
The Hidden Monopolies That Raise Drug Prices - frgtpsswrdlame
http://prospect.org/article/hidden-monopolies-raise-drug-prices-0#main-content
======
kellanem
The article does a good job of starting to explain the forces, but it's
actually even more complicated.

A number of the PBMs are cross invested in pharmacies and insurance companies,
and the incentives of 2-3 large pharmacies that control the majority of the
market (and how they get paid) is very different than how small pharmacies get
paid.

Additionally the way the generic market works vs the branded (patented) meds
is completely different. (and the system of how drugs move from patented to
generic is _nothing_ like the way patents work in software)

Which is all to say, it's a fascinating space. It's very ripe for innovation.

If you're interested in this kind of thing at Blink we're building a price
transparency and payment platform that both routes over and routes around PBMs
and gives a unified fair price for everyone in the US.

If you're interested in roughly what the wholesale price is plus a very small
markup, you can find it on [https://blinkhealth.com](https://blinkhealth.com)

And we're hiring.
[https://www.blinkhealth.com/careers](https://www.blinkhealth.com/careers)

Also the re-importing from Canada is a total red herring. As is implied in the
term "re-importing" these drugs are made here in the US, there is nothing
special about sending them to Canada and bringing them back. There just needs
to be a payment platform that allows people to pay the wholesale price with a
small markup (vs the "Average Wholesale Price" which is often a 2000-3000%
markup over the real wholesale)

Finally one of the challenges with moving to a centrally managed pricing
solution like what works so well in Canada and most of Western Europe is right
now R&D into pharmaceuticals is largely financed by the opportunity size
available in the US market. If you were to just adopt the centralized model
tomorrow R&D would grind to a stop, at least for some period of time until we
found new ways to finance it.

~~~
spangry
_" Finally one of the challenges with moving to a centrally managed pricing
solution like what works so well in Canada and most of Western Europe is right
now R&D into pharmaceuticals is largely financed by the opportunity size
available in the US market. If you were to just adopt the centralized model
tomorrow R&D would grind to a stop, at least for some period of time until we
found new ways to finance it."_

That would be bad. Based on 5 minutes of googling and 10 minutes of reading,
the largest US pharma company is Johnson & Johnson. Their latest earnings
report has the following for the 12 months in 2016 (not all expenses are
listed here):

\- Sales (i.e. revenue): $71.8bn

\- Marketing expense: $19.9bn

\- R&D expense: $9.1bn

\- After tax, after expenses profit: $16.5bn

So, on behalf of my fellow Australians, I'd just like to thank J&J for selling
into my country at a substantial loss (and, in doing so, bravely running the
risk of breaching their fiduciary duties to their shareholders).

I'd also like to express my gratitude to consumers in the United State, who
are apparently so generous that they are willing to subsidise my country's
single-purchaser medical system. It's a shame you can't have one as well, but
at least you have the world's gratitude for your sacrifice. USA #1!

EDIT: Link -
[http://files.shareholder.com/downloads/JNJ/4178180194x0x9249...](http://files.shareholder.com/downloads/JNJ/4178180194x0x924921/BCDFDBBF-7CC2-49FF-8ECF-3EC12FC88406/JNJ_News_2017_1_24_Financial_Releases.pdf)

~~~
jessriedel
With all the sarcasm, it's hard to tell how broad of a point you're trying to
make. Do dispute the fact that Australia free-rides to a non-trivial extent on
US medical R&D?

~~~
spangry
Yes I do dispute that notion. Actually I dispute the entire idiot notion that
the US is somehow subsidising the rest of the worlds' healthcare.

In actual fact, pharmaceutical / medical device companies will simply charge
whatever the market will bear, and it just so happens the US market will bear
almost any price. If some market won't bear a profit making price, pharma
companies simply won't sell into it.

It makes utterly no sense to sell at a loss and then cross subsidise using the
massive rents extracted from US markets, yet that is exactly what most people
here seem to think is happening. Although maybe Trump really has managed to
'make America great again'. Speaking of great...

The US spends 17.1% of of its GDP on healthcare. The 5 countries that are
richer than the USA (GDP per capita) pay an average of 7.77%. Excluding Qatar,
it's 9.03%. The top 10 richest countries (excluding the USA) spend an average
of 8.03% of their GDP on healthcare, and I'm pretty sure at least a few of
these have universal public health insurance.

You're paying more than DOUBLE compared to the 9 other richest countries in
the world. You're simply getting gouged. If you can't even admit that maybe
there's a problem here, and instead want to persist with all these insane
American exceptionalist fantasies, it's unlikely anything is going to change
in American healthcare.

Data from here:
[http://data.worldbank.org/indicator/SH.XPD.TOTL.ZS?end=2014&...](http://data.worldbank.org/indicator/SH.XPD.TOTL.ZS?end=2014&start=2014&view=bar&year_high_desc=false)

And here:
[https://en.wikipedia.org/wiki/List_of_countries_by_GDP_(nomi...](https://en.wikipedia.org/wiki/List_of_countries_by_GDP_\(nominal\)_per_capita)
(using IMF GDP figures)

~~~
jessriedel
That's a long rant that doesn't even address the standard econ 101 argument.
It's especially weird to quote spending data since that's what one would
expect if the US was subsidizing the world.

~~~
spangry
It's also what one would expect if US consumers are getting horribly gouged on
prices. But then I guess you'd also expect to see pharmaceutical companies
enjoying super high profit levels... Oh wait...

EDIT: Given I am unable to address the 'econ101 argument', would you care to
take a shot?

~~~
jessriedel
No, I think your tone is completely inappropriate for HN and is not compatible
with a constructive discussion.

~~~
spangry
Fair enough.

FWIW I do apologise for the sarcastic tone of my posts above. You're right;
it's probably not the right way to spark a constructive discussion. To be
honest, my tone was a fairly deliberate departure from how I usually post.
It's just that I've been in a number of these 'US Healthcare' discussions on
HN now and have seen the same points and counterpoints made many times, yet no
progress seems to have been made.

I suppose that's a good indication that I should just stay out of these
threads until I can maintain a civil tone.

------
iamleppert
I deal with Express Scripts and CVS Caremark. I have Hemophilia, a bleeding
disorder condition I've been born with.

By far, these are the most corrupt organizations in the medical/drug industry.
At least the phrama companies actually make something at the end of the day
and do research, and employ more than just business people. I am forced by
whatever insurance plan I have, to deal with these companies directly because
they have whats called a "carve out" \-- an exclusive agreement with the major
insurance carriers that requires I deal with them directly. I literally have
no choice or alternative from which to get my medication.

The reason is clear: my medication costs between $60,000 - $150,000 per month.
I'm not kidding, either. It's been this way forever, despite the patents
expiring on the medication. Its so lucrative and it makes me ill that so many
people are benefiting and using me as some kind of financial conduit due to my
medical condition. A significant amount of the money goes to one of these
companies. They literally have a markup on the medication on a per-unit basis.
So they tack on 20% or 30% to each unit of my medication (think pills, but its
actually IU potency units -- its an IV medication I give to myself).

I'm fortunate that, because of these extreme costs, these companies have
actually worked out in my favor: they have a dedicated rep assigned to me, and
continually renegotiate their position with the insurance carriers to maximize
their profit (I'm a high-profit user and thus very important to them).

These companies have no interest in getting costs down, and actually fight for
the opposite. A few years ago they bullied the drug companies into offering a
co-pay assistance program so they can literally take my insurance for all its
worth. Their goal is to max out whatever benefits I have, and at that point
usually the patient can be a blocker because they don't have the money for the
maximum yearly deductible. However, they basically worked with/forced the drug
companies into creating a co-pay program, then raised up the prices for the
first order of the year. What happens is the first order I place is always
more expensive, and then it gets discounted by some amount (usually my yearly
co-pay). I don't have to pay this money however, it comes directly from the
manufacture's co-pay assistance program.

So I guess its a triumph in the fact I don't really have to pay much -- if
anything for my medication, but that's only because its extreme high price.
I'm sure its not like this for other people on the middle and lower ends of
the system.

~~~
e40
So I read this and I'm horrified. And I know that no one in the coming years
will make this or anything like it a priority in Congress. They give no shits
about us. The media spends all day talking about tweets and Russian influence
in our election and on our newly minted government officials. Yeah, the latter
is important, but health care is really, really important. It's the reason our
new POTUS was elected, according to the post-mortums I've seen. NOTHING WILL
BE DONE (that is good for the people, things might be done that will be great
for businesses).

~~~
TheAdamAndChe
Remember, Donald Trump was elected because people want change. Most people are
aware at this point that the system is rigged, and are looking to change it.
It's unclear currently whether populism or socialism will win in the long run,
but don't lose hope yet.

~~~
ch4s3
Socialism and populism are not necessarily mutually exclusive. Quite often
socialism takes the form of populist socialism (think Bernie Sanders or
Chavez).

Also, I think anyone who voted Trump to generate populist change, are likely
getting a raw deal. The administration is loaded with Billionaires and
business leaders, the opposite of populism. And, they've already set about
enacting changes that negatively affect average people, like rolling back
privacy protections, and pushing for health reforms that would cause 20
million people to lose insurance coverage, while according to the CBO raising
costs.

~~~
TheAdamAndChe
Thank you, I wasn't aware of that. I thought they were completely different.
How would Trump's direction be described, then? Nationalism?

Also, I agree that electing Trump was a raw deal. But between the two
presidential candidates, Trump was the Change candidate and Clinton was the
Status Quo candidate. From what I understand, a lot of studies show that
Sanders would have won the election if he wasn't suppressed on the Democratic
side. Most people don't feel like the country is going in the right direction,
and they want change.

~~~
ch4s3
Trump is more or less a (far-ish)right populist and economic nationalist.

Not to rehash the election unnecessarily, but I seriously doubt Sanders had
any chance nationally. The US has a political center that is center right to
right wing on an absolute scale, meaning the average American Democrat would
fit comfortable in most moderate/centrist conservative parties in the rest of
the developed world. No judgement there, it's just a historical fact and
likely the result of some political realignments in the 20th century due to
the Cold War. That is to say that someone as far left of center as Sanders
would have no chance in most swing states where the election is decided.

------
chimeracoder
> Americans pay the highest health-care prices in the world, including the
> highest for drugs, medical devices, and other health-care services and
> products. Our fragmented system produces many opportunities for excessive
> charges. But one lesser-known reason for those high prices is the
> stranglehold that a few giant intermediaries have secured over distribution.
> The antitrust laws are supposed to provide protection against just this kind
> of concentrated economic power. But in one area after another in today’s
> economy, federal antitrust authorities and the courts have failed to
> intervene. In this case, PBMs are sucking money out of the health-care
> system—and our wallets—with hardly any public awareness of what they are
> doing.

As I and other have mentioned before, the easiest way to fix this would be to
permit re-importing drugs that were manufactured within the US.

For example, permitting trade across the US-Canadian border provides an
equalizing force on the prices across the border, even though, at steady-
state, no drugs actually need to make the return trip. In other words,
allowing the trade puts an upper bound on the difference between the prices
charged in the US and the prices charged in Canada: that difference can be no
greater than the costs of reimporting those drugs, or else it becomes cheaper
for people to source their drugs from Canada.

By disallowing the trade, we allow the difference to grow unbounded.

A few days before Obama left office, there was a bill that would have fixed
that, but nine Democrats joined the Republicans in voting it down:
[https://www.senate.gov/legislative/LIS/roll_call_lists/roll_...](https://www.senate.gov/legislative/LIS/roll_call_lists/roll_call_vote_cfm.cfm?congress=115&session=1&vote=00020)

~~~
rayiner
We "disallow trade" for lots of legitimate reasons. One such reason is when
government intervention in another country drives prices below market levels (
_e.g._ we put high tariffs on Chinese steel to counter heavy Chinese
government subsidization of that industry).

That's exactly what happens in Canada. Because the healthcare system is
publicly funded, the government has enormous market power that it can use to
drive drug prices below efficient levels: [http://www.becker-posner-
blog.com/2009/12/should-the-governm...](http://www.becker-posner-
blog.com/2009/12/should-the-government-use-its-monopsony-power-to-reduce-the-
price-of-drugs-posner.html). Allowing re-importation of those drugs into the
U.S. would create a price ceiling at whatever level the Canadian government
had negotiated, and would effectively allow the Canadian government to set
drug prices in the U.S.

That would be good for consumers in the short term, but not necessarily in the
long term. It's no coincidence that the U.S. is the epicenter of
pharmaceutical advancements. When I was a kid (early 1990s), HIV/AIDS was
something we regarded as a death sentence. I vividly remember people talking
in hushed tones when Magic Johnson was diagnosed in 1991. 26 years later,
Magic Johnson is still kicking, HIV is no longer a death sentence, and we have
Big Pharma to thank for it (and not Canada).

~~~
chimeracoder
> we put high tariffs on Chinese steel to counter heavy Chinese government
> subsidization of that industry

That's not a good comparison, because we're talking about _reimportation_ \-
ie, drugs that are produced in the US and exported to another country before
being reimported. In general, nobody's interested in reimporting steel
produced in the US and exported to China.

> Because the healthcare system is publicly funded, the government has
> enormous market power that it can use to drive drug prices below efficient
> levels

First, Canadian healthcare is run at the provincial level, not at the federal
level. So while each province/territory is a monopsony, they're each fairly
small.

Secondly, pharmaceuticals are typically _not_ covered in Canada; patients pay
for most drugs out of pocket, and their generic prices are actually not much
lower than they are in the US[0]

> Allowing re-importation of those drugs into the U.S. in effect allows the
> Canadian government to set drug prices in the U.S.

With free trade, another country is still free to subsidize the goods that it
imports from the US, but with the knowledge that they'll be subsidizing
whatever portion of Americans choose to reimport those drugs at the subsidized
prices.

In reality, that reimportation won't need to happen, because it'll just apply
backpressure on the initial sale prices in both markets from the manufacturer.

[0]
[https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3107113/](https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3107113/)

~~~
jessriedel
> patients pay for most drugs out of pocket, and their generic prices are
> actually not much lower than they are in the US[0]

But rayiner's entire point is about incentivizing R&D by allowing the
collection of monopoly rents on _patented_ drugs; he's not talking about
generics. How the market for generics is structure has essentially no impact
on R&D. And as you say, since Canada's generics are nearly as expensive as in
the US, or are more expensive (see below), re-importing generics does not
usefully push down prices.

[http://news.nationalpost.com/news/canada/this-is-why-
canada-...](http://news.nationalpost.com/news/canada/this-is-why-canada-has-
the-second-highest-medication-costs-in-the-world)

~~~
chimeracoder
> But rayiner's entire point is about incentivizing R&D by allowing the
> collection of monopoly rents on patented drugs.

I'm pointing to the generics as an illustration of Canada's pharmaceutical
prices not being as controlled as people often think. (In fact, in Canada
they're not controlled directly at all - they're simply pegged by law to other
countries which set their own prices).

I actually agree with rayiner's point about incentivizing R&D by allowing
(temporary) collection of monopoly rents on patented drugs. I'm just saying
that they should be collecting those monopoly rents from all countries that
consume the drugs. Right now, they basically collect them only in the US, and
allowing reimporting from other countries which respect US patent laws would
ensure that all countries are contributing towards that in proportion to the
amount that they actually consume the results of the R&D.

~~~
jessriedel
Ahh, I see. Thank you for clarifying.

------
refurb
It's interesting how the villains of drug pricing have gone from the drug
companies to the PBMs.

At any rate, I don't agree that PBMs cause drug costs to increase. PBMs are
simply purchasing groups for insurance companies. They take advantage of bulk
purchasing and offer that service to insurers. They also handle the all the
complexities in setting a formulary which includes evaluating new drugs,
negotiating with drug companies and adjudicating claims. That has real value.

The best example of how PBMs have controlled drug pricing is in HCV. Express
Script directly attacked the pricing of Harvoni and Sovaldi. However there was
nothing they could do since they were the only HCV drugs available. However,
when Viekira Pak became available, Express Script did an exclusive deal with
Abbvie which caused Gilead to scramble to price match. The cost of HCV drugs
came down by almost 40% overnight. It saved the health care system a lot of
money.

Now, I do agree that PBMs pull a fast one on some insurance companies. They
are intentionally opaque when it comes to how much you pay for their services.
The smart insurance companies ask for "pass through" pricing and then pay the
PBM a fee for their services. The not-so-smart insurance companies don't ask
for those numbers and get put over a barrel.

~~~
attaboyjon
Actually the PBMs are a big villain here. They pocket the difference between
the retail price of a drug and the discounts they negotiate with the drug
makers. They choose the drugs on their formulary based on this spread.

This one of the reasons why you will see prices for drugs like Insulin going
up with each manufacturer raising price in lock-step. The drug makers are not
competing to sell the consumer insulin, they are competing to get on the
formulary of the PBM.

~~~
refurb
But that's their job! They are supposed to negotiate lower prices. They, in
turn, can market their formulary to insurance companies by saying "If you use
us, we can offer a lower cost pharmacy benefit."

And if you're a smart insurance company, you do your due diligence and don't
negotiate a contract where you have no transparency into the PBMs costs.

~~~
baloneyman
What "job" is that? There is no reason for these companies to exist.
Incentivizing drug companies to raise prices in lockstep... to keep the
middlemen happy? That is a very perverse incentive

~~~
xadhominemx
>There is no reason for these companies to exist.

It is clear you don't know much about PBMs. Maybe try to rephrase your comment
as a question.

------
maxxxxx
This is just another example of how messed up the US medical "market" is.
Almost everywhere you look there are hidden prices, hidden middlemen and so
on. I am not aware of any other market where things are so opaque and
convoluted.

If the current administration was serious about markets they should mandate
that all pricing becomes transparent so a real functioning market can actually
develop.

~~~
novalis78
Absolutely agree. Something long the lines of what pricepain.com had in mind.
This "market" is so ripe for disruption like no other. Sadly, its guarded by a
lot of lobbying power and artificial regulations. I think they get away with
it "because health".

~~~
maxxxxx
Americans are now so used to this insane system they can't even conceive that
it actually doesn't have to be that way.

~~~
spangry
I see you're getting downvoted, but you're right. This whole thread is filled
with utter lunacy. Just look at the top post. It's some middle-man explaining
how his company is innovative because they've figured out how to take a cut of
the massive economic rents, and everyone seems to just be nodding along
sagely.

What really gets me is this idiot notion that the US is somehow subsidising
everyone else's healthcare. In actual fact, pharmaceutical / medical device
companies will simply charge whatever the market will bear, and it just so
happens the US market will bear almost any price. If some market won't bear a
profit making price, pharma companies simply won't sell into it.

It makes utterly no sense to sell at a loss and then cross subsidise using the
massive rents extracted from US markets, yet that is exactly what most people
here seem to believe is happening. Then again, maybe basic economics somehow
doesn't apply to these super exceptional markets in the super exceptional USA.

------
kyleblarson
Interesting takeaway: going forward I'll always ask the pharmacy if paying out
of pocket would actually be cheaper than using my insurance and paying a
copay.

~~~
MichaelApproved
I have insurance with a high deductible. That means, I'm most likely paying a
price similar to a cash patient.

Often, it makes more sense to use a free 3rd party "coupon/membership"
prescription company to get a better price.

Here are two that have saved me money.

[https://www.goodrx.com](https://www.goodrx.com)
[https://www.blinkhealth.com/](https://www.blinkhealth.com/)

------
txmx2000
> The Pharmaceutical Care Management Association, the industry’s lobbying
> group, claims that PBMs will save health plans $654 billion over the next
> decade.

That's about $16 per person per month. Not a very compelling argument for
keeping your drug monopolies: eliminating them costs little more than a
Netflix subscription.

~~~
refurb
Keep in mind that insurance companies make decisions based on a change in cost
of only $0.05 per member. $16 per person is HUGE when you're talking about an
insurer who covers 30M+ people.

------
AnonMePBM
I can say this article rings very true. I am generally very impressed by the
accuracy of the points raised. But make sure not to associate all PBMs with
this practice. We too don't like it. I am pretty high up at a PBM (not one of
the big three), and can say our model does not play the same games (crimes!).
The point about MAC pricing is not exactly fair however. Some customers prefer
to engage this way since it reflects revenue based solely on the usage of
medications prescribed. It might sound odd, but this way we reduce (or near
zero) other fees that we charge the customer. In general, we DONT recommend
this model, but in some cases, it makes sense. I have to stay anon, since I
don't speak officially for the company; all opinions are my own.

------
torpfactory
I'm going to make the statement that perscription drugs aren't like other
products and shouldn't be viewed as such. People literally need them to
survive. This whole system of having something you need to survive being
subject to market forces like some other widget is ridculous. Price fixing is
absolutely a reasonable tactic to employ when the market for prescription
drugs in the US is as completely useless at delivering reasonable costs to
patients as it is.

~~~
joshuaheard
We need food to survive, and market forces work fine. In fact, I would say
that the U.S. supermarket is a model of market efficiency.

~~~
torpfactory
When I can buy drugs from the Pharamacy for $1.69 a pound I'll be happy to see
it driven by market forces. The market simply isn't doing a good enough job
getting medications to consumers at a reasonable price.

~~~
unabridged
Look at OTC medication costs, every store makes their own generic and they are
very cheap.

~~~
replicatorblog
Not to be pedantic, but a handful of pharma companies, like Teva and Perrigo
make them on behalf of the stores. It's a small, but important distinction.
The pharma market is more of a market than most people appreciate. One pharma
co's margin is another's opporunity.

------
koolba
Besides the freedom of speech issue, what arguments are there for _not_
banning prescription drug ads?

------
exabrial
Side note:It's also important to remember it takes an extraordinary amount of
investment to get a new drug to market. Often our 'staple' drugs are being
used to fund future cures.

------
AstralStorm
Ah, the tried and true method of making a market non-free. Increase number of
middlemen and make processes complicated so that no transparency remains.

------
encoderer
I think blaming drug companies and wholesalers just misses the point.

Drugs are really good today. Not even the life saving types, but also things
like migraine medication or acid reflux relief. If you suffer and have the
means, you'll pay what the market demands for relief. And we live in a wealthy
country.

~~~
clueless123
If your drug is so good, you should let the market decide what the fair price.

The problem is that drug companies and wholesalers don't let that happen by
lobbying against open markets and government paid healthcare.

~~~
refurb
_If your drug is so good, you should let the market decide what the fair
price._

Contrary to what people think, drug companies can't just charge whatever they
want. Take a look at the HCV drugs. They priced too high and their sales are
eroding very quickly. If they had priced lower, they probably would have seen
even greater profits.

~~~
kgwgk
How so? There are only so many patients to treat. Sales are eroding mostly
because competition has brought prices down and improved drugs allow for
shorter treatments.

~~~
refurb
The price was too high. There are millions of untreated HCV patients out there
that can't get treated because insurance companies won't pay for the drugs.

~~~
kgwgk
Now the prices are lower... and the profits as well.

~~~
refurb
Yes, but insurance companies haven't loosened the reins on these drugs. Even
with the lower prices, patients are being denied.

~~~
kgwgk
Not completely true (the restrictions have been eased a bit) but how does this
fact support your claim? ("If they had priced lower, they probably would have
seen even greater profits.") Profits were higher when prices were higher.

~~~
refurb
Yes, access has gotten better, somewhat driven by discounts, but also driven
by lawsuits against Medicaid.

Where I'm coming from is that there are 3.5M people in the US with HCV. Let's
say 10% are in California (350,000). Many of them are on Medicaid. Medicaid
estimates it will be spend $1B on these drugs in 2017[1]. Based on that
article, it comes out to 14,300 patients. A small fraction of those with HCV.

I would imagine if Gilead had priced lower (maybe starting at $40K and
discounting from there) they would have had much less payer pushback and
likely a huge increase in numbers treated. Payers are still telling people
"yes you have HCV, but no you're not sick enough".

[1][http://californiahealthline.org/news/medi-cal-to-spend-
nearl...](http://californiahealthline.org/news/medi-cal-to-spend-
nearly-1-billion-on-hepatitis-c-drugs-next-year/)

~~~
kgwgk
I see is no reason to think the increase in numbers treated would have been so
large that payers would have spent more dollars than they did, so its not
clear that Gilead's revenue (let alone profit) would have been higher.

~~~
refurb
We agree to disagree!

I think Gilead's pricing scheme left a bad taste in the payer's mouths and
probably caused them to be much more restrictive than they otherwise would
have.

Yes, payers still would have worried about total budget impact, but a lower
price means more value. If a payer can spend another $1M and treat another 50
patients (at $20K) vs. 10 patients (at $100K) I get the sense they would have
felt it more worthwhile.

~~~
kgwgk
But the price is lower now! They could be spending a bit more (or even the
same) to treat many more patients than they did in 2015, but instead they
choose to spend much less to treat a few more patients. Of course you are free
to imagine that it could have happened differently.

