Democrats' insulin dilemma

Even if Democrats soon pass a massive health care bill on a party line vote, there's a chance they could fail to deliver on one of their most politically appealing drug price reforms: capping what patients pay out-of-pocket for insulin.

Between the lines: Insulin-specific policies are absent from a compromise reconciliation deal while a bipartisan pair of senators push standalone insulin legislation. But the two-track approach risks leaving the insulin bill behind and alienating patients with diabetes heading into the midterms.

State of play: The House-passed Build Back Better Act included insulin co-pay caps along with measures that allow Medicare to negotiate drug prices, limit drug price hikes and restructure the Part D benefit.

• But a scaled-down compromise negotiated by Senate Majority Leader Chuck Schumer and Sen. Joe Manchin doesn't include the insulin policies. Some are in the standalone bill championed by Sens. Jeanne Shaheen (D-N.H.) and Susan Collins (R-Maine) — including a cap on cost-sharing at $35 per month within private insurance and Medicare.
• The Shaheen-Collins measure would require 60 votes — meaning at least 10 Republicans — to pass the Senate, and it's not clear yet whether enough members support the bill.
• One huge factor for Republicans: Insulin caps are a key issue for Georgia Democratic Sen. Raphael Warnock, whose seat the GOP would love to flip in November.

Why it matters: As insulin prices continue to increase, so has the amount that patients have to pay out-of-pocket for their medication.

Be smart: Although the BBB and the Shaheen-Collins bills both limit cost-sharing, they address the underlying price of insulin differently.

• The House-passed bill allowed Medicare to negotiate the price of insulin, and these medications weren't included in the annual limit on how many drugs are covered by direct government price negotiations. Although insulin products could still qualify for negotiations under the most recent Senate version, they'd count toward the annual limit.
• The Shaheen-Collins bill incentivizes manufacturers to reduce their list prices, but not via government negotiations.

What we're watching: Whether Democrats try to add the insulin components back into their reconciliation bill, despite the tight timeline they're operating under — and whether those provisions would even comply with Senate rules.

• If they don't and wind up passing the bigger health bill through the partisan reconciliation process, they'll be hard-pressed to convince 10 Republicans to collaborate on anything else before the midterms, especially something that could help arguably the Democrats' most vulnerable senator.