An ADA Working Group assigned to investigate insulin affordability in the US reports its conclusions and recommendations this month in Diabetes Care (p. 1299). It comes as list prices for insulin have been increasing by~ 10–20% per year over the last 10 years and at a time when inflation has been~ 2% and spending on prescription drugs has only increased by~ 3% year on year. Using public information sources and meetings/interviews with key stakeholders, the Insulin Access and Affordability Working Group describes a complex insulin supply chain, including opaque pricing mechanisms and a myriad of different health insurance policies, that has contributed to the steep rising price for insulin over the previous decade. In particular the Working Group notes that there may be numerous incentives within a system that it says cannot be beneficial to the health of patients with diabetes. Detailing the many complexities in the system, the group points out that while list prices (the price for insulin set by the manufacturer) appeared to triple between 2002 and 2012, the net price reflecting what the manufacturer receives is much less. However, the article singles out the system of rebates as a major issue when accounting for the apparent difference between list price and net price. The article also notes that a lack of transparency means it is very difficult to understand where the money flows. Those rebates often do not make it to the point of sale for the patient. While highlighting a number of other issues, the Working Group goes on to make a series of conclusions and recommendations in relation to insulin affordability and access, expressing concern about the complexity and opaqueness of the system that ultimately appears to be driving prices higher and higher. Commenting more widely on the ADA statement, the chair of the Working Group William T. Cefalu said:“The Working Group was convened to provide high-level direction in the implementation of insulin access and affordability initiatives. After discussions with over 20 stakeholders in the insulin supply chain, we remain concerned with the complexity of the system. It was the consensus of the Working Group that the incentives throughout the insulin supply chain, which facilitate high list prices, need to be addressed.”