HR-6255-119
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 Angie Craig (D-MN)
What it does
This bill would amend the Public Health Service Act, the Internal Revenue Code, and ERISA to require group health plans and individual health insurance issuers to cover at least one insulin product of each type and dosage form, with no deductible applied and monthly cost-sharing capped at the lesser of $35 or 25% of the negotiated net price per 30-day supply. The cap would apply to plan years beginning on or after January 1, 2026, and would extend to catastrophic health plans. Any cost-sharing paid under the cap would count toward a patient's deductible and out-of-pocket maximum.
Who benefits
People with diabetes who use insulin and have private insurance (employer-sponsored or individual market), including the estimated 7–8 million Americans who rely on insulin. Patients currently paying high deductibles before insulin coverage kicks in would benefit most. People enrolled in catastrophic health plans, who previously had no pre-deductible insulin coverage, would gain new access. Patients using multiple insulin types or dosage forms (e.g., vials, pumps, inhalers) would benefit from the requirement to cover at least one product of each type. Employers offering group health plans may benefit indirectly from a healthier, more productive workforce.
Who is hurt
Health insurers and pharmacy benefit managers (PBMs) would be required to absorb costs above the cap, which may be partially offset by negotiated rebates. Employers sponsoring self-insured group health plans would face new mandatory benefit requirements. Uninsured patients and those on Medicaid or Medicare Part D (already covered by the IRA's $35 cap) would not be directly affected by this bill. Insulin manufacturers could face indirect downward pricing pressure. Broadly insured populations may see modest premium increases if insurers spread absorbed costs across the risk pool. Small businesses offering group coverage could face higher plan costs.
Supporters argue
Supporters argue that insulin prices in the U.S. have risen dramatically over recent decades — with some products costing ten times more than in comparable countries — forcing an estimated one in four insulin-dependent patients to ration doses, a practice linked to hospitalizations and preventable deaths. They contend the bill closes a gap left by the Inflation Reduction Act of 2022, which capped insulin costs only for Medicare Part D enrollees, leaving tens of millions of privately insured patients without similar protection. Supporters also point to voluntary manufacturer commitments to cap insulin at $35, which they argue are insufficient without a legal mandate to ensure consistent, durable coverage.
Opponents argue
Opponents argue that price caps on cost-sharing do not address the underlying list prices set by manufacturers, and that mandating below-market patient costs shifts expenses to insurers, employers, and ultimately all policyholders through higher premiums — a cost redistribution rather than a cost reduction. They contend that imposing new federal benefit mandates on employer-sponsored plans under ERISA limits the flexibility businesses need to design cost-effective coverage, and that the bill's structure may reduce incentives for PBMs and insurers to negotiate aggressively on net insulin prices. Critics also argue that targeted mandates for a single drug class set a precedent for further federal micromanagement of private insurance benefit design.
Constitutional context
Congress regulates private insurance markets and employer benefit plans under the Commerce Clause (Art. I, §8, cl. 3) and the Necessary and Proper Clause. NFIB v. Sebelius (2012) affirmed broad congressional authority to regulate existing commercial activity in insurance markets, though it distinguished compelling new activity. The bill amends existing statutory frameworks (PHSA, IRC, ERISA) rather than creating a new standalone mandate, which places it on firmer Commerce Clause footing than the individual mandate at issue in NFIB.
Checks and balances
Congress sets the cost-sharing cap and coverage requirements; HHS, the IRS, and the Department of Labor share enforcement authority across their respective statutory domains; insurers and employers may challenge specific provisions through administrative and judicial review.
Historical precedent
The Inflation Reduction Act of 2022 established a $35 monthly cap on insulin cost-sharing for Medicare Part D enrollees; early data showed meaningful reductions in out-of-pocket costs for affected seniors.