The NCSL Blog


By Colleen Becker

Like fashion, trends in health policy come and go—and aren’t always to everyone’s taste. Unlike bell-bottoms, when state lawmakers returned to work for the 2021 session, they were eager to find policy levers palatable to both parties.

DrugsPrescription drug access and affordability is one area legislators looked for common ground, and over 700 bills were introduced in 48 states and Puerto Rico. Of those, at least 104 laws have been enacted in 33 states. This number kept pace with 2020 where almost the same number of bills were proposed.

With most states’ 2021 sessions now concluded, NCSL takes a look at this year’s state legislative prescription drug policy trends. Though the first three trends below focus either on consumer cost or state costs, virtually all 2021 proposals would impact the cost of drugs across the health care system.

Addressing consumer access and affordability was a chief concern among lawmakers. In particular, many introduced legislation related to insulin. Since 2019, when Colorado passed the first law capping the amount a person pays for insulin, interest in this approach significantly gained legislative interest.

At least 93 bills in 33 states related to insulin were proposed this session. New laws passed in Alabama, Arkansas, Kentucky, Oklahoma, Oregon, Rhode Island and Texas bring the total number of states limiting a patient’s cost for insulin to 18.

Other approaches aimed at saving consumers money include limiting the use of copayment adjustment programs by health plans and pharmacy benefit managers (PBMs).

A copay adjustment program, also known as a copay accumulator or maximizer program, limits the amount a manufacturer’s coupon counts toward a patient’s annual out-of-pocket spending. Legislators in 20 states proposed 37 bills, with most proposals requiring these payments or coupons be applied to a consumer’s annual cost-sharing requirement, like their deductibles. Eleven states and Puerto Rico now have laws preventing the use of these programs.

Looking to save money on their own state’s drug purchases, some policymakers have increased their purchasing clout by participating in a bulk purchasing pool. Twenty-nine state Medicaid programs currently participate in some sort of pool; however, Nevada will soon be the 30th state with legislation passing this year.

Over 200 bills in 48 states were introduced related to pharmacy benefit manager (PBM) reform, and 46 laws passed in 27 states. PBM reform has been at the forefront of debates in legislatures across the nation for several years and all 50 states now have at least one law addressing PBM business practices. Laws cover a wide range of provisions but one strategy sparking significant interest is allowing providers of PBM services to compete for a state’s business through a reverse auction process—where companies compete by lowering their offers until a contract is awarded. Six states—Colorado, Louisiana, Maryland, New Hampshire and New Jersey—are pursuing this option.

Transparency across the prescription drug supply chain remains a top focus for legislators. Many efforts to compile cost and pricing information include a requirement that certain data be reported to the state. At least a dozen states have reporting requirements that apply to PBMs, drug manufacturers and health plans, with North Dakota and Virginia joining the list in 2021. When implemented, the law in Virginia will also apply to drug wholesalers.

Some states have established prescription drug affordability boards (PDAB). Maryland first formed one in 2019 and seven other states now also have some version of a PDAB—Colorado, Maine, Massachusetts, New Hampshire, New York, Ohio and Oregon. While some differences exist, the overarching goal of a PDAB is to identify prescription drugs that pose affordability challenges and make recommendations to the legislature.

Fall is rapidly approaching and with so many issues still left on the table, lawmakers are sure to stay busy ramping up for next session. Like the bell-bottom, it’s anyone’s guess which trends we will see in 2022, and which will resurface another day. But if 2021 is a trendsetter, there will be more bipartisan legislation to come.

Learn about these policies and more in NCSL’s recently released, Prescription Drug Policy Recommendations Work Group report, “Prescription Drug Policy: A Bipartisan Remedy.”

Also visit NCSL’s Prescription Drug Law Database where we have information on over 7,000 pieces of legislation.

Colleen Becker is a senior policy specialist in NCSL’s Health Program.

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About the NCSL Blog

This blog offers updates on the National Conference of State Legislatures' research and training, the latest on federalism and the state legislative institution, and posts about state legislators and legislative staff. The blog is edited by NCSL staff and written primarily by NCSL's experts on public policy and the state legislative institution.