No, Mr. President, the insulin affordability problem isn't solved

That the price of insulin came up during last week's presidential debate is a testament to the hard work of advocates such as Nicole Smith-Holt.

The Twin Cities woman lost her 26-year-old son, Alec, in 2017. He died after trying to ration the medication he needed to manage his diabetes. His death galvanized his mother and others, putting an unprecedented spotlight on insulin's high cost in the United States.

Their plight has President Donald Trump's attention. He mentioned insulin during the Sept. 29 debate, but his remark proved unhelpful. When Smith-Holt heard him say that insulin's price is so cheap "it's like water"— she nearly spewed out what she was drinking. Insulin costs around $300 a vial and can last a few days or up to a week depending on the user. "The millions of Americans who require insulin to stay alive will agree that it is not as cheap as water,'' she said. "If it was, they would not be rationing, or dying, or traveling to Third World countries to purchase at affordable prices."

Regrettably, the chaotic debate between Trump and former Vice President Joe Biden moved on rapidly, potentially leaving Americans with the impression that insulin cost is no longer a problem. That is not the case. While Minnesota passed an emergency insulin measure this year, the industry trade group has filed suit to overturn it. Some insurers here and elsewhere have also reduced enrollees' out-of-pocket expenses, but not all plans provide this relief.

There is more work to be done to ensure that insulin and other lifesaving prescription medications are affordable. Roughly a fourth of seniors, as well as adults who take at least one prescription drug, report difficulty with affordability, according to the respected Kaiser Family Foundation. Not surprisingly, those who struggle most often have the most serious health problems.

The COVID-19 pandemic has dominated the 2020 campaign, but shouldn't overshadow this important issue, particularly when Trump has either made high-profile promises to provide drug price relief or signed executive orders to do so. One such recent measure: a presidential vow to send $200 gift cards to seniors on Medicare, the federal health program for those 65 and up.

The gift card made headlines late last month, yet there have been few details about how it will be implemented. There are multiple shortcomings. It would be a one-time boost, it wouldn't go very far given many medications' high cost, and it would only help those on Medicare. As Smith-Holt's son's death tragically illustrates, younger people also struggle with drug prices.

The gift card plan also obscures a much larger problem: The Trump administration has aided and abetted a group of Republican state attorneys general who have mounted a serious legal challenge to the Affordable Care Act. The case will be heard before the U.S. Supreme Court in November. If the entire law is struck down, along with it go the "doughnut hole" protections that have helped shield seniors from high drug expenses.

To its credit, the Trump administration has put forward other measures that could be helpful, such as taking steps that could potentially allow states to set up programs to reimport certain drugs (it's not clear which ones) from other countries with less expensive drug prices. Other administration initiatives that merit scrutiny: linking the cost of some Medicare drug prices to prices paid in other countries, and making insulin more available to low-income patients at "federally qualified health centers," though these may not be easily accessible to many patients, particularly in rural areas.

But it takes time and follow-through to actually turn these policies into a reality. And as the drug trade group's lawsuit against the Minnesota insulin program illustrates, legal challenges are likely. In addition, drug companies seeking to protect their bottom lines could also limit shipments to the nations serving as hubs for a reimportation program.

Democrats don't have easy fixes, either. The Biden health care plan also calls for reimporting drugs, though its main push is allowing Medicare to wield its vast purchasing power to negotiate prices with manufacturers. That too, would face an uphill challenge from the mighty pharmaceutical industry.

The major advantage of the Biden plan: It would build on the ACA instead of scrapping it. Trump merits credit for pursuing some innovative ideas to cut drug costs, but these initiatives wouldn't go far in blunting the coverage losses and missing doughnut hole protections if the landmark ACA falls.