North Dakota capped patients' out-of-pocket insulin costs at $25 a month, and the limit is written to hold even when a deductible is still unpaid. Lawmakers enacted it in 2025.
The number is narrower than it sounds. The cap reaches health plans the state regulates, not the coverage many people get through larger employers. A Red River Valley family still counting diabetes bills in the thousands shows what a copay ceiling does not automatically clear.
The account comes from reporting by Noam Levey for KFF Health News, published through NPR.
A Bill That Insulin Alone Does Not Explain
Nina Kritzberger, now 17, was diagnosed with Type 1 diabetes at 7. Her mother, Ang Kritzberger, has said she checked on Nina every two hours, around the clock, through the first 60 days after that diagnosis.
The family farms in the Red River Valley, and has for more than a century. Insulin has been in clinical use about that long. The modern ledger is less historical. The Kritzbergers pay at least $8,000 a year out of pocket for drugs, supplies and medical appointments, and Ang has said the household was carrying an incredible amount of debt.
That $8,000 is not an insulin copay. It bundles drugs, supplies and appointments, so a $25 monthly ceiling on one product does not describe what the year costs this household.
Where the $25 Actually Applies
The cap limits monthly out-of-pocket insulin costs in plans North Dakota regulates, including for patients who still have high deductibles. It caps what the patient is billed.
Republican state Sen. Sean Cleary co-sponsored the 2025 legislation. He has said there was broad agreement that the insulin market was not functioning for people. The bill passed with overwhelming bipartisan support in a Senate of 42 Republicans and five Democrats. The margin is less surprising than the subject.
Megan Hruby told lawmakers that coverage mandates do not make health insurance more affordable. The insulin bill carried evidence that a similar diabetes measure for state employees had little impact on insurance premiums. That is a narrower finding than a promise that every household's premium will sit still, and it is not a forecast of what this cap will do to anyone's rate.
A Patchwork of Ceilings
Colorado became the first state to enact an insulin copay cap, in 2019, barring state-regulated plans from charging more than $100 for a 30-day supply. North Dakota's $25 monthly figure is tighter on paper. Both laws share the same structural limit: the state can touch only some plans.
In 2022, President Joe Biden signed legislation capping insulin costs for Medicare enrollees at $35 a month. Patient advocates have pushed for out-of-pocket caps and other protections, and the argument has pulled Democrats and Republicans into the same fight in more than one capital.
North Dakota is one of 29 states with insulin copay caps. Set beside $100, $35 and $25, the word "cap" starts to look like a family of different deals, each aimed at a different slice of coverage.
Lower Averages, Same Old Risk
About a fifth of an estimated 40 million Americans with diabetes depend on insulin. Federal data cited in the KFF Health News report put average annual out-of-pocket insulin costs for privately insured users at $470 in 2018 and $220 in 2025.
That drop is an average, not a household budget. It does not describe a family paying thousands for the rest of diabetes care, or someone who skips doses.
A century of a drug in use has not produced a century of predictable bills. The privately insured average fell by more than half across those seven years and still left the political argument intact, because an average insulin copay and a year's worth of supplies are not the same expense.
Washington's Turn, Still Unfinished
Congress is considering a national insulin price cap. Among the bipartisan co-sponsors is North Dakota Republican Sen. Kevin Cramer.
Until that happens, the practical map stays split. A $25 cap can hold down the insulin bill on a state-regulated plan, deductible or not, and still leave a 17-year-old's supplies, appointments and any federally regulated coverage on a different set of rules.
