ASPE ASSISTANT SECRETARY FOR PLANNING AND EVALUATION OFFICE OF DATA POINT HEALTH POLICY January 24, 2023 0 Insulin Affordability and the Inflation Reduction Act: Medicare Beneficiary Savings by State and Demographics Under the Inflation Reduction Act, out-of-pocket costs for insulin in Medicare are now capped at $35 per monthly prescription for Part D, as of January 1, 2023, witha similar cap taking effect in Part B on July 1, 2023. Medicare beneficiaries who use insulin would have saved $734 million in Part D and $27 millionin Part B if these caps had been in effect in 2020. Bisma A. Sayed, Kenneth Finegold, T. Anders Olsen, Nancy De Lew, Steve Sheingold, Kaavya Ashok, and Benjamin D. Sommers KEY POINTS The Inflation Reduction Act (IRA) caps insulin out-of-pocket spending at $35 per month's supply of eachinsulin product covered under a Medicare Part D plan, with similar limits for out-of-pocket costs for insulin supplied under Part B, and reduces out-of-pocket drug spending in Medicare in other ways. These provisions will make insulin more affordable for people covered by Medicare. We examined out-of-pocket spending on insulin using 2019 survey data for individuals with Medicare, Medicaid, or private insurance, and for those without health coverage. We then estimated the potential effects of the IRA's insulin cap provisions on out-of-pocket spending for insulin among Medicare beneficiaries using 2020 Medicare claims data. Nationally, the average out-of-pocket cost was $58 per insulin fill, typically for a 30-day supply. The average cost per fill among people who were uninsured for the entire year was $123, more than double the national average. Patients with private insurance or Medicare paid about $63 per fillon average. About 37 percent of insulin fills for Medicare enrollees (Part B and Part D) required cost-sharing exceeding $35 per fill, including 24 percent that exceeded $70 per fill. About 36 percent of insulin fills for people without insurance and 35 percent for people with private insurance had cost sharing above $35 per fill. These estimates are only for enrollees who filled an insulin prescription and do not include potential costs for patients who did not fill their insulin due to cost or other reasons. We estimate that 1.5 million Medicare beneficiaries would have benefited from the new IRA insulin cost-sharing limits if they had been in effect in 2020, with savings to those beneficiaries of about $734 million in Part D and$27 million in Part B- or approximately $500 in average annual savings per person among those benefiting from the provision. aspe.hhs.gov 1 BACKGROUND An estimated 37 million Americans, representing about 11.3 percent of the U.S. population, have diabetes. + Diabetes is characterized byinsulin dysfunction that occurs when the pancreas does not produce enough insulin (type 1 diabetes), or when the body does not respond to insulin properly and/or have enough insulin production to overcome this deficit (type 2 diabetes). 3 More than7 million individuals with diabetes, including all individuals with type 1 diabetes and a substantial number of those with type 2 diabetes, need to use insulin daily to manage their blood sugars and prevent the adverse consequences associated with uncontrolled diabetes. 4 Although insulin is critical for the patients who require it to manage their illness, it can be expensive. List prices have increased over time, nearly doubling between 2012 and 2016, * before stabilizing somewhat in recent years. Highinsulin prices can contribute to challenges with adherence to prescribed insulin regimens, which can, in turn, lead to complications including ketoacidosis, * kidney disease, vision loss, and others. & These complications are expensive to treat, severely impact patients' quality of life, and may lead to hospitalizations, amputations, and death. " Recognizing the importance of insulin affordability, * the Inflation Reduction Act (IRA) of 2022 includes provisions to limit out-of-pocket costs of insulin for people with Medicare, a population with higher prevalence of diabetes (nearly 30 percent) than the general population (about 11 percent). ® ? Most people with Medicare coverage access insulinthrough Medicare Part D, which covers injectable insulin, inhaled insulin, and disposable "patch" pumps. 2° Cost sharing for insulin in Part D varies depending on whether the enrollee qualifies for the Low-Income Subsidy (LIS) and, prior to the IRA, the Part D coverage phase of the enrollee at the time that they obtained insulin. * Medicare Part B provides coverage for insulin when it is medically required to be administered through non- disposable insulin pumps. *! Prior to the IRA, under Medicare Part B, beneficiaries were responsible for 20 percent of the cost after they met the Part B deductible, which may have been covered for some beneficiaries by supplemental coverage. The IRA includes several provisions that limit out-of-pocket spending on insulin for Medicare Part D and Part B enrollees: 12 e Effective January 1, 2023, people enrolled in a Medicare Part D prescription drug plan (PDP) or a Medicare Advantage plan with a prescription drug coverage (MA-PD) have no deductible for covered insulin products and have a copayment cap of $35 per month supply of each covered insulin product. § * Ketoacidosis occurs when the body does not have enough insulin to use glucose, the body's normal source of energy, and this condition produces life-threatening metabolic disturbancesthat can lead to coma and death. * Recognizing insulin affordability as a key priority, even prior to the IRA, the Centers for Medicare and Medicaid Services launched the Part D Senior Savings Model (PDSS), which tested changes to the Part D benefit design including requirements that enrollees of participating plans would not need to pay more than $35 fora monthly supply of insulin. Details about the PDSS Modelare available here: https://innovation.cms.gov/innovation-models/part-d-savings-model. * For eligible enrollees whose income and resources are limited, the Medicare Prescription Drug, Improvement and Modernization Act of 2003 established extra help (a subsidy) for prescription drugs, referred to as the Low-Income Subsidy (LIS). Subsidiesare paid by the Federal government to drug plans and provide assistance with premiums, deductibles, and co-payments. § Many patients with diabetes requiring insulin therapy have complex insulin regimens that may include a combination of therapies, including insulin with other oral medications or multiple different types of insulinto manage diabetes and reduce risk of serious health effects. January 2023 DATA POINT 2 e Effective July 1, 2023, Medicare Part B beneficiaries or those enrolled in a Medicare Advantage plan who use an insulin pump furnished via durable medical equipment will no longer have to pay a deductible for insulin and will have a copayment cap of $35 per month supply for their Part B covered insulin. e Effective January 1, 2024, one year after the $35 cap, eligibility for the Part D LIS will expand. The IRA raises the income limit for certain people covered by Medicare for the full LIS from 135 percent of the Federal Poverty Level (FPL) to 150 percent of FPL, which will allow these enrollees to further reduce their out-of-pocket costs for insulin and other medications. In this Data Point, we examine out-of-pocket costs of insulin and the average cost per insulin prescription fill by health insurance coverage type. We then examine what would have happened to out-of-pocket spending on insulin among Medicare beneficiaries if the IRA's monthly copayment cap of $35 for a one-month supply of a covered insulin product had been in effect in 2020. For more information about this research, see our recently released Report to Congress. ** 13 METHODS We used the 2019 Medicare Expenditure Panel Survey Household Component (MEPS HC) to examine out-of- pocket cost per insulin fill, which was most commonly a 30-day supply of insulin. We also examined the average cost per fill of insulin by the type of health coverage. Next, we focused specificallyon the Medicare population to examine the IRA insulin provisions that aim to reduce out-of-pocket spending and improve affordability of insulin for Medicare enrollees. We used the Medicare Prescription Drug Event, Enrollment, and Part B data files to calculate the total amount enrollees spent on insulin per month. Then for each enrollee, we computed the totalamount spent above the IRA's limits on cost sharing for insulin. This allowed us to estimate how much people with Medicare Part D and Part B would have saved in out-of-pocket costs if the IRAinsulin out-of-pocket cap had been in effect in 2020. We identified the number of enrollees who would have had lower out-of-pocket costs for insulin and their total savings compared with what they actually paid in 2020, if the insulin cap had been in effect in 2020. These estimates are based on the number of Medicare Part D enrollees who spent more than $35 in any month of 2020 on insulin in Part D and Part B combined. We did not model other provisions of the IRAthat may impact Medicare enrollees' out-of-pocket spending for insulin, such as the additional effect of LIS expansion, which will be implemented in 2024, or the potential effects of negotiation on prices for selected prescription drugs, which will begin in 2026. Moreover, the estimates presented are based on Medicare enrollees who filled an insulin prescription in 2020 and do not take into account individuals who did not fill their insulin prescription. For Part D, our estimates include both Medicare Advantage prescription drug plans (MA-PD) and prescription drug plans (PDP) enrollees. Except as noted, Part B estimates are only for individuals covered by fee-for-service Medicare. FINDINGS Out-of-Pocket Spending for Insulin Table 1 indicates that the overall mean out-of-pocket cost for insulin obtained from retail, mail, and online pharmacies in 2019 was $58 per fill. Among the prescriptions with reported days supplied, 30 days was the ™ This Data Point includes selected findings from the Insulin Affordability Report to Congress: Office of the Assistant Secretary for Planning and Evaluation, U.S. Department of Health & Human Services. Report on the Affordability of Insulin. December 16, 2022. https://aspe.hhs.gov/reports/insulin-affordability-rtc January 2023 DATA POINT 3 mode and median number of days, indicating that fills typically represent an approximate 30-day supply of insulin. These estimates are only for individuals who filled an insulin prescription in 2019 and do not include estimates for those who did not fill an insulin prescription because of cost or other reasons. The estimates in Table 1 demonstrate wide variation in the amounts paid in out-of-pocket costs for insulin by type of coverage for prescription drugs. Among people uninsured for the entire year, the average out-of- pocket cost per fill was $123, more than double the overall average. Patients with private insurance or Medicare both paid $63 per fill on average. The median overall out-of-pocket payment was substantially lower than the meanat $9, meaning that half of fills were for that amount or less. The large difference between the mean and median estimates indicates variability in the data and suggests that a subset of patients have a higher out-of-pocket cost burden thanthe mean or median estimates. Out-of-pocket costs for uninsured patients would likely have been greater if not for charity care, safety net providers, patient assistance programs, free or sliding scale access through federally qualified health centers and safety net providers, and coupons. ** Availability of some types of insulin at low cost from certain commercial retailers and authorized generic products from manufacturers with no rebates may contribute to reduced costs of insulin for patients who do not have insurance. Similarly, out-of-pocket costs for patients with private insurance would likely have been greater if not for patient assistance programs andcoupons. In addition, many patients covered through Marketplace with low incomes qualify for cost-sharing reductions, which reduce their out-of-pocket costs. Table 1. Median and Mean Out-of-Pocket Cost Per Insulin Fill, by Type of Coverage, 2019 Type of Coverage Mean Median Overall $58 s9 Private $63 $25 ** Medicare $63 $10 4 Medicaid S6 **a SO **a Uninsured® $123 ** $12 Source: Medical Expenditure Panel Survey (MEPS), 2019. Civilian noninstitutionalized population. Notes: The insurance categoriesare treated as mutually exclusive according to the following hierarchy: Medicare (with or without Part D drug coverage, including Medicare only, Medicare and Medicaid, and Medicare and private insurance), private insurance (including private insurance only and Marketplace any time during the year), Medicaid (includes Medicaid only or Medicaid and other government programs), other government programs only, and uninsured (lacked insurance from any source for the entire calendar year). "Medicare" includes fills under Part D (MA-PDP and PDP) and Part B (Fee for Service and Medicare Advantage). "Overall" also includes adults who had insurance through other government programs. * Statistically significantly different from overall at the .05 level. ** Statistically significantly different from overall at the .01 level. @ Estimates are imprecise due to small sample sizes. > For the uninsured population, annual average estimates are from the MEPS, 2014-2019 dueto small sample sizes in 2019. Out-of-pocket expenditures on insulin for 2014 to 2018 are inflated to 2019 dollars usingthe Consumer Price Index for prescription drugs. For overall, private, Medicare, and Medicaid coverage categories, we used the 2019 MEPS data. Figure 1 presents the shares of insulin prescription fills, by type of coverage, for which there was any out-of- pocket spending. Overall, 63 percent of insulin fills required some cost-sharing, with 32 percent of fills * Manufacturer programs and coupons are treated like other discounts and are not countedas expenditures by the patient or other payers. January 2023 DATA POINT 4 requiring more than $35, and 20 percent requiring more than $70. Fills for privately insured and uninsured patients were significantly more likely to require cost-sharing than other coverage groups, while most Medicaid beneficiaries with insulin fills had no cost-sharing at all. Among Medicare patients, 68.5 percent had out-of-pocket costs, with 37 percent paying more than $35 per prescription fill - including nearly a quarter who paid more than $70 per fill. While 30 days was the most common prescription length in the dataset, 32 percent of prescriptions lacked information on the number of days supplied, and smaller numbers of prescriptions may represent more or less than a 30-day supply; these factors introduce some uncertainty into our estimates of the proportion of insulin users paying more than $35 per 30-day supply. Figure 1. Share of Insulin Prescription Fills with Cost Sharing Per Fill, by Type of Coverage, 2019 0% 20% 40% 60% 80% 100% Overall 37% 32% 12% Medicare Rye ERR wy Medicaid 84% 14% Uninsured yay uy oh mSO m>S0to$35 m>$35to$70 m>s70 Source: Medical Expenditure Panel Survey (MEPS), 2019. Civilian noninstitutionalized population. Notes: The insurance categoriesare hierarchical (see Notes to Table 1). "Medicare" includes fills under Part D (MA-PDP and PDP) and Part B (Fee for Service and Medicare Advantage). "Overall" also includesadults who had insurance through other government programs. For overall, private, Medicare, and Medicaid coverage categories, we used the 2019 MEPS data. For the uninsured population, annual average estimates are from the MEPS, 2014-2019 due to small sample sizes in 2019. Out-of-pocket expenditures on insulin for 2014 to 2018 are inflated to 2019 dollars usingthe Consumer Price Index for prescription drugs. Effects of IRA Insulin Provisions on Out-Of-Pocket Spending for Medicare Enrollees Our analyses of the impact of the IRA's out-of-pocket insulin cap estimated how much individuals with Medicare Part D and Part B would have saved if these provisions had been in effect in 2020. Table 2 shows that nearly 1,518,000 Part D enrollees would have benefited, saving $734 million, if the IRA insulin provisions had been in effect in 2020. ** Most of the savings would have accrued to enrollees who do not qualify for LIS, which reduces out-of-pocket costs for Part D enrollees who meet income and resource limits. * Our estimate of 1.5 million Part D enrollees who would have had lower out-of-pocket costs for insulin if the IRA provisions had beenin effect in 2020 is slightly different from the CMS estimate of 1.4 million (https: //www.cms.gov/newsroom/fact-sheets/inflation-reduction-act-lowers-health-care-costs-millions-americans). January 2023 DATA POINT 5 1.5 million Medicare beneficiaries would have saved money in Part D, Part B, or both under the IRA's $35 insulin cap provisions. Table 2 alsoshows that the IRA's Part B insulin out-of-pocket cap would have produced additional savings of $27 million for about 31,000 Part B beneficiaries, or about $866 per beneficiary in 2020. There is some overlap betweenthe Part D and Part B insulin users who benefit from the out-of-pocket cap, but some Part B beneficiaries do not have Part D coverage. Overall, about 1.52 million Medicare enrollees would have saved money in Part D, Part B, or both under the IRA's $35 insulin cap provisions. Combining the estimated Part D and Part B savings, total savings in 2020 would have been $761 million, or just over $500 per beneficiary with savings. Table 2. Estimated Out-of-Pocket Savings If Inflation Reduction Act $35/month Out-of-Pocket Insulin Cap Had Been in Effect in 2020 Part D Part B Total Outcome Non-LIS LIS Total Total (Combined Part B and D) Total IRA Savings (S $723.2 $10.8 $734.0 $27.2 $761.16 millions) Number of Insulin 1,477,327 | 76,503 | 1,517,817 31,376 1,519,856 Users with Savings Average Savings $490 $141 $484 $866 $501 per Insulin User with Savings (S$) Source: ASPE analysis of CMS Medicare Part D 2020 Prescription Drug Event (PDE), Enrollment, and Part B data files. LIS = Low-Income Subsidy Table 3 shows the distribution of savings by gender, race, ethnicity, and age. The estimates indicate that substantial numbers of beneficiaries would benefit from the policy across all demographic groups analyzed. Part D LISenrollees who benefit from the cap are more likely than Part D non-LlIS enrollees or Part B beneficiaries to be women, Black, or below the age of 65 (indicating eligibility for Medicare on the basis of disability or End-Stage Renal Disease). Overall, about 1.25 million White beneficiaries, 160,000 Black beneficiaries, 28,000 Latino beneficiaries, 20,000 Asian beneficiaries, and 7,000 American Indian / Alaska Native beneficiaries will benefit from the new provision. January 2023 DATA POINT Table 3. Demographic Characteristics of Medicare Enrollees with Out-of-Pocket Savings If Inflation Reduction Act Insulin Provisions Had Been in Effect in 2020 Part D Part B Total Non-LI$ LIS Total Category (n) % (n) % (n) % (n) % Gender Female 708,281 47.9% 43,862 57.3% 16,465 52.5% 732,729 48.2% Male or Unknown 769,046 52.1% 32,641 42.7% 14,911 47.5% 787,127 51.8% Race and Ethnicity White 1,217,545 82.4% 55,424 72.4% 29,005 92.4% 1,248,912 82.2% Black 154,311 10.4% 14,093 18.4% 922 2.9% 161,810 10.7% Latino 25,901 1.8% 3,512 4.6% 137 0.4% 27,788 1.8% Asian 19,795 1.3% 1,146 1.5% 128 0.4% 20,344 1.3% AI/AN 6,705 0.5% 525 0.7% 47 0.2% 6,961 0.5% Other 53,070 3.6% 1,803 2.4% 1,137 3.6% 54,041 3.6% Age Under 65 115,104 7.8% 20,366 26.6% 4,674 14.9% 128,634 8.5% 65-69 284,559 19.3% 14,413 18.8% 7,722 24.6% 292,603 19.3% 70-74 420,654 28.5% 15,092 19.7% 10,153 32.4% 428,893 28.2% 75-79 319,859 21.7% 11,566 15.1% 5,618 17.9% 325,856 21.4% 80-84 196,240 13.3% 8,281 10.8% 2,356 7.5% 200,283 13.2% 85-89 95,927 6.5% 4,454 5.8% 700 2.2% 97,838 6.4% 90 or Older 44,984 3.0% 2,331 3.0% 153 0.5% 45,749 3.0% Source: ASPE analysis of CMS Medicare Part D 2020 Prescription Drug Event (PDE), Enrollment, and Part B data files. LIS = Low-Income Subsidy AI/AN = American Indianand Alaskan Native Effects of IRA Insulin Provisions on Out-Of-Pocket Spending by State We also examined the effects of the IRAinsulin cap on out-of-pocket spending for people with Medicare coverage in each state. Table 4 shows that across both Medicare Part D and B, 114,000 beneficiaries in Texas, 108,000 in California, and 90,000 in Florida are projected to have the highest number of enrollees that will benefit from the new IRA provision. Among those projected to have out-of-pocket savings, Texas ($50,395,627), Pennsylvania ($43,565,423), and Florida ($42,920,606) have the highest projected savings from the IRA's $35 insulin caps. North Dakota ($805), lowa ($725), and South Dakota ($725) have the highest average annual out-of-pocket savings per individual among those withsavings. Separate estimates for Medicare Part D and Part B are presented in Appendix Tables A1 and A2. January 2023 DATA POINT 7 Table 4. Estimated Out-of-Pocket Savings If Inflation Reduction Act $35 Out-of-Pocket Insulin Cap Had Been in Effect in 2020, by State Total Number of Enrollees in Part Projected IRA Mean Annual Out-of-Pocket State D and B Who Would Experience . Savings Per Enrollee with Savings Savings ($) Savings (S) Alabama 29,127 512,800,687 5439 Alaska 1,026 $613,867 $598 Arizona 28,124 $14,545,058 $517 Arkansas 15,559 $8,395,598 $540 California 108,164 $36,622,758 $339 Colorado 16,085 58,288,613 $515 Connecticut 11,444 $6,749,195 $590 Delaware 6,066 $2,707,378 S446 District of Columbia 650 $262,462 $404 Florida 90,181 $42,920,606 S476 Georgia 45,625 $21,764,218 S477 Hawaii 3,703 $1,440,292 $389 Idaho 7,927 $4,801,119 $606 Illinois 59,718 $30,975,919 $519 Indiana 42,310 $22,876,374 $541 lowa 18,834 513,648,044 $725 Kansas 15,657 $10,170,650 $650 Kentucky 27,797 $12,590,086 $453 Louisiana 22,071 $9,095,485 $412 Maine 5,976 $3,169,201 $530 Maryland 21,052 $9,868,664 $469 Massachusetts 26,287 $13,248,195 $504 Michigan 66,726 526,908,214 5403 Minnesota 27,128 $18,232,052 $672 Mississippi 15,366 $8,344,497 $543 Missouri 34,881 $18,256,529 $523 Montana 4,835 $2,913,023 $602 Nebraska 9,716 $6,576,898 $677 Nevada 10,769 $4,725,569 $439 New Hampshire 6,586 $3,533,326 $536 NewJersey 39,641 $20,239,433 $511 New Mexico 8,716 $3,856,841 $443 New York 75,601 $36,526,747 $483 North Carolina 56,921 $25,580,364 $449 North Dakota 4,527 $3,642,152 $805 Ohio 72,854 $36,536,703 $502 Oklahoma 19,556 $10,417,603 $533 Oregon 17,915 $10,586,279 $591 Pennsylvania 80,197 $43,565,423 $543 Rhode Island 4,678 $2,269,088 $485 South Carolina 31,235 $14,896,443 $477 January 2023 DATA POINT 8 South Dakota 4,568 $3,313,226 $725 Tennessee 39,562 $19,534,028 $494 Texas 114,242 $50,395,627 $441 Utah 11,393 $7,110,735 $624 Vermont 3,118 $2,153,816 $691 Virginia 36,461 518,597,268 $510 Washington 28,063 $16,917,285 $603 West Virginia 12,656 55,706,666 $451 Wisconsin 31,935 $20,064,260 $628 Wyoming 2,469 $1,597,721 $647 Source: ASPE analysis of CMS Medicare Part D 2020 Prescription Drug Event (PDE), Enrollment, and Part B data files. CONCLUSION Patient out-of-pocket costs impact adherence to insulin, and non-adherence can worsen the rates of diabetes- related complications. 14 15 High out-of-pocket health care costs can also contribute to financial hardships that impact an individuals' overall health and wellbeing as individuals may have to make tradeoffs between health spending and other basic living necessities. 1 Our analysis of survey and administrative data on insulin costs indicate that 1.5 million Medicare beneficiaries using insulin will experience savings under the IRA's new out- of-pocket spending cap that took effect on January1, 2023. In addition, the IRAinsulin cap may allow increased access to insulin for patients who were previously unable to fill their insulin prescription due to cost. Based on the research evidence on the role of medication adherence in improving outcomes for patients with diabetes, these changes may produce downstream health benefits as well. Future researchshould monitor the impacts of these new provisions. January 2023 DATA POINT 9 APPENDIX Table A1. Estimated Medicare Part D Annual Out-of-Pocket Savings If Inflation Reduction Act $35/month Out-of-Pocket Insulin Cap Had Been in Effect in 2020, by LIS Status and State State Non-LiS LIS Total Part D Mean Annual Number Total Savings Number Tot al Number Total OOP Savings with Savings ($) with Savings with Savings ($) Per Enrol lee Savings (S) Savings with Savings ($) Alabama 28,003 $11,815,018 1,775 $268,778 29,066 $12,083,796 $415.74 Alaska 990 $582,152 58 $5,802 1,023 $587,953 $574.73 Arizona 27,455 $13,830,586 1,109 $166,823 28,075 $13,997,410 $498.57 Arkansas 14,841 $7,805,379 1,132 $177,075 15,521 $7,982,454 $514.30 California 106,345 $35,250,745 4,022 $358,146 108,092 $35,608,891 $329.43 Colorado 15,649 57,860,192 746 $103,227 16,062 $7,963,419 $495.79 Connecticut 11,253 56,540,640 520 $18,080 11,433 56,558,720 $573.67 Delaware 5,933 $2,536,364 243 $30,213 6,060 $2,566,577 $423.53 District of Columbia 619 §252,990 64 5950 647 $253,940 $392.49 Florida 87,486 $40,173,151 4,646 $521,412 90,003 $40,694,563 $452.15 Georgia 43,873 $20,475,237 2,982 $362,556 45,532 $20,837,793 $457.65 Hawaii 3,629 $1,410,522 137 $20,251 3,701 $1,430,774 $386.59 Idaho 7,717 $4,623,058 338 $52,263 7,909 $4,675,321 $591.14 Illinois 58,329 $29,231,359 2,810 $330,467 59,642 $29,561,826 $495.65 Indiana 41,389 $21,695,855 1,896 $179,074 42,253 $21,874,929 $517.71 lowa 18,358 $13,062,005 790 $107,007 18,783 $13,169,011 $701.11 Kansas 15,150 $9,692,101 836 $113,857 15,630 $9,805,958 $627.38 Kentucky 26,531 $11,747,790 2,976 $286,489 27,750 $12,034,278 $433.67 Louisiana 21,378 58,713,930 1,393 $148,732 22,038 $8,862,661 $402.15 Maine 5,851 $2,925,752 388 $6,293 5,967 $2,932,045 $491.38 Maryland 20,285 59,209,453 1,155 $189,666 20,996 $9,399,119 $447.66 Massachusetts 25,790 $12,695,158 961 $121,436 26,264 $12,816594 $487.99 Michigan 65,305 $25,804,236 2,540 $388,152 66,674 $26,192388 $392.84 Minnesota 26,570 $17,248,122 1,025 $156,585 27,083 $17,404,707 $642.64 Mississippi 14,765 $7,668,044 935 $138,816 15,336 $7,806,860 $509.05 Missouri 33,782 $17,205,616 1,874 $252,922 34,817 $17,458,538 $501.44 Montana 4,692 52,744,380 218 $34,469 4,829 $2,778,849 $575.45 Nebraska 9,466 56,197,689 440 $57,578 9,702 $6,255,267 $644.74 Nevada 10,499 $4,554,867 429 $61,393 10,755 $4,616,260 $429.22 New Hampshire 6,398 $3,327,493 333 $49,725 6,572 $3,377,218 $513.88 NewJersey 38,813 $19,425,572 1,630 $263,276 39,612 $19,688,849 $497.04 New Mexico 8,452 $3,692,046 473 $58,173 8,702 $3,750,219 $430.96 New York 73,739 $35,101,368 4,280 $481,505 75,526 $35,582,873 $471.13 North Carolina 54,677 $23,913,854 3,637 $554,791 56,848 $24,468,645 $430.42 North Dakota 4,443 $3,519,944 165 $28,390 4,522 $3,548,334 $784.68 Ohio 71,057 $35,024,530 3,382 $472,564 72,798 $35,497,094 $487.61 January 2023 DATA POINT 10 Oklahoma 18,972 59,959,808 980 $142,137 19,524 $10,101,945 $517.41 Oregon 17,408 $10,181,803 816 $125,532 17,891 $10,307,335 $576.12 Pennsylvania 77,935 $41,238,148 4,028 $662,135 80,108 $41,900,282 $523.05 Rhode Island 4,522 $2,146,243 273 = $37,724 4,675 $2,183,967 $467.16 South Carolina 30,164 $14,015,620 1,820 $301,840 31,179 $14,317,459 $459.20 South Dakota 4,450 $3,175,345 198 $29,276 4,558 $3,204,621 $703.08 Tennessee 38,074 $18,055,834 2,403 $375,905 39,494 $18,431,739 5466.70 Texas 110,446 $48,013,573 6,511 $955,289 114,122 $48,968,862 $429.09 Utah 11,183 $6,850,762 349 $60,050 11,378 56,910,811 $607.38 Vermont 2,981 $2,030,768 244 $49,463 3,117 $2,080,231 $667.38 Virginia 35,343 $17,595,051 1,876 $267,486 36,405 $17,862,537 $490.66 Washington 27,253 $16,147,677 1,305 $198,890 27,985 $16,346,568 $584.12 West Virginia 12,133 $5,411,873 843 $149,416 12,642 $5,561,289 $439.91 Wisconsin 31,439 $19,348,080 1,121 $111,812 31,895 $19,459,892 $610.12 Wyoming 2,410 $1,511,413 108 $10,092 2,464 $1,521,505 $617.49 Source: ASPE analysis of CMS Medicare Part D 2020 Prescription Drug Event (PDE) and Enrollment data files. OOP = Out-of-Pocket January 2023 DATA POINT 11 Table A2. Estimated Medicare Part B Annual Out-of-Pocket Savings If Inflation Reduction Act $35/month Out-of-Pocket Insulin Cap Had Been in Effect in 2020, by State Mean Annual OOP Savings Per State Number with Savings Total Savings (S) Enrollee with Savings Alabama 679 5716,891 $1,056 Alaska 41 $25,913 $632 Arizona 727 $547,648 $753 Arkansas 459 $413,144 $900 California 1,332 $1,013,795 $761 Colorado 450 $324,247 $721 Connecticut 205 $190,475 $929 Delaware 159 $140,386 5883 District of Columbia 12 $8,522 $710 Florida 2,433 $2,225,736 $915 Georgia 1,052 $926,236 $880 Hawaii 15 $9,518 $635 Idaho 195 $125,798 $645 Illinois 1,559 $1,412,609 5906 Indiana 1,170 $1,000,730 $855 lowa 754 $474,335 $629 Kansas 583 $363,689 $624 Kentucky 558 $555,808 $996 Louisiana 279 $232,811 $834 Maine 273 $237,156 $869 Maryland 543 $469,439 $865 Massachusetts 518 $431,601 $833 Michigan 843 $715,826 $849 Minnesota 945 $793,885 $840 Mississippi 604 $537,637 $890 Missouri 880 $797,746 $907 Montana 177 $134,174 $758 Nebraska 454 $320,834 $707 Nevada 146 5109,309 $749 New Hampshire 180 $156,109 S867 NewJersey 585 $550,309 $941 New Mexico 148 $106,622 $720 New York 989 $943,874 $954 North Carolina 1,239 $1,111,681 $897 North Dakota 108 $79,880 $740 Ohio 1,154 $1,038,659 $900 Oklahoma 361 5315,658 5874 Oregon 396 $278,944 $704 Pennsylvania 1,651 $1,665,126 $1,009 Rhode Island 95 $85,121 $896 South Carolina 664 $578,953 $872 January 2023 DATA POINT 12 South Dakota 155 599,248 $640 Tennessee 1,071 $1,101,514 $1,028 Texas 1,645 $1,425,196 $866 Utah 240 $199,924 $833 Vermont 94 $73,584 $783 Virginia 802 $734,731 $916 Washington 751 $570,156 $759 West Virginia 192 $145,377 S757 Wisconsin 698 $576,426 $826 Wyoming 104 $76,216 $733 Source: ASPE analysis of CMS Medicare Enrollment and Part B data files. OOP = Out-of-Pocket January 2023 DATA POINT REFERENCES 1 Centers for Disease Control and Prevention. (2022, June 29). National Diabetes Statistics Report. Centers for Disease Control and Prevention. Retrieved November 28, 2022, from https://www.cdc.gov/diabetes/data/statistics- report/index.html 2 Martinez, R.(Ed.). (2022, January 24). Pancreas hormones. Endocrine Society. Retrieved November 28, 2022, from https://www.endocrine.org/patient-engagement/endocrine-ibrary/hormones-and-endocrine-function/pancreas- hormones 3 American Diabetes Association. (2022). Insulinand Other Injectables. Insulin Basics. Retrieved November 28, 2022, from https://diabetes.org/healthy-living/medication-treatments/insulin-other-iniectables/insulin-basics 4 Cefalu, W.T., Dawes, D. E., Gavlak, G., Goldman, D., Herman, W.H., Van Nuys, K., Powers, A.C., Taylor, S.1., Yatvin, A. L. (2018, May 11). Insulin access and affordability working group: Conclusionsand recommendations. American Diabetes Association. Retrieved January 23, 2023, from https://diabetesjournals.org/care/article/41/6/1299/36487/Insulin-Access- and-Affordability-Working-Group 5 Cefalu, W.T., Dawes, D. E., Gavlak, G., Goldman, D., Herman, W.H., Van Nuys, K., Powers, A.C., Taylor, S. I., Yatvin, A. L. (2018, May 11). Insulin access and affordability working group: Conclusionsand recommendations. American Diabetes Association. Retrieved January 23, 2023, from https: //diabetesjournals.org/care/article/41/6/1299/36487/Insulin-Access- and-Affordability-Working-Group ® Gafney, A, Himmelstein, D, & Woolhandler, S. (2022) Prevalence and correlates of patient rationing of insulin in the United States: A National Survey. Annals of Internal Medicine Letters, 175(11), 1623-1626 7 Stanley, T. (2019, January7). What happens when a lifesaving drug becomes intolerably expensive? The Washington Post. Retrieved November 28, 2022, from https://www.washingtonpost.com/news/magazine/wp/2019/01/07/feature/insulin-is-a-lifesaving-drug-but-it-has- become-intolerably-expensive-and-the-consequences-can-be-tragic/ 8 Centers for Medicare and Medicaid Services. (2020). "Diabetes period prevalence by state, 2020." Retrieved from: b2- diabetes-state-current-year.jpg (1536x600) (ccwdata.org) ° Centers for Medicare and Medicaid Services. "Diabetes disparities in Medicare fee-for-service beneficiaries. Retrieved from: Diabetes Disparities in Medicare (cms.gov) 10 Centers for Medicare and MedicaidServices. "Your Medicare Coverage: Insulin." Retrievedfrom: https://www.medicare.gov/coverage/insulin 11 Centers for Medicare and Medicaid Services. "Your Medicare Coverage: Insulin." Retrievedfrom: https://www.medicare.gov/coverage/insulin 2 United States Congress. (2022, August 16). Text-H.R.5376 - 117th Congress (2021-2022): Inflation reduction act. Congress.gov. Retrieved January 23, 2022, from hitps://www.congress.gov/bill/117th-congress/house-bill/5376/text 33 Office of the Assistant Secretary for Planning and Evaluation, U.S. Department of Health & Human Services. Reporton the Affordability of Insulin. December 16, 2022. https://aspe.hhs.gov/reports/insulin-affordability-rtc 4 McAdam-Mar, C., Ruiz-Negron, N., Sullivan, J.M., & Tucker,J.M. (2022). The effects of patient out-of-pocket costs for insulin on medication adherence and health care utilizationin patients with commercial insurance; 2007-2018. Journal of Managed Care & Specialty Pharmacy, 28(5), 494-506. https://doi.org/10.18553/jmcp.2022.21481 15 Office of the Assistant Secretary for Planning and Evaluation, U.S. Department of Health & Human Services. Reporton the Affordability of Insulin. December 16, 2022. https://aspe.hhs.gov/reports/insulin-affordability-rtc 16 Stanley, T. (2019). "Insulinis a lifesaving drug, butithas become intolerably expensive. And the consequences can be tragic." Washington Post, January7. https://www.washingtonpost.com/news/magazine/wp/2019/01/07/feature/insulin- is-a-lifesaving-drug-but-it-has-become-intolerably-expensive-and-the-consequences-can-be-tragic/ January 2023 DATA POINT 14 U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES Office of the Assistant Secretaryfor Planning and Evaluation 200 Independence Avenue SW, Mailstop 447D Washington, D.C. 20201 For more ASPE briefs and other publications, visit: aspe.hhs.gov/reports ABOUT THE AUTHORS Bisma A. Sayed is an Economist in the Office of Health Policyin ASPE. Kenneth Finegold is a Senior Social Science Analyst in the Office of Health Policyin ASPE. T. Anders Olsen is an Oak Ridge Institute for Science and Education (ORISE) Fellow in the Office of Health Policy in ASPE. Nancy De Lew is the Acting Deputy Assistant Secretary for Health Policy in ASPE. Steven Sheingoldis the Director of the Division of Health Care Financing Policyfor the Office of Health Policy in ASPE. Kaavya Ashok is a graduate intern in the Office of Health Policy in ASPE. Benjamin D. Sommers is Senior Counselor, ASPE. The authors are grateful for the contributions of Acumen, LLCstaff to analysis of CMS Medicare data. The statements expressed in this Data Point do not necessarilyreflect the views of Acumen, LLC. SUGGESTED CITATION Sayed, BA, Finegold, K, Olsen, TA, De Lew, N, Sheingold, S, Ashok, K, Sommers, BD. Insulin Affordability and the Inflation Reduction Act: Medicare Beneficiary Savings by State and Demographics. (Issue Brief No. HP-2023-02). Office of the Assistant Secretary for Planning and Evaluation, U.S. Department of Health and Human Services. January 2023. COPYRIGHT INFORMATION All material appearing in this reportis in the public domainand may be reproduced or copied without permission; citation as to source, however, is appreciated. DISCLOSURE This communication was printed, published, or produced and disseminated at U.S. taxpayer expense. Subscribeto ASPE mailing list to receive email updates on new publications: https://list.nih.gov/cgi-bin/wa.exe?SUBED1=ASPE-HEALTH-POLICY&A=1 For general questions or general information about ASPE: aspe.hhs.gov/about January 2023 DATA POINT 15