Yale's diabetes patients rationed insulin at the same rate in 2024 as in 2017

Twenty-three states have no out-of-pocket insulin cap at all, since the count stands at 27 states plus Washington DC ^[1][20]. Where the laws do exist, they cap costs for "many people who take insulin", in the Vox summary, and some who take it fall outside them ^[1].

Apply T1 International's 34 percent rationing rate to the roughly 8.4 million Americans who depend on insulin and the count comes to about 2.9 million people ^[6][7][21]. The two 2024 measurements were taken separately and landed near each other. Yale's cost-only figure was about one in four patients, and 38 percent once insurance delays and supply limits were counted ^[4][5].

"And shockingly, frustratingly, critically, the data from our 2024 survey showed that the rationing rates were worse than ever," said Shaina Kasper, executive director of T1 International, a nonprofit that advocates for people with diabetes ^[9][18].

One academic clinic's patients are not a plan population. The useful part of the Yale finding is the flat line: the same rate in 2017 and in 2024, with the Colorado law in 2019 and the Inflation Reduction Act's Medicare cap in 2022 arriving in between ^[4][2][3]. Kasia Lipska, the Yale endocrinologist who co-authored it, said she expected better ^[19]. "I was surprised because I've been looking at the policy and advocating for policy change; you think things are moving, they should be really improving," Lipska said ^[11].

Her account of why is about coverage plumbing. "There's just still a lot of holes in one who is covered by various protections and then how they're covered and how they access this," Lipska said ^[10]. Vox names the uninsured as one group still paying cash prices, and reports that enrolling in manufacturer savings cards to get advertised lower prices can be difficult ^[16][15]. A 2023 congressional investigation found uninsured patients paying an average of nearly $100 for insulin despite Eli Lilly's pledge that its generic product would be available at $25 per vial ^[8]. The article does not break the remaining gap down by plan type, so a sponsor cannot tell from it whether its own members sit inside a cap.

That leaves the question answerable only from a plan's own pharmacy data: fill rates, gaps between refills, prescriptions abandoned at the counter.

Kasper said out-of-pocket caps were always a temporary fix for a very broken system ^[12]. The durable fix Vox describes is drug pricing reform, insurance mandates and possibly public manufacturing ^[13]. That is a decade of legislative work, out of reach of what a benefits owner decides this quarter. The choice available this quarter is smaller: log the $35 number as done, or pay for the eligibility mapping and refill analysis that would show who in the population is rationing. The first option costs nothing now. What it costs later is the long-term health damage the surveys attribute to rationing ^[17].