State Insulin Out-of-Pocket Cap Policies and Estimated Eligible Populations in the United States, 2019–2026

Abstract

OBJECTIVE High insulin prices are a major barrier to diabetes management in the U.S. Since 2019, several states have implemented legislation to mitigate high out-of-pocket (OOP) costs for commercially insured individuals by setting caps on monthly OOP payments for insulin. In this study, we examine the reach of these policies. RESEARCH DESIGN AND METHODS We identified insulin OOP cap legislation enacted through 2026 for each state and Washington, DC. Using public data on diabetes prevalence and health insurance coverage, we identified the population eligible and exposed to OOP caps legislation: adults aged 18–64 years with diabetes, using insulin, enrolled in state-regulated commercial plans, and residing in states that enacted OOP caps legislation. We then estimated the number of commercially insured individuals using insulin still left unprotected due to 1) enrolled in federally regulated plans, regardless of state of residence; or 2) enrolled in state-regulated plans but living in states without OOP cap legislation. RESULTS By 2026, 29 states and Washington, DC, had enacted OOP caps on insulin, covering an estimated 0.99 million individuals with diabetes, using insulin, and enrolled in state-regulated commercial plans. Despite these gains, policy reach remains uneven: 0.67 million adults with diabetes using insulin and insured by state-regulated plans live in states without an insulin OOP cap, and 2.2 million more are insured by federally regulated commercial plans that fall outside of state jurisdiction. CONCLUSIONS State OOP caps have the potential to reduce OOP insulin costs for many commercial plan enrollees but have limited reach. Legislative efforts to contain costs at the federal level are therefore needed to decrease the financial burden of insulin therapy.