Rep. Michael Howard, sponsor of the Alec Smith Emergency Insulin bill, thanked supporters outside the House chamber in February 2020. PhRMA argues the law is unconstitutional. (Glen Stubbe, Star Tribune file/The Minnesota Star Tribune)

The fate of Minnesota's insulin safety net program was debated in federal appeals court on Wednesday, as pharmaceutical manufacturers seek to undo a 2020 state law that provides the lifesaving drug in emergency situations to people who can't afford it.

Advocates for affordable insulin call the legal challenge "morally reprehensible," citing the nearly 500 people who have utilized the program since the law took effect last year.

"David beat Goliath and ultimately hundreds of Minnesotans are benefiting," said Rep. Michael Howard, DFL-Richfield, who helped craft the law after a protracted battle at the Capitol. "The reason we are here today is because Goliath isn't done yet. ... They are trying to rip insulin from the hands of people in need."

Under the law, Minnesotans facing a short-term emergency insulin shortage who cannot afford the medicine can go to their pharmacy and get a 30-day supply. Minnesotans can also apply for a longer-term supply — up to a year — if they're struggling to afford insulin.

The new law requires insulin manufacturers to supply the drug or reimburse pharmacies giving out insulin. They can face fines if they don't comply.

The Pharmaceutical Research and Manufacturers of America, or PhRMA, challenged the law the day it took effect in July 2020, arguing it violates clauses in the U.S. Constitution that prohibit the state from taking a manufacturer's property for public use without compensation.

In this case, they say the state of Minnesota is forcing insulin manufacturers to give their product to residents for free when they already offer alternatives to help people with diabetes.

U.S. District Judge David Doty dismissed the lawsuit in March, saying the case should be heard in state court and leaving the door open for an appeal. The trade group argues that the federal court has authority to declare the law unconstitutional and appealed to the Eighth U.S. Circuit Court of Appeals.

"The district court had the power to strike down this unconstitutional law and should have done so," Reid Porter, PhRMA's senior director of public affairs, said in a statement Wednesday. "The Minnesota law codifies repeated constitutional violations by taking manufacturers' private property without just compensation instead of addressing a faulty system that stands in the way of common-sense solutions known to help patients afford their insulin."

Proponents say the program provides long-term protections for individuals who need insulin but cannot afford rising prices and may not qualify for drug manufacturer assistance programs. The law was named after Alec Smith, a 26-year-old who died in 2017 after rationing his insulin. He couldn't afford the drug after aging out of his parents' insurance.

"We cannot allow more lives to be lost to corporate greed. It's amazing that we have to be here to fight for laws that save our lives," said Nicole Smith-Holt, Alec's mother, who advocated for the law. "We will not stop fighting."

Attorney General Keith Ellison, whose team is defending the law in court, said the price of insulin has increased 1,100% in the last 20 years because of greed.

"Pharmaceutical companies have made millions, if not billions, in profit off insulin while people are still dying because they can't afford it," Ellison said. "The Legislature passed the Alec Smith Insulin Affordability Act so that no Minnesotan would have to die like Alec did."

Democrats in the Legislature are preparing to bring proposals next session to lower the price of prescription drugs, including a copay cap on insulin, in the event the court undoes the law.