interruption of stable health, and even the loss of life. The practice of rationing insulin is not an uncommon response on the part of patients—it has become commonplace and is quite understandable when one considers the complex intersection of needs, wants, dollars, and priorities. The pharmaceutical supply chain, with its many twists and turns, contributes mightily to the rising cost of insulin, but the blame game should not be limited to manufacturers, wholesalers, pharmacy benefit mangers (PBMs), employers, insurance payers, or pharmacists. Culpability even includes physicians and patients. When physicians prescribe insulin without specifically addressing the issue of cost and inquiring as to how the patient will be able to access and afford insulin, they are treating the patient as a mere client or chart number—we can and must do better for our patients and their families. When patients and families have a solid understanding of the disease and yet allow an emerging crisis to become a real catastrophe, they also share the blame by not being more proactive in reaching out to their pharmacist and/or physician. Pharmaceutical manufacturers have used effective marketing techniques, including samples, coupons, pharmaceutical representatives, perks, and meals to convince physicians and patients that each and every new product released on the market is better than the last. Marketing initiatives have insidiously and successfully brainwashed too many people into thinking that the use of any inexpensive old-fashioned insulin products delivered by old-fashioned syringes obtained from old-fashioned vials associated with old fashioned costs is second-class care associated with terrible prognoses and likely future loss of limbs or kidneys. Savvy physicians realize that, while insulin analogues contain glitzy bells and whistles, old-fashioned, less expensive human-based products can still do an adequate job in many situations in managing diabetes in accordance with best practice standards. Stalled legislation My perception of the recent 2019 session of the Minnesota Legislature was unfavorable, as many important topics were blocked from committee hearings by chairpersons, and a behind-the-scene triumvirate team—the governor, senate majority leader, and speaker of the house canceled out much committee policy work done during the first five months of legislative meetings. Many political pundits termed the session as a “dud” and House Republican Minority Leader Kurt Daudt said this: “This has been the least productive, least transparent session in the history of this state. Minnesotans should be ashamed of the process at the end of this legislative session.” Nevertheless, one bright spot did occur as a strong pharmacy benefit manager bill was passed and signed by the governor. (I was privileged to serve as chief author.) This legislation focused on PBM licensure, increased transparency requirements regarding manufacturer rebate trails, PBM strategies utilizing aggressive “spread pricing” and “clawbacking” tools to increase retail costs and copays in an attempt to increase revenues, and the ability of employers and insurance companies to view more financial data from PBM activities. ﷯ Despite the passage of a biennial budget, many other important initiatives fell by the wayside. One of these was the insulin bill chief-authored by Senator Melissa Wiklund (DFL) and co-authored by me. This bill had several components, one of which was authorization for emergency prescription refills of insulin in situations when a current prescription was not available—this feature was added onto the Health and Human Services omnibus bill, which passed in the special session. However, the actual insulin assistance program clause—the heart of the Alec Smith bill, named for a Minneapolis man who died because he could not afford his insulin—did not get a hearing in the Senate, nor did it get tacked on to any other bills. During a truncated and chaotic end-of-session discussion of numerous insulin proposals—two Republican and two Democratic submissions—no insulin initiatives were allowed to be vetted in the customary manner, and nothing passed in the House or Senate. In the special session, the tribunal of leaders decreed there would be no amendments allowed on any of the omnibus bills and that the session had to adjourn by 7 a.m. on May 25. This edict essentially killed the possibility of enacting any insulin assistance program legislation. In early June a bipartisan, bicameral group of legislators came together to remedy the legislative shortcoming regarding an insulin assistance program and hammered out details establishing applicant eligibility criteria, a network of participating pharmacies, and possible sustainable sources of funding. Today only the funding issue remains a point of contention and this question cannot be resolved without Gov. Tim Walz, Sen. Paul Gazelka (R), and Rep. Melissa Hortman (DFL) coming together, rolling up their sleeves, and putting forth a joint proposal. The puzzling aspect for me regarding the development of an insulin assistance program is this: if both parties care deeply about people with pre-existing conditions, why don’t the leaders in the House and Senate commit to getting a program in place? Arguably, there is no more prevalent and galvanizing chronic disease than diabetes. When diabetes care involves insulin with its punishingly inflated prices, lives become threatened. The time is now. Minnesota can lead as we have led before. A basic package of health care services for all Minnesotans is not too much to ask. Sharing the burden of pre-existing conditions and the cost associated with chronic medical problems is not too much to ask. And finally doing something now rather than later to create an insulin assistance program is not too much to ask. And, in fact, Minnesotans are asking. Scott Jensen, MD, is a family physician practicing in Watertown and Chaska, Minnesota. He is an associate professor at the University of Minnesota Medical School and a state senator (R) serving as vice-chair of the Health and Human Services committee. He was chair of the Senate Select Committee on Health Care Consumer Access and Affordability in 2017 and 2018. ﷯

﷯ Legislation Insulin pricing A crisis and an opportunity By Sen. Scott Jensen, MD ﷯ day of reckoning has arrived for Minnesotans. Across the state this question is being asked repeatedly: “Who bears the costs of chronic medical problems able to be successfully treated with life-sustaining expensive medications?” Insulin has become the center point in this discussion regarding the inadequacies in our current health care system. While this is frustrating to some, I believe it presents an opportunity to pivot the conversation towards “who are we and what do we want our health care system to do?” History For too long, patients suffering from pre-existing conditions have been left alone to navigate the medical maze that accompanies the ownership of chronic diseases such as diabetes, epilepsy, asthma, peanut allergies, and many other maladies. Even though these illnesses can be successfully managed with medications and/or avoidance measures, the journey to find a way to obtain, afford, and manage the necessary prescriptions is an arduous one. A step back in time may be instructive. Fifty years ago, the first human landed on the moon, the Mets won the World Series, the crowds at Woodstock dispersed, and health care coverage was expanding rapidly. Four years earlier, the creation of Medicare and Medical Assistance piggybacked on an already expanding employee-based health insurance industry to give rise to a question destined to nag society for decades: “Is health care a right or a privilege?” ﷯ I believe that in the wake of Obamacare and so many other initiatives, this question now approximates irrelevance. A 30,000-foot view sees an affluent country trying to pivot around the question of responsibility: “What responsibility does society and government have for providing basic health care services to all?” Alongside this question lies a challenge to all citizens to be responsible users of health care services and to recognize that the common good is served best by a restrained appetite for medicines, tests, and professional medical attention. Currently more than 80% of Minnesotans believe that a basic package of health care should be available to all. I agree with this assessment, but I am impressed virtually every day by the challenge of gaining bipartisan consensus to support this viewpoint that society is best served through the provision of medical care for all. The vast majority of physicians agree that creating a universally accessible and affordable first-world health care system will require an underlying social contract between government and its citizens, recognizing that resources have limitations and abuse of consumption can and will undermine the best of intentions. We turn our attention now to the never-ending bickering about what to do with our health care system with all of its myriad problems—lack of access, unaffordable costs, epidemic corporate greed, excessive patient utilization of resources, physician profiteering from the use of low-value services, and so many more abuses. The last eight months may be viewed by many as a distasteful political stew of scheming and backroom machinations devised to blame the “other political party” for not being motivated to solve the insulin price crisis. The end result was predictable: “kick the can” down the road. Rising price tags A quick summary will refresh our minds with the following facts: an astronomical rise in the cost of insulin products has inflicted catastrophic effects on patients who experience an interruption in their continuous supply of insulin. A perfect storm of adverse marketplace trends has compromised access to affordable insulin, and this very real hardship has now become one of the premiere health care issues throughout America. ﷯ Rather than go into detail regarding the cost of insulin products, I share one fact: in the last couple of decades a single unit of insulin has gone from a few pennies to almost half a dollar in some circumstances. Insulin is a biologic product and, as such, generating cost-effective biosimilars does not parallel the relatively conventional process of creating inexpensive generic small molecule products. Virtually every primary care physician in Minnesota and many specialists can share numerous anecdotal stories about how their patients have suffered from the exponential rise in the cost of insulin, which has often led to devastating financial impacts, the interruption of stable health, and even the loss of life. The practice of rationing insulin is not an uncommon response on the part of patients—it has become commonplace and is quite understandable when one considers the complex intersection of needs, wants, dollars, and priorities. The pharmaceutical supply chain, with its many twists and turns, contributes mightily to the rising cost of insulin, but the blame game should not be limited to manufacturers, wholesalers, pharmacy benefit mangers (PBMs), employers, insurance payers, or pharmacists. Culpability even includes physicians and patients. When physicians prescribe insulin without specifically addressing the issue of cost and inquiring as to how the patient will be able to access and afford insulin, they are treating the patient as a mere client or chart number—we can and must do better for our patients and their families. When patients and families have a solid understanding of the disease and yet allow an emerging crisis to become a real catastrophe, they also share the blame by not being more proactive in reaching out to their pharmacist and/or physician. Pharmaceutical manufacturers have used effective marketing techniques, including samples, coupons, pharmaceutical representatives, perks, and meals to convince physicians and patients that each and every new product released on the market is better than the last. Marketing initiatives have insidiously and successfully brainwashed too many people into thinking that the use of any inexpensive old-fashioned insulin products delivered by old-fashioned syringes obtained from old-fashioned vials associated with old fashioned costs is second-class care associated with terrible prognoses and likely future loss of limbs or kidneys. Savvy physicians realize that, while insulin analogues contain glitzy bells and whistles, old-fashioned, less expensive human-based products can still do an adequate job in many situations in managing diabetes in accordance with best practice standards. Stalled legislation My perception of the recent 2019 session of the Minnesota Legislature was unfavorable, as many important topics were blocked from committee hearings by chairpersons, and a behind-the-scene triumvirate team—the governor, senate majority leader, and speaker of the house canceled out much committee policy work done during the first five months of legislative meetings. Many political pundits termed the session as a “dud” and House Republican Minority Leader Kurt Daudt said this: “This has been the least productive, least transparent session in the history of this state. Minnesotans should be ashamed of the process at the end of this legislative session.” Nevertheless, one bright spot did occur as a strong pharmacy benefit manager bill was passed and signed by the governor. (I was privileged to serve as chief author.) This legislation focused on PBM licensure, increased transparency requirements regarding manufacturer rebate trails, PBM strategies utilizing aggressive “spread pricing” and “clawbacking” tools to increase retail costs and copays in an attempt to increase revenues, and the ability of employers and insurance companies to view more financial data from PBM activities. ﷯ Despite the passage of a biennial budget, many other important initiatives fell by the wayside. One of these was the insulin bill chief-authored by Senator Melissa Wiklund (DFL) and co-authored by me. This bill had several components, one of which was authorization for emergency prescription refills of insulin in situations when a current prescription was not available—this feature was added onto the Health and Human Services omnibus bill, which passed in the special session. However, the actual insulin assistance program clause—the heart of the Alec Smith bill, named for a Minneapolis man who died because he could not afford his insulin—did not get a hearing in the Senate, nor did it get tacked on to any other bills. During a truncated and chaotic end-of-session discussion of numerous insulin proposals—two Republican and two Democratic submissions—no insulin initiatives were allowed to be vetted in the customary manner, and nothing passed in the House or Senate. In the special session, the tribunal of leaders decreed there would be no amendments allowed on any of the omnibus bills and that the session had to adjourn by 7 a.m. on May 25. This edict essentially killed the possibility of enacting any insulin assistance program legislation. In early June a bipartisan, bicameral group of legislators came together to remedy the legislative shortcoming regarding an insulin assistance program and hammered out details establishing applicant eligibility criteria, a network of participating pharmacies, and possible sustainable sources of funding. Today only the funding issue remains a point of contention and this question cannot be resolved without Gov. Tim Walz, Sen. Paul Gazelka (R), and Rep. Melissa Hortman (DFL) coming together, rolling up their sleeves, and putting forth a joint proposal. The puzzling aspect for me regarding the development of an insulin assistance program is this: if both parties care deeply about people with pre-existing conditions, why don’t the leaders in the House and Senate commit to getting a program in place? Arguably, there is no more prevalent and galvanizing chronic disease than diabetes. When diabetes care involves insulin with its punishingly inflated prices, lives become threatened. The time is now. Minnesota can lead as we have led before. A basic package of health care services for all Minnesotans is not too much to ask. Sharing the burden of pre-existing conditions and the cost associated with chronic medical problems is not too much to ask. And finally doing something now rather than later to create an insulin assistance program is not too much to ask. And, in fact, Minnesotans are asking. Scott Jensen, MD, is a family physician practicing in Watertown and Chaska, Minnesota. He is an associate professor at the University of Minnesota Medical School and a state senator (R) serving as vice-chair of the Health and Human Services committee. He was chair of the Senate Select Committee on Health Care Consumer Access and Affordability in 2017 and 2018. ﷯
﷯ Legislation Insulin pricing A crisis and an opportunity By Sen. Scott Jensen, MD ﷯ day of reckoning has arrived for Minnesotans. Across the state this question is being asked repeatedly: “Who bears the costs of chronic medical problems able to be successfully treated with life-sustaining expensive medications?” Insulin has become the center point in this discussion regarding the inadequacies in our current health care system. While this is frustrating to some, I believe it presents an opportunity to pivot the conversation towards “who are we and what do we want our health care system to do?” History For too long, patients suffering from pre-existing conditions have been left alone to navigate the medical maze that accompanies the ownership of chronic diseases such as diabetes, epilepsy, asthma, peanut allergies, and many other maladies. Even though these illnesses can be successfully managed with medications and/or avoidance measures, the journey to find a way to obtain, afford, and manage the necessary prescriptions is an arduous one. A step back in time may be instructive. Fifty years ago, the first human landed on the moon, the Mets won the World Series, the crowds at Woodstock dispersed, and health care coverage was expanding rapidly. Four years earlier, the creation of Medicare and Medical Assistance piggybacked on an already expanding employee-based health insurance industry to give rise to a question destined to nag society for decades: “Is health care a right or a privilege?” ﷯ I believe that in the wake of Obamacare and so many other initiatives, this question now approximates irrelevance. A 30,000-foot view sees an affluent country trying to pivot around the question of responsibility: “What responsibility does society and government have for providing basic health care services to all?” Alongside this question lies a challenge to all citizens to be responsible users of health care services and to recognize that the common good is served best by a restrained appetite for medicines, tests, and professional medical attention. Currently more than 80% of Minnesotans believe that a basic package of health care should be available to all. I agree with this assessment, but I am impressed virtually every day by the challenge of gaining bipartisan consensus to support this viewpoint that society is best served through the provision of medical care for all. The vast majority of physicians agree that creating a universally accessible and affordable first-world health care system will require an underlying social contract between government and its citizens, recognizing that resources have limitations and abuse of consumption can and will undermine the best of intentions. We turn our attention now to the never-ending bickering about what to do with our health care system with all of its myriad problems—lack of access, unaffordable costs, epidemic corporate greed, excessive patient utilization of resources, physician profiteering from the use of low-value services, and so many more abuses. The last eight months may be viewed by many as a distasteful political stew of scheming and backroom machinations devised to blame the “other political party” for not being motivated to solve the insulin price crisis. The end result was predictable: “kick the can” down the road. Rising price tags A quick summary will refresh our minds with the following facts: an astronomical rise in the cost of insulin products has inflicted catastrophic effects on patients who experience an interruption in their continuous supply of insulin. A perfect storm of adverse marketplace trends has compromised access to affordable insulin, and this very real hardship has now become one of the premiere health care issues throughout America. ﷯ Rather than go into detail regarding the cost of insulin products, I share one fact: in the last couple of decades a single unit of insulin has gone from a few pennies to almost half a dollar in some circumstances. Insulin is a biologic product and, as such, generating cost-effective biosimilars does not parallel the relatively conventional process of creating inexpensive generic small molecule products. Virtually every primary care physician in Minnesota and many specialists can share numerous anecdotal stories about how their patients have suffered from the exponential rise in the cost of insulin, which has often led to devastating financial impacts, the interruption of stable health, and even the loss of life. The practice of rationing insulin is not an uncommon response on the part of patients—it has become commonplace and is quite understandable when one considers the complex intersection of needs, wants, dollars, and priorities. The pharmaceutical supply chain, with its many twists and turns, contributes mightily to the rising cost of insulin, but the blame game should not be limited to manufacturers, wholesalers, pharmacy benefit mangers (PBMs), employers, insurance payers, or pharmacists. Culpability even includes physicians and patients. When physicians prescribe insulin without specifically addressing the issue of cost and inquiring as to how the patient will be able to access and afford insulin, they are treating the patient as a mere client or chart number—we can and must do better for our patients and their families. When patients and families have a solid understanding of the disease and yet allow an emerging crisis to become a real catastrophe, they also share the blame by not being more proactive in reaching out to their pharmacist and/or physician. Pharmaceutical manufacturers have used effective marketing techniques, including samples, coupons, pharmaceutical representatives, perks, and meals to convince physicians and patients that each and every new product released on the market is better than the last. Marketing initiatives have insidiously and successfully brainwashed too many people into thinking that the use of any inexpensive old-fashioned insulin products delivered by old-fashioned syringes obtained from old-fashioned vials associated with old fashioned costs is second-class care associated with terrible prognoses and likely future loss of limbs or kidneys. Savvy physicians realize that, while insulin analogues contain glitzy bells and whistles, old-fashioned, less expensive human-based products can still do an adequate job in many situations in managing diabetes in accordance with best practice standards. Stalled legislation My perception of the recent 2019 session of the Minnesota Legislature was unfavorable, as many important topics were blocked from committee hearings by chairpersons, and a behind-the-scene triumvirate team—the governor, senate majority leader, and speaker of the house canceled out much committee policy work done during the first five months of legislative meetings. Many political pundits termed the session as a “dud” and House Republican Minority Leader Kurt Daudt said this: “This has been the least productive, least transparent session in the history of this state. Minnesotans should be ashamed of the process at the end of this legislative session.” Nevertheless, one bright spot did occur as a strong pharmacy benefit manager bill was passed and signed by the governor. (I was privileged to serve as chief author.) This legislation focused on PBM licensure, increased transparency requirements regarding manufacturer rebate trails, PBM strategies utilizing aggressive “spread pricing” and “clawbacking” tools to increase retail costs and copays in an attempt to increase revenues, and the ability of employers and insurance companies to view more financial data from PBM activities. ﷯ Despite the passage of a biennial budget, many other important initiatives fell by the wayside. One of these was the insulin bill chief-authored by Senator Melissa Wiklund (DFL) and co-authored by me. This bill had several components, one of which was authorization for emergency prescription refills of insulin in situations when a current prescription was not available—this feature was added onto the Health and Human Services omnibus bill, which passed in the special session. However, the actual insulin assistance program clause—the heart of the Alec Smith bill, named for a Minneapolis man who died because he could not afford his insulin—did not get a hearing in the Senate, nor did it get tacked on to any other bills. During a truncated and chaotic end-of-session discussion of numerous insulin proposals—two Republican and two Democratic submissions—no insulin initiatives were allowed to be vetted in the customary manner, and nothing passed in the House or Senate. In the special session, the tribunal of leaders decreed there would be no amendments allowed on any of the omnibus bills and that the session had to adjourn by 7 a.m. on May 25. This edict essentially killed the possibility of enacting any insulin assistance program legislation. In early June a bipartisan, bicameral group of legislators came together to remedy the legislative shortcoming regarding an insulin assistance program and hammered out details establishing applicant eligibility criteria, a network of participating pharmacies, and possible sustainable sources of funding. Today only the funding issue remains a point of contention and this question cannot be resolved without Gov. Tim Walz, Sen. Paul Gazelka (R), and Rep. Melissa Hortman (DFL) coming together, rolling up their sleeves, and putting forth a joint proposal. The puzzling aspect for me regarding the development of an insulin assistance program is this: if both parties care deeply about people with pre-existing conditions, why don’t the leaders in the House and Senate commit to getting a program in place? Arguably, there is no more prevalent and galvanizing chronic disease than diabetes. When diabetes care involves insulin with its punishingly inflated prices, lives become threatened. The time is now. Minnesota can lead as we have led before. A basic package of health care services for all Minnesotans is not too much to ask. Sharing the burden of pre-existing conditions and the cost associated with chronic medical problems is not too much to ask. And finally doing something now rather than later to create an insulin assistance program is not too much to ask. And, in fact, Minnesotans are asking. Scott Jensen, MD, is a family physician practicing in Watertown and Chaska, Minnesota. He is an associate professor at the University of Minnesota Medical School and a state senator (R) serving as vice-chair of the Health and Human Services committee. He was chair of the Senate Select Committee on Health Care Consumer Access and Affordability in 2017 and 2018. ﷯

﷯ Legislation Insulin pricing A crisis and an opportunity By Sen. Scott Jensen, MD ﷯ day of reckoning has arrived for Minnesotans. Across the state this question is being asked repeatedly: “Who bears the costs of chronic medical problems able to be successfully treated with life-sustaining expensive medications?” Insulin has become the center point in this discussion regarding the inadequacies in our current health care system. While this is frustrating to some, I believe it presents an opportunity to pivot the conversation towards “who are we and what do we want our health care system to do?” History For too long, patients suffering from pre-existing conditions have been left alone to navigate the medical maze that accompanies the ownership of chronic diseases such as diabetes, epilepsy, asthma, peanut allergies, and many other maladies. Even though these illnesses can be successfully managed with medications and/or avoidance measures, the journey to find a way to obtain, afford, and manage the necessary prescriptions is an arduous one. A step back in time may be instructive. Fifty years ago, the first human landed on the moon, the Mets won the World Series, the crowds at Woodstock dispersed, and health care coverage was expanding rapidly. Four years earlier, the creation of Medicare and Medical Assistance piggybacked on an already expanding employee-based health insurance industry to give rise to a question destined to nag society for decades: “Is health care a right or a privilege?” ﷯ I believe that in the wake of Obamacare and so many other initiatives, this question now approximates irrelevance. A 30,000-foot view sees an affluent country trying to pivot around the question of responsibility: “What responsibility does society and government have for providing basic health care services to all?” Alongside this question lies a challenge to all citizens to be responsible users of health care services and to recognize that the common good is served best by a restrained appetite for medicines, tests, and professional medical attention. Currently more than 80% of Minnesotans believe that a basic package of health care should be available to all. I agree with this assessment, but I am impressed virtually every day by the challenge of gaining bipartisan consensus to support this viewpoint that society is best served through the provision of medical care for all. The vast majority of physicians agree that creating a universally accessible and affordable first-world health care system will require an underlying social contract between government and its citizens, recognizing that resources have limitations and abuse of consumption can and will undermine the best of intentions. We turn our attention now to the never-ending bickering about what to do with our health care system with all of its myriad problems—lack of access, unaffordable costs, epidemic corporate greed, excessive patient utilization of resources, physician profiteering from the use of low-value services, and so many more abuses. The last eight months may be viewed by many as a distasteful political stew of scheming and backroom machinations devised to blame the “other political party” for not being motivated to solve the insulin price crisis. The end result was predictable: “kick the can” down the road. Rising price tags A quick summary will refresh our minds with the following facts: an astronomical rise in the cost of insulin products has inflicted catastrophic effects on patients who experience an interruption in their continuous supply of insulin. A perfect storm of adverse marketplace trends has compromised access to affordable insulin, and this very real hardship has now become one of the premiere health care issues throughout America. ﷯ Rather than go into detail regarding the cost of insulin products, I share one fact: in the last couple of decades a single unit of insulin has gone from a few pennies to almost half a dollar in some circumstances. Insulin is a biologic product and, as such, generating cost-effective biosimilars does not parallel the relatively conventional process of creating inexpensive generic small molecule products. Virtually every primary care physician in Minnesota and many specialists can share numerous anecdotal stories about how their patients have suffered from the exponential rise in the cost of insulin, which has often led to devastating financial impacts, the interruption of stable health, and even the loss of life. The practice of rationing insulin is not an uncommon response on the part of patients—it has become commonplace and is quite understandable when one considers the complex intersection of needs, wants, dollars, and priorities. The pharmaceutical supply chain, with its many twists and turns, contributes mightily to the rising cost of insulin, but the blame game should not be limited to manufacturers, wholesalers, pharmacy benefit mangers (PBMs), employers, insurance payers, or pharmacists. Culpability even includes physicians and patients. When physicians prescribe insulin without specifically addressing the issue of cost and inquiring as to how the patient will be able to access and afford insulin, they are treating the patient as a mere client or chart number—we can and must do better for our patients and their families. When patients and families have a solid understanding of the disease and yet allow an emerging crisis to become a real catastrophe, they also share the blame by not being more proactive in reaching out to their pharmacist and/or physician. Pharmaceutical manufacturers have used effective marketing techniques, including samples, coupons, pharmaceutical representatives, perks, and meals to convince physicians and patients that each and every new product released on the market is better than the last. Marketing initiatives have insidiously and successfully brainwashed too many people into thinking that the use of any inexpensive old-fashioned insulin products delivered by old-fashioned syringes obtained from old-fashioned vials associated with old fashioned costs is second-class care associated with terrible prognoses and likely future loss of limbs or kidneys. Savvy physicians realize that, while insulin analogues contain glitzy bells and whistles, old-fashioned, less expensive human-based products can still do an adequate job in many situations in managing diabetes in accordance with best practice standards. Stalled legislation My perception of the recent 2019 session of the Minnesota Legislature was unfavorable, as many important topics were blocked from committee hearings by chairpersons, and a behind-the-scene triumvirate team—the governor, senate majority leader, and speaker of the house canceled out much committee policy work done during the first five months of legislative meetings. Many political pundits termed the session as a “dud” and House Republican Minority Leader Kurt Daudt said this: “This has been the least productive, least transparent session in the history of this state. Minnesotans should be ashamed of the process at the end of this legislative session.” Nevertheless, one bright spot did occur as a strong pharmacy benefit manager bill was passed and signed by the governor. (I was privileged to serve as chief author.) This legislation focused on PBM licensure, increased transparency requirements regarding manufacturer rebate trails, PBM strategies utilizing aggressive “spread pricing” and “clawbacking” tools to increase retail costs and copays in an attempt to increase revenues, and the ability of employers and insurance companies to view more financial data from PBM activities. ﷯ Despite the passage of a biennial budget, many other important initiatives fell by the wayside. One of these was the insulin bill chief-authored by Senator Melissa Wiklund (DFL) and co-authored by me. This bill had several components, one of which was authorization for emergency prescription refills of insulin in situations when a current prescription was not available—this feature was added onto the Health and Human Services omnibus bill, which passed in the special session. However, the actual insulin assistance program clause—the heart of the Alec Smith bill, named for a Minneapolis man who died because he could not afford his insulin—did not get a hearing in the Senate, nor did it get tacked on to any other bills. During a truncated and chaotic end-of-session discussion of numerous insulin proposals—two Republican and two Democratic submissions—no insulin initiatives were allowed to be vetted in the customary manner, and nothing passed in the House or Senate. In the special session, the tribunal of leaders decreed there would be no amendments allowed on any of the omnibus bills and that the session had to adjourn by 7 a.m. on May 25. This edict essentially killed the possibility of enacting any insulin assistance program legislation. In early June a bipartisan, bicameral group of legislators came together to remedy the legislative shortcoming regarding an insulin assistance program and hammered out details establishing applicant eligibility criteria, a network of participating pharmacies, and possible sustainable sources of funding. Today only the funding issue remains a point of contention and this question cannot be resolved without Gov. Tim Walz, Sen. Paul Gazelka (R), and Rep. Melissa Hortman (DFL) coming together, rolling up their sleeves, and putting forth a joint proposal. The puzzling aspect for me regarding the development of an insulin assistance program is this: if both parties care deeply about people with pre-existing conditions, why don’t the leaders in the House and Senate commit to getting a program in place? Arguably, there is no more prevalent and galvanizing chronic disease than diabetes. When diabetes care involves insulin with its punishingly inflated prices, lives become threatened. The time is now. Minnesota can lead as we have led before. A basic package of health care services for all Minnesotans is not too much to ask. Sharing the burden of pre-existing conditions and the cost associated with chronic medical problems is not too much to ask. And finally doing something now rather than later to create an insulin assistance program is not too much to ask. And, in fact, Minnesotans are asking. Scott Jensen, MD, is a family physician practicing in Watertown and Chaska, Minnesota. He is an associate professor at the University of Minnesota Medical School and a state senator (R) serving as vice-chair of the Health and Human Services committee. He was chair of the Senate Select Committee on Health Care Consumer Access and Affordability in 2017 and 2018. ﷯
﷯ Legislation Insulin pricing A crisis and an opportunity By Sen. Scott Jensen, MD ﷯ day of reckoning has arrived for Minnesotans. Across the state this question is being asked repeatedly: “Who bears the costs of chronic medical problems able to be successfully treated with life-sustaining expensive medications?” Insulin has become the center point in this discussion regarding the inadequacies in our current health care system. While this is frustrating to some, I believe it presents an opportunity to pivot the conversation towards “who are we and what do we want our health care system to do?” History For too long, patients suffering from pre-existing conditions have been left alone to navigate the medical maze that accompanies the ownership of chronic diseases such as diabetes, epilepsy, asthma, peanut allergies, and many other maladies. Even though these illnesses can be successfully managed with medications and/or avoidance measures, the journey to find a way to obtain, afford, and manage the necessary prescriptions is an arduous one. A step back in time may be instructive. Fifty years ago, the first human landed on the moon, the Mets won the World Series, the crowds at Woodstock dispersed, and health care coverage was expanding rapidly. Four years earlier, the creation of Medicare and Medical Assistance piggybacked on an already expanding employee-based health insurance industry to give rise to a question destined to nag society for decades: “Is health care a right or a privilege?” ﷯ I believe that in the wake of Obamacare and so many other initiatives, this question now approximates irrelevance. A 30,000-foot view sees an affluent country trying to pivot around the question of responsibility: “What responsibility does society and government have for providing basic health care services to all?” Alongside this question lies a challenge to all citizens to be responsible users of health care services and to recognize that the common good is served best by a restrained appetite for medicines, tests, and professional medical attention. Currently more than 80% of Minnesotans believe that a basic package of health care should be available to all. I agree with this assessment, but I am impressed virtually every day by the challenge of gaining bipartisan consensus to support this viewpoint that society is best served through the provision of medical care for all. The vast majority of physicians agree that creating a universally accessible and affordable first-world health care system will require an underlying social contract between government and its citizens, recognizing that resources have limitations and abuse of consumption can and will undermine the best of intentions. We turn our attention now to the never-ending bickering about what to do with our health care system with all of its myriad problems—lack of access, unaffordable costs, epidemic corporate greed, excessive patient utilization of resources, physician profiteering from the use of low-value services, and so many more abuses. The last eight months may be viewed by many as a distasteful political stew of scheming and backroom machinations devised to blame the “other political party” for not being motivated to solve the insulin price crisis. The end result was predictable: “kick the can” down the road. Rising price tags A quick summary will refresh our minds with the following facts: an astronomical rise in the cost of insulin products has inflicted catastrophic effects on patients who experience an interruption in their continuous supply of insulin. A perfect storm of adverse marketplace trends has compromised access to affordable insulin, and this very real hardship has now become one of the premiere health care issues throughout America. ﷯ Rather than go into detail regarding the cost of insulin products, I share one fact: in the last couple of decades a single unit of insulin has gone from a few pennies to almost half a dollar in some circumstances. Insulin is a biologic product and, as such, generating cost-effective biosimilars does not parallel the relatively conventional process of creating inexpensive generic small molecule products. Virtually every primary care physician in Minnesota and many specialists can share numerous anecdotal stories about how their patients have suffered from the exponential rise in the cost of insulin, which has often led to devastating financial impacts, the interruption of stable health, and even the loss of life. The practice of rationing insulin is not an uncommon response on the part of patients—it has become commonplace and is quite understandable when one considers the complex intersection of needs, wants, dollars, and priorities. The pharmaceutical supply chain, with its many twists and turns, contributes mightily to the rising cost of insulin, but the blame game should not be limited to manufacturers, wholesalers, pharmacy benefit mangers (PBMs), employers, insurance payers, or pharmacists. Culpability even includes physicians and patients. When physicians prescribe insulin without specifically addressing the issue of cost and inquiring as to how the patient will be able to access and afford insulin, they are treating the patient as a mere client or chart number—we can and must do better for our patients and their families. When patients and families have a solid understanding of the disease and yet allow an emerging crisis to become a real catastrophe, they also share the blame by not being more proactive in reaching out to their pharmacist and/or physician. Pharmaceutical manufacturers have used effective marketing techniques, including samples, coupons, pharmaceutical representatives, perks, and meals to convince physicians and patients that each and every new product released on the market is better than the last. Marketing initiatives have insidiously and successfully brainwashed too many people into thinking that the use of any inexpensive old-fashioned insulin products delivered by old-fashioned syringes obtained from old-fashioned vials associated with old fashioned costs is second-class care associated with terrible prognoses and likely future loss of limbs or kidneys. Savvy physicians realize that, while insulin analogues contain glitzy bells and whistles, old-fashioned, less expensive human-based products can still do an adequate job in many situations in managing diabetes in accordance with best practice standards. Stalled legislation My perception of the recent 2019 session of the Minnesota Legislature was unfavorable, as many important topics were blocked from committee hearings by chairpersons, and a behind-the-scene triumvirate team—the governor, senate majority leader, and speaker of the house canceled out much committee policy work done during the first five months of legislative meetings. Many political pundits termed the session as a “dud” and House Republican Minority Leader Kurt Daudt said this: “This has been the least productive, least transparent session in the history of this state. Minnesotans should be ashamed of the process at the end of this legislative session.” Nevertheless, one bright spot did occur as a strong pharmacy benefit manager bill was passed and signed by the governor. (I was privileged to serve as chief author.) This legislation focused on PBM licensure, increased transparency requirements regarding manufacturer rebate trails, PBM strategies utilizing aggressive “spread pricing” and “clawbacking” tools to increase retail costs and copays in an attempt to increase revenues, and the ability of employers and insurance companies to view more financial data from PBM activities. ﷯ Despite the passage of a biennial budget, many other important initiatives fell by the wayside. One of these was the insulin bill chief-authored by Senator Melissa Wiklund (DFL) and co-authored by me. This bill had several components, one of which was authorization for emergency prescription refills of insulin in situations when a current prescription was not available—this feature was added onto the Health and Human Services omnibus bill, which passed in the special session. However, the actual insulin assistance program clause—the heart of the Alec Smith bill, named for a Minneapolis man who died because he could not afford his insulin—did not get a hearing in the Senate, nor did it get tacked on to any other bills. During a truncated and chaotic end-of-session discussion of numerous insulin proposals—two Republican and two Democratic submissions—no insulin initiatives were allowed to be vetted in the customary manner, and nothing passed in the House or Senate. In the special session, the tribunal of leaders decreed there would be no amendments allowed on any of the omnibus bills and that the session had to adjourn by 7 a.m. on May 25. This edict essentially killed the possibility of enacting any insulin assistance program legislation. In early June a bipartisan, bicameral group of legislators came together to remedy the legislative shortcoming regarding an insulin assistance program and hammered out details establishing applicant eligibility criteria, a network of participating pharmacies, and possible sustainable sources of funding. Today only the funding issue remains a point of contention and this question cannot be resolved without Gov. Tim Walz, Sen. Paul Gazelka (R), and Rep. Melissa Hortman (DFL) coming together, rolling up their sleeves, and putting forth a joint proposal. The puzzling aspect for me regarding the development of an insulin assistance program is this: if both parties care deeply about people with pre-existing conditions, why don’t the leaders in the House and Senate commit to getting a program in place? Arguably, there is no more prevalent and galvanizing chronic disease than diabetes. When diabetes care involves insulin with its punishingly inflated prices, lives become threatened. The time is now. Minnesota can lead as we have led before. A basic package of health care services for all Minnesotans is not too much to ask. Sharing the burden of pre-existing conditions and the cost associated with chronic medical problems is not too much to ask. And finally doing something now rather than later to create an insulin assistance program is not too much to ask. And, in fact, Minnesotans are asking. Scott Jensen, MD, is a family physician practicing in Watertown and Chaska, Minnesota. He is an associate professor at the University of Minnesota Medical School and a state senator (R) serving as vice-chair of the Health and Human Services committee. He was chair of the Senate Select Committee on Health Care Consumer Access and Affordability in 2017 and 2018. ﷯