As the November elections approach and complicate bipartisan support, US lawmakers attempting to reduce the cost of insulin for more than a million Americans to $35 per month are unlikely to succeed, according to health policy and political experts.

In March, the United States House of Representatives passed legislation capping monthly out-of-pocket insulin costs for those with health insurance at $35. Senators are working on a broader bill that would incentivize drug-makers to lower list prices.

To move forward, both houses must pass the same legislation.

The Democratic-backed legislation was once thought to have a good chance of passing because it avoided requiring drug companies to cut prices, which the pharmaceutical industry would have opposed. Republicans have stated their support for drug pricing reform.

According to Reuters, insulin legislation faces significant obstacles, according to health policy experts, pharmaceutical industry sources, patient advocates, and Congressional staffers. Some Democrats said they were still hoping for the 10 Republican votes needed in the Senate to pass the bill.

“As we get closer to the summer and the election, it appears that there may not be a lot of appetite to potentially give Democrats a win going into the elections,” said Ipsita Smolinski, managing director at Capitol Street research firm.

According to the American Diabetes Association, approximately 8.4 million of the 37 million diabetics in the United States use insulin.

According to a 2021 report on drug prices by health information company IQVIA, one-in-five insured Americans pay more than $35 per month for the treatment, while the rest pay around $23 per month. Monthly out-of-pocket insulin costs are already limited in 20 states and the District of Columbia. According to the ADA, the cap is $35 or less in nine of those states and D.C.

The bill would assist an estimated 1.7 million people who have private insurance or Medicare coverage and pay more than $35 per month for insulin due to their location, the design of their insurance plan, or the type of insulin they require. According to Laura Marston, co-founder of the advocacy group The Insulin Initiative, the bill would only have reduced co-pays for about 20% of diabetes patients, and her organization will continue to fight for lower list prices.

“From my perspective, it’s not a setback in our fight to cap the price of insulin for all, not just the co-pay,” she said.

According to a 2020 Commonwealth Fund study, approximately 17% of insulin users aged 18 to 64, or 5 million to 6 million people, were uninsured or had a gap in coverage. Two-thirds of that group paid the full price for the life-sustaining medicine, which cost an average of $900 per month.

As a result, many people are rationing or skipping insulin doses, putting their health at risk. The legislation has the backing of the Pharmaceutical Research and Manufacturers of America (PhRMA), a trade group for the pharmaceutical industry, as well as insulin manufacturers. Sanofi SA, Eli Lilly and Company, and Novo Nordisk control 90% of the insulin market, which was invented in the 1920s.

“A $35 co-pay cap is an elegant policy solution to help people afford their insulin,” said Shawn O’Neail, an executive at Eli Lilly.

According to O’Neail and other industry sources, insurers would have to pass on the after-market discounts they receive from drug-makers to patients rather than incorporating them into the monthly premium price for everyone.

According to AHIP, the largest trade group for the health insurance industry, capping co-pays would result in a cost shift, which would result in higher insurance premiums.

CVS Health Corp, Cigna Corp, and UnitedHealth Group Inc are three of the largest pharmacy and health insurance benefit managers.

According to the nonpartisan Congressional Budget Office (CBO), imposing the $35 co-pay would cost the US government $20 billion over ten years as premiums in government-sponsored Obamacare, Medicare, and Medicaid plans rise.

Higher private insurance premiums would also result in lower wages and, as a result, lower tax revenue, according to the CBO.