In Hillsboro, North Dakota, the Kritzberger family has farmed in the Red River Valley for more than a century, growing sugar beets, soybeans and grains. For the past 10 years they have also been part of a national fight over insulin prices, NPR reported.
Their daughter Nina was diagnosed with Type 1 diabetes when she was 7. "I slept by her bedside for the first 60 days," her mother, Ang Kritzberger, said. "And I had to stick her finger every two hours, 24 hours a day, to make sure that she was OK." The family has insurance, but they still pay at least $8,000 a year out of pocket for drugs, supplies and appointments. "We're in an incredible amount of debt," Ang Kritzberger said.
That frustration helped move a Republican-led state to cap what patients pay. State Sen. Sean Cleary, a Republican, co-sponsored legislation last year to cap patients' insulin bills at $25 a month. North Dakota is one of 29 states that have enacted such measures. The cap limits monthly out-of-pocket costs even if a high deductible would otherwise force a family to pay thousands of dollars before coverage kicks in for other care.
A century-old drug, and a market that 'wasn't functioning'
About a fifth of the estimated 40 million Americans with diabetes depend on insulin. The drug has been in use for a century, but steep price hikes pushed average yearly out-of-pocket costs for people with private insurance to $470 in 2018, according to federal data cited by NPR. Prices have since moderated after a public backlash, and those average yearly costs declined to $220 in 2025. Families like the Kritzbergers still wanted a cap as protection against future spikes.
Nina, now 17, listed the equipment she has to keep close: insulin, a spare pump, a spare Dexcom, a testing kit, Gatorade and glucose. A missed dose could land her in the hospital. "My body would start attacking itself and start shutting down," she said. "And then I would die."
Colorado became the first state to enact an insulin copay cap in 2019, limiting state-regulated plans there to $100 for a 30-day supply. In 2022, President Joe Biden signed legislation that capped insulin prices for Medicare enrollees at $35 a month. An effort to extend that cap to people with private insurance, including employer coverage, sank after Republican opposition in Congress, NPR reported.
In North Dakota, Democratic state Sen. Tim Mathern led the effort. He is one of only five Democrats in a Senate with 42 Republicans. Health insurers and the state chamber of commerce argued that price relief would mean higher 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. AARP lobbyist Janelle Moos said many Republican lawmakers told her it "wasn't the role of government."
A bipartisan vote, and a national follow-up
Ang and Nina Kritzberger and other families drove hours to testify in Bismarck. Supporters showed that a similar limit for state employees with diabetes had little impact on premiums. Lawmakers also voiced frustration with drugmakers and insurers. "Why are folks paying hundreds of dollars a month for a drug that's been commercially available for decades?" Cleary asked. "This market seems so broken." When the bill came up, it passed with overwhelming bipartisan support.
The cap does not cover every plan. States can typically regulate only some health insurance; coverage from larger employers is usually regulated by the federal government. Still, a KFF survey earlier this year found that about 7 in 10 U.S. adults — including 68 percent of Republicans and 77 percent of Democrats — said there is not enough government regulation to limit prescription drug prices. Congress is now considering a national cap, with a bipartisan list of co-sponsors that includes Sen. Kevin Cramer, a North Dakota Republican.
"Typically, Republicans are more on the free-market side of things, Democrats are more supportive of intervening," Cleary said. "But in this case, I think there was broad-enough agreement that this market just wasn't functioning for folks."