The $35 Fix That Could Rewrite the Rules of Drug Pricing

Senator Warnock pushed hard for this piece, pointing to his prior "Insulin Deserts" analysis with Senator Kennedy that identified areas where uninsured diabetics have the fewest options. The pilot also comes with an insulin resource hotline, because apparently in 2026, we still need a helpline to help people afford a drug that's been around since the 1920s.

The PBM Problem Gets a Spotlight

If you've ever wondered why insulin costs so much when the underlying science isn't particularly new, allow me to introduce you to pharmacy benefit managers (PBMs). These are the middlemen who negotiate drug prices between manufacturers and insurers, and they've long been accused of keeping list prices artificially high so they can pocket bigger rebates.

The INSULIN Act takes a swing at that. It would require PBMs to pass 100% of insulin rebates and discounts from manufacturers directly to plan sponsors. No more skimming off the top. Senator Collins specifically called out PBM reform as a priority, framing it as the key to reducing not just copays but actual premiums.

This provision dovetails with broader PBM reform Congress already signed into law. The Consolidated Appropriations Act of 2026, signed in February, mandated full rebate pass-through and new transparency requirements for PBMs across Medicare and commercial markets, effective 2028-2029. The insulin bill extends that same philosophy to a specific, high-profile drug.

Big Pharma Already Blinked

Here's the interesting part: the three companies that control roughly 90% of the U.S. insulin market (Eli Lilly, Novo Nordisk, and Sanofi) already moved in this direction voluntarily.

Back in March 2023, all three announced massive list price cuts. Lilly slashed Humalog by 70%. Novo Nordisk dropped NovoLog by 75%. Sanofi cut Lantus by 78%. Each company also introduced its own $35 per month cap for commercially insured patients at participating pharmacies.

So why does this bill matter if the companies already capped prices? Because voluntary programs can be reversed. A company can kill a discount program with a press release. A federal law is a different animal entirely. It locks in the floor and removes the option to quietly raise prices once the political heat fades.

The Real Story Is What Comes Next

Insulin is the test case. The warm-up act. The pilot episode before the full season order.

Congress has been inching toward broader drug pricing controls for years, and the INSULIN Act fits neatly into that trajectory. Medicare's drug price negotiation program under the IRA already produced at least 38% reductions from list prices for the first 10 drugs, saving Medicare an estimated $6 billion per year. A third round of 15 drugs is being negotiated now, with prices taking effect in 2028.

If Congress can cap insulin prices for private insurance and get bipartisan support, the template is set. Lawmakers on both sides could point to it as proof that price caps work without destroying the market. The bill even includes a federal study on market barriers and biosimilar adoption, essentially building the research case for future interventions.

A Democratic aide told reporters the sponsors are looking for additional co-sponsors and plan to attach the bill to must-pass legislation like tax extenders. That's the legislative equivalent of sneaking vegetables into a smoothie: if it rides along with something Congress has to pass anyway, the odds improve dramatically.

The $35 Question

Twenty-nine states plus Washington, D.C. already cap insulin copays at somewhere between $25 and $100. The federal bill would create a nationwide standard, eliminating the patchwork. For patients who happen to live in a state without protections, that's the difference between affording medication and rationing it.

But the bigger question isn't about insulin at all. It's about whether this becomes the playbook. If a bipartisan group can cap the price of one drug category for private insurance and survive politically, every expensive drug with a broad patient population becomes a potential target.

The pharmaceutical industry hasn't publicly opposed this bill yet, perhaps because the major insulin makers already adopted similar caps voluntarily. But you can bet the lobbying machines are watching closely. If the INSULIN Act passes and becomes a template, the next bill might target a drug category where companies haven't been quite so cooperative.

For now, roughly 40 million Americans with diabetes are watching to see if Washington can finish what it started in 2022. The bipartisan support is real. The midterm pressure is real. And the precedent, if it happens, would be very real indeed.