North Dakota caps insulin copays at $25 a month for patients

Poll finds 68% of Republicans want more drug-price regulation

North Dakota capped what patients pay out of pocket for insulin at $25 a month, becoming one of 29 states that have enacted such measures amid a national debate over how to protect people with diabetes from high drug costs. The North Dakota bill passed last year with overwhelming bipartisan support, in a legislature where Democrats hold five of 47 Senate seats and Republicans hold 42.

The measure arrived through the lived experience of families like the Kritzbergers, who have farmed in the Red River Valley for more than a century. They once had livestock. Now they grow sugar beets, soybeans and grains. Like many farmers, they labor to balance the books. Their daughter Nina was diagnosed with Type 1 diabetes when she was 7.

“I slept by her bedside for the first 60 days,” Ang Kritzberger said. “And I had to stick her finger every two hours, 24 hours a day, to make sure that she was OK.”

Ten years after Nina’s diagnosis, the family pays at least $8,000 a year out of pocket for drugs, supplies and appointments, despite having insurance. “We’re in an incredible amount of debt,” Ang Kritzberger said.

Soaring insulin prices for years forced people with diabetes to pay hundreds or even thousands of dollars, and many rationed insulin, with sometimes deadly consequences. About a fifth of the estimated 40 million Americans with diabetes depend on insulin. The drug has been in use for a century. Federal data show average yearly out-of-pocket costs for insulin reached $470 in 2018 for people with private health insurance, then declined to $220 in 2025 as drug companies faced a public backlash.

The cap limits what patients pay each month for insulin even if they have a high deductible that would otherwise require them to pay thousands of dollars before coverage begins for other care. Patient advocates including the American Diabetes Association began pushing for such protections amid spiking prices and stories of patients who died because they could not afford their medicine.

But for many families like the Kritzbergers, the prospect of a government cap offered protection from future price hikes and some relief from the anxiety of a serious disease.

Nina Kritzberger, now 17, describes a daily inventory of contingencies: “I have to make sure I have insulin, a spare pump, a spare Dexcom,” she said. A missed dose could put her in the hospital. “My body would start attacking itself and start shutting down,” she said. “And then I would die.”

The strategy initially caught on with Democrats. Colorado became the first state to enact an insulin copay cap in 2019, barring state-regulated health plans from charging patients more than $100 for a 30-day supply. In 2022, President Joe Biden signed legislation capping insulin prices for Medicare enrollees at $35 a month. Biden and congressional Democrats wanted to extend the cap to people with private health insurance, including employer-provided coverage, but Republican opposition sank that proposal.

In North Dakota, state Sen. Tim Mathern, one of only five Democrats in the Senate, led the effort and struggled for a long time to find supporters. “One is very lonely being a Democrat,” Mathern said, “especially if you espouse the more progressive end of public policy.”

Health insurers and the state chamber of commerce argued that price relief for people with diabetes would raise premiums for everyone else. “We do not make health insurance more affordable by passing coverage mandates,” Blue Cross Blue Shield of North Dakota lobbyist Megan Hruby told lawmakers. Janelle Moos, a state lobbyist for AARP, which backed the bill, said the industry tapped into lawmakers’ skepticism about regulation: “It wasn’t the role of government,” she said she was told by many GOP lawmakers.

Ang and Nina Kritzberger joined other families who drove hours across the state to testify in Bismarck. “It was me and six other lobbyists that were going to be giving their testimony against me,” Ang Kritzberger recalled. Supporters showed that a similar measure limiting out-of-pocket costs for state employees with diabetes had little impact on insurance premiums.

Republican lawmakers who had grown frustrated with drugmakers and insurers lined up behind the bill. “Why are folks paying hundreds of dollars a month for a drug that’s been commercially available for decades?” Cleary asked. “I just kept coming back to the fact that this market seems so broken and these families are having to make impossible decisions about rationing medication or skipping treatment.”

State Rep. Carrie McLeod, a Republican and a diabetes educator, said the health care system had become too focused on the bottom line. “The insurance companies started out to really help people with catastrophic needs, but things have gotten out of control,” McLeod said.

The cap will not make health care affordable overnight. States can regulate only some health plans; insurance provided by larger employers is typically regulated by the federal government.

Polling points in the same direction as the statehouse votes. About 7 in 10 U.S. adults — including 68% of Republicans and 77% of Democrats — said in a KFF survey earlier this year that there isn’t enough government regulation to limit the price of prescription drugs. Congress is now considering a national cap on insulin prices, and among the bipartisan co-sponsors is Sen. Kevin Cramer, a North Dakota Republican.

Back on the farm, Ang Kritzberger said the insulin debate showed something else. “We’re very connected in North Dakota,” she said, recalling how neighbors had recently helped a farmer with brain cancer harvest his sugar beets. “It’s all about being connected and finding that common ground.”