HR-10133-119
Referred to the Committee on Energy and Commerce, and in addition to the Committees on Ways and Means, and Education and Workforce, for a period to be subsequently determined by the Speaker, in each case for consideration of such provisions as fall within the jurisdiction of the committee concerned.
Sponsored by Hillary Scholten (D-MI)
What it does
This bill would prohibit group health plans and insurers (including through pharmacy benefit managers) from charging patients a copay, deductible, or coinsurance for a covered outpatient drug that exceeds the nationwide average consumer purchase price for that drug, as measured by an existing federal drug pricing survey. The limit would apply to drugs dispensed at in-network pharmacies and would take effect for plan years beginning after enactment, amending the Public Health Service Act, ERISA, and the Internal Revenue Code in parallel.
Who benefits
Insured patients who currently pay copays or coinsurance higher than the average market price of a drug, particularly those with high-deductible plans or drugs subject to steep coinsurance percentages. Patients taking expensive brand-name or specialty drugs where cost-sharing can exceed the drug's average sale price may see the largest reductions. Pharmacies may benefit from reduced patient abandonment of prescriptions.
Who is hurt
Insurers and pharmacy benefit managers, who would need to redesign benefit structures and absorb costs above the new cap, potentially passing costs through to premiums for all enrollees. Employers sponsoring group health plans could face administrative compliance costs. Uninsured individuals and those in short-term or non-group plans not covered by these titles would not benefit. Plans may also face implementation costs tied to obtaining and applying the nationwide average pricing survey data.
Supporters argue
Supporters argue that patients are sometimes charged cost-sharing amounts, especially coinsurance percentages or pre-deductible costs, that exceed what the drug actually costs on the open market, forcing patients to effectively subsidize insurer or PBM margins. They contend tying copays to a transparent, existing federal benchmark (the same survey used for Medicaid drug pricing) would prevent patients from being charged more than the drug's real average price, directly reducing out-of-pocket costs for people taking maintenance or specialty medications.
Opponents argue
Opponents argue that capping cost-sharing at average market price could force insurers to raise premiums broadly to offset lost cost-sharing revenue, spreading costs across all enrollees rather than targeting those who need help most. They contend the mechanism could also reduce insurers' ability to use cost-sharing to steer patients toward lower-cost alternatives, and that compliance burdens from tracking a rotating nationwide average price for thousands of drugs could raise administrative costs passed on to plan sponsors and enrollees.
Constitutional context
Congress has authority to regulate the terms of employer-sponsored and individual health insurance under the Commerce Clause, as affirmed in NFIB v. Sebelius (2012), which recognized broad federal authority to regulate existing insurance markets even while limiting the power to compel new commercial activity. This bill regulates plan terms rather than compelling purchases, so it falls within the more settled category of insurance market regulation rather than the mandate issue at stake in that case.
Checks and balances
Congress would set the statutory cost-sharing limit directly in law; enforcement would run through existing federal agencies (HHS, Labor, Treasury) that regulate the respective plan types, with courts available to review agency implementation and any disputes over compliance.
Historical precedent
The Inflation Reduction Act of 2022 similarly capped Medicare Part D insulin copays at $35, establishing a precedent for Congress directly limiting drug cost-sharing amounts in federal law, though that law targeted a single drug class rather than all covered outpatient drugs.