Health Outcome Changes in Individuals With Type 1 Diabetes After a State-Level Insulin Copayment Cap

Abstract

Many insulin users ration doses due to high out-of-pocket costs. Starting January 2020 with Colorado, 25 states and the District of Columbia enacted laws that cap insulin copayments. To estimate the association of Colorado's $100 copayment cap with out-of-pocket spending, medication adherence, and health care services utilization for diabetes-related complications. In this cohort study using Colorado's All-Payer Claims Database, nonelderly insulin users with type 1 diabetes were analyzed from January 2019 to December 2020. Outcome changes were compared in the prepolicy and postpolicy period among individuals continuously enrolled in state-regulated and non-state-regulated plans using difference-in-differences regressions. Subgroup analyses were conducted based on individuals' prepolicy spending (low: never ≥$100 out-of-pocket vs high: ≥$100 out-of-pocket cost at least once). Data were analyzed from June 2023 to May 2024. Enrollment in state-regulated health insurance plans subject to the copayment cap legislation. Adherence to basal and bolus insulin treatment was evaluated using the proportion of days covered measure, out-of-pocket spending reflected prescription cost for a 30-day supply, and health care utilization for diabetes-related complications was identified using primary diagnosis codes from medical claims data. The panel included 1629 individuals with type 1 diabetes (39 096 person-months), of which 924 were male (56.7%), 540 (33.1%) had 1 or more comorbidities, and the mean (SD) age was 40.6 (15.9) years. Overall, the copayment cap was associated with out-of-pocket spending declines of $17.3 (95% CI, -$27.3 to -$7.3) for basal and $11.5 (95% CI, -$24.7 to $1.7) for bolus insulins and increases in adherence of 3.2 (95% CI, 0.0 to 6.5) percentage points for basal and 3.3 (95% CI, 0.3 to 6.4) percentage points for bolus insulins. Changes in adherence were associated with increases within the prepolicy high-spending group (basal, 9.9; 95% CI, 2.4 to 17.4 percentage points; bolus, 13.0; 95% CI, 5.1 to 20.9 percentage points). The policy was also associated with a mean reduction of -0.09 (95% CI, -0.16 to -0.02) medical claims for diabetes-related complications per person per month among high spenders, a 30% decrease. In this cohort study of Colorado's insulin copayment cap among individuals with type 1 diabetes, the policy was associated with an overall decline in out-of-pocket spending, an increase in medication adherence, and a decline in claims for diabetes-related complications only among insulin users who spent more than $100 in the prepolicy period at least once.