
Why drug prices in America are so high (2016) - ThomPete
http://www.economist.com/blogs/economist-explains/2016/09/economist-explains-2?fsrc=scn/fb/te/bl/ed/whydrugpricesinamericaaresohigh
======
RcouF1uZ4gsC
This has a very simple fix, and is a fix that would appeal to Donald Trump:

Require that pharmaceutical companies do not charge Americans any more for
their drugs than what they charge any developed country.

This lets other countries do the dirty work of negotiating prices while
reaping the benefits for the US. In addition, it goes along with his whole
America is getting screwed narrative - ie that other companies are taking
advantage of the fact that American markets pay for the drug developments, and
other countries reap benefits of cheap drugs and that he would put America
back on equal footing.

EDIT: Thanks for the great comments. To ease with the concern about hurting
the very poor countries, we could substitute "developed country" with "OECD
country" ([http://www.oecd.org/about/membersandpartners/list-oecd-
membe...](http://www.oecd.org/about/membersandpartners/list-oecd-member-
countries.htm) which are relatively rich countries).

~~~
frgtpsswrdlame
Why would that appeal to Donald Trump? It would hurt the profits of the drug
industry in America which will cost jobs, pharma execs will tell him how bad
this is for America and how harmful it is to drug R&D, etc etc. Donald Trump
may have campaigned as a negotiator for the common man but he identifies with
CEOs, anything that hurts them is not something that appeals to him.

~~~
dv_dt
The high price of medical care costs lives as well as jobs in other
industries...

~~~
frgtpsswrdlame
That didn't stop him from trying to repeal Obamacare. I personally think we
should institute drug price controls for many reasons including that one but
I'm not sure why we are thinking that Donald Trump is going to do it.

~~~
dv_dt
I don't know why Donald Trump does anything. But, I do think he's is of an
unknown position in this particular area - so given that we have a problem in
the US, and that Trump maybe doesn't have a defined position on the issue, it
doesn't hurt to chase the possibility. (On the other hand if I'm just guessing
with low-data: the chance does seems low).

------
doktrin
> These high prices support innovation, they argue—not just for America, but
> for the world.

I suspect this is in fact somewhat true, but how is it a coherent argument in
favor of higher prices? The American people / American _elderly_ (obviously)
don't have some unspoken moral obligation to subsidize pharmaceutical R&D for
the whole world.

Governments around the world are able to negotiate affordable rates for their
citizens, yet in the US we have to listen to these completely insane
justifications?

IMO if the US government (who presumably agree with the drug companies on
this) feels this strongly about subsidizing research they could always expand
federal research grants and/or NIH funding. Yet I suspect that's a non starter
for political reasons.

~~~
ferentchak
This. Do we need to subsidize Sweden and Germany?

I have wondered for a while why we don't make a law saying the highest price
you can sell a drug for in the US is no higher than the lowest negotiated
price that drug is sold to in other rich countries.

So if Canada negotiates a drug for $10 then that is the highest price you can
sell it for here etc. That way they can set the prices however they want but
collective buying agreements that are a part of socialized healthcare don't
end up shifting the burden of cost to the US.

~~~
chimeracoder
> I have wondered for a while why we don't make a law saying the highest price
> you can sell a drug for in the US is no higher than the lowest negotiated
> price that drug is sold to in other rich countries.

You don't need a rule to enforce that. You just need to allow the US to
reimport prescription drugs that were originally exported from the US. It
would be far and away the simplest solution and would have the same end
result[0].

Unfortunately, Congress has voted against that, so we're stuck with the status
quo.

[0] The difference between the prices charged in the US and the prices charged
in any other country could be no greater than the costs of reimporting the
drugs from that country - or else people would just buy the reimported
versions instead of the domestic ones[1]. This has the desired outcome of
equalizing the prices

[1] Which, remember, are literally the same drugs manufactured at the same
plants by the same company.

~~~
ferentchak
It's a nit pick but those prices would always be a bit higher after the effort
to import them and source them etc. Of course this will never happen. No
politician wants to have her name tied to the bill that allowed all those
dangerous drugs into the country that killed kids. One mistaken import or a
badly made counterfeit being imported would be a media frenzy.

~~~
chimeracoder
> It's a nit pick but those prices would always be a bit higher after the
> effort to import them and source them etc.

That's what I said:

> The difference between the prices charged in the US and the prices charged
> in any other country could be no greater than the costs of reimporting the
> drugs from that country

As for:

> Of course this will never happen. No politician wants to have her name tied
> to the bill that allowed all those dangerous drugs into the country that
> killed kids.

That's not true at all. The Senate voted on this exact proposal on Jan 17th
(not for the first time). The measure failed, but only by a few votes[0].

> One mistaken import or a badly made counterfeit being imported would be a
> media frenzy.

We're talking about importing drugs only from countries which recognize US
patent laws, such as Canada. The risk of counterfeit drugs entering the supply
from reimporting is no greater than the risk of counterfeit drugs entering the
supply domestically in either US or Canada.

Besides, this is already done for other drugs, just not prescription drugs
that are on patent.

[0]
[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)

------
calvinbhai
Drug prices in US go up because of collusion between Insurance Companies and
Drug manufacturers.

Would I buy expensive health insurance if drugs cost me $100 a month? Most
probably never.

What if the sticker price for my monthly dose of drugs was $10,000 or $50,000?
You bet I'd go get an insurance that'd cost $500 a month.

With such sticker shock, manufacturer reaps in profits. Insurance companies
get to charge higher premiums.

Solution: Fix IP laws for drugs in US. If the drug costs beyond the 2x or 5X
of what it costs in India, or than the average of drug prices in a few
countries, then that drug loses all its IP protections in US. Manufacturer is
still free to charge zillions for that product, but there'll be no
restrictions on copycats or generic versions from outside US taking over the
market.

It'll help in keeping a sensible profit margin for manufacturers without
ripping off Americans.

Most problems in healthcare costs in US, are due to insurance companies
dictating terms.

~~~
allenz
> Drug prices in US go up because of collusion between Insurance Companies and
> Drug manufacturers.

It's great that you're interested in healthcare policy, but you should be
careful about making blanket statements without the evidence. Drugs are 9% of
healthcare costs[1] and 14% of insurance costs[2]--hardly the decisive factor
in your choice of health insurance. And expensive drugs are expensive
primarily because it really does cost $1B+ to develop a new drug.[3] Even if
you wipe out drug company profits (which we really don't want to do), you'll
save at most 3% on your insurance.[4]

Like other types of insurance, cheap health insurance is cheap primarily
because it limits your coverage. The biggest impact is that you pay more to
see fewer specialists and undergo fewer procedures. It also results in
situations in which you're denied a cure for liver disease until you have
severe liver damage.[5]

Your solution doesn't solve collusion so much as make a major tradeoff: we can
have a world in which drugs cost $1000/year, if we stop researching drugs that
cure liver disease. We can have cheap health insurance, if we give up most of
the coverage. You probably didn't know you were making that tradeoff, and
that's probably not a tradeoff you want to make.

[1] [http://www.huffingtonpost.com/2014/12/03/health-care-
spendin...](http://www.huffingtonpost.com/2014/12/03/health-care-
spending_n_6256166.html)

[2] PwC report, page 12
[http://www.amcp.org/WorkArea/DownloadAsset.aspx?id=12727](http://www.amcp.org/WorkArea/DownloadAsset.aspx?id=12727)

[3]
[https://www.washingtonpost.com/news/wonk/wp/2014/11/18/does-...](https://www.washingtonpost.com/news/wonk/wp/2014/11/18/does-
it-really-cost-2-6-billion-to-develop-a-new-drug/)

[4] Profit margins are less than 20%
[http://www.bbc.com/news/business-28212223](http://www.bbc.com/news/business-28212223)

[5]
[http://america.aljazeera.com/articles/2015/10/16/insurance-p...](http://america.aljazeera.com/articles/2015/10/16/insurance-
providers-deny-hepatitis-drugs.html)

~~~
rlpb
> And expensive drugs are expensive primarily because it really does cost $1B+
> to develop a new drug.

Nope. More of the cost of a drug goes to marketing than development:
[https://www.washingtonpost.com/news/wonk/wp/2015/02/11/big-p...](https://www.washingtonpost.com/news/wonk/wp/2015/02/11/big-
pharmaceutical-companies-are-spending-far-more-on-marketing-than-research/)

~~~
allenz
Nope. Development costs $1B+ by itself, as you can see from my source or your
link. Marketing spend is on top of the R&D cost.

I agree that we should limit drug advertising, but that Global Data report is
off by an order of magnitude. Total advertising for Rx drugs is $15B to
physicians and $5.2B to consumers.[1,2] The discrepancy is due to several
factors.

First, the Global Data report lists combined sales and marketing. Sales
includes essential logistics needed for us to get our drugs, so you can't
really say that marketing alone costs more than R&D.

Second, most marketing is for over-the-counter drugs, for obvious reasons.
Tylenol, sold by Johnson & Johnson, has an enormous marketing budget, but it's
not exactly the kind of drug that forces people to buy insurance.

Third, drugs only account for 40% of J&J sales--their scary marketing budget
includes lots of advertising for non-pharmaceutical products.

[1] [http://www.pewtrusts.org/en/research-and-analysis/fact-
sheet...](http://www.pewtrusts.org/en/research-and-analysis/fact-
sheets/2013/11/11/persuading-the-prescribers-pharmaceutical-industry-
marketing-and-its-influence-on-physicians-and-patients)

[2] [https://www.statnews.com/2016/03/09/drug-industry-
advertisin...](https://www.statnews.com/2016/03/09/drug-industry-advertising/)

~~~
rlpb
> Nope. Development costs $1B+ by itself, as you can see from my source or
> your link. Marketing spend is on top of the R&D cost.

Irrelevant. You said: "And expensive drugs are expensive _primarily_ because
it really does cost $1B+ to develop a new drug" [emphasis mine] and I
demonstrated this to be untrue. The data shows that the primary cost is not in
R&D.

It doesn't matter what you say about the necessity of that sales and
marketing. I didn't comment on that. The _primary cost_ is still not in R&D.

> Third, drugs only account for 40% of J&J sales--their scary marketing budget
> includes lots of advertising for non-pharmaceutical products.

This may be true and perhaps more data is needed, but I haven't seen any
evidence that demonstrates unequivocally that the primary cost of drugs in the
US is due to R&D.

------
danans
Friends in the pharma and medical device development industry have told me
that the business case for any drug or medical device is built on top of US
sales at currently inflated US prices.

According to them, the other developed countries that have negotiated lower
rates for drugs serve a different purpose. Those countries have lower
requirements around testing of drugs and medical devices, and they are able to
move to human trials and market sooner there. The trade-off for those
countries is slightly higher risk of sub-optimal outcomes, but this appears to
be more accepted by the populations of those countries than it is by
Americans.

I'm not writing this to vouch for this setup - it seems like it is pretty
unbalanced and ultimately does a lot of harm to people in the US due to drug
inaccessibility - but I thought I'd share it for another perspective.

~~~
_acme
Do you have support for the claim that US-developed drugs are generally
available sooner in non-US markets? My understanding was that these drugs are
generally available first in the US market, but that the developers may use
FDA approval to help with EU approval, etc.

~~~
danans
In the case of the medical device company in question, the trials took place
in Europe due to an easier regulatory process around testing. As I said, it's
their personal story, but here is an article that describes the differences
between the systems:
[http://www.nejm.org/doi/full/10.1056/NEJMhle1113918#t=articl...](http://www.nejm.org/doi/full/10.1056/NEJMhle1113918#t=article)

I didn't mean to imply that US drug prices necessarily have anything to do
with its regulatory structure, or that the European regulatory structure had
anything to do with their prices, only that the companies have probably
optimized their development and pricing strategies for the economic and
political situations in the local markets.

------
ThomPete
_" The simple answer is because they can. European governments control prices
in various ways—Britain has the strictest system, refusing to pay for
medicines that fail to meet a threshold of cost-effectiveness. But in America
companies set whatever official price they like."_

~~~
Apfel
If anyone's interested, England's system of health technology assessment (HTA)
for the NHS is extremely transparent and world-leading.

It's one of the things that we Brits should be extremely proud of (although
pharma-sponsored sob story campaigns in tabloid newspapers may suggest
otherwise).

All new technologies are investigated in terms of incremental quality of life
gain (vs current treatment norms) and changes in costs.

Furthermore, they consider everything in a wider context of opportunity cost
of adopting a new treatment and budget constraints.

For a lot more detail, have a look at the NICE reference case here:
[https://www.nice.org.uk/process/pmg9/chapter/the-
reference-c...](https://www.nice.org.uk/process/pmg9/chapter/the-reference-
case)

~~~
refurb
I would argue HTA is not without it's problems. That's why the UK has a cancer
drug fund. NICE has said "no" to those drugs, yet the public still clammers
for them. So a separate funding mechanism was created to pay for them.[1]

[1][https://www.england.nhs.uk/cancer/cdf/](https://www.england.nhs.uk/cancer/cdf/)

~~~
chimeracoder
> I would argue HTA is not without it's problems. That's why the UK has a
> cancer drug fund. NICE has said "no" to those drugs, yet the public still
> clammers for them. So a separate funding mechanism was created to pay for
> them.

See also: PrEP. PrEP is available in the US (and covered by almost every
private insurer[0] with drug co-pays covered by the manufacturer[1]). And
while it's less convenient, there are public clinics where you can get
prescriptions to avoid paying the co-pay to a GP. In other words, absent the
cost of your time, you can get it in the US for _free_.

In the UK, PrEP is not covered by the NHS. The National AIDS Trust had to sue
the NHS just to get them to _announce_ their decision not to cover it - before
that, they refused to make a statement one way or the other, and kept kicking
the can down the road. Now, you can only get it by paying a private doctor
(out-of-pocket) for a prescription, and then fill that prescription privately,
which can cost up to $13/pill.

(This is technically not HTA, but for the purposes of this discussion that
distinction isn't relevant.)

[0] And, as an aside, on the rare case that your insurer does _not_ cover it,
Gilead (the manufacuter) offers assistance programs that provide it
essentially for free.

[1] This is a separate program to enroll in; Gilead basically reimburses the
co-pays that the insurers charge

~~~
DanBC
Sexual health is part of public health, and thus we'd expect PrEP to be funded
by Public Health England, not the NHS.

The target of your anger here should be local authorities (who hold
responsibility for Public Health), not the NHS.

[https://www.england.nhs.uk/2016/11/update-on-
prep/](https://www.england.nhs.uk/2016/11/update-on-prep/)

~~~
chimeracoder
> Sexual health is part of public health, and thus we'd expect PrEP to be
> funded by Public Health England, not the NHS.. The target of your anger here
> should be local authorities (who hold responsibility for Public Health), not
> the NHS.

First, PHE and NHS are both part of the DH, as is NICE.

Second, sexual health is one aspect of PrEP, but it's not the full picture
(though of course, that's how the NHS press release you linked would be
inclined to portray it. The lower court disagreed with that portrayal, even if
the appeals court did not.)

Finally, the arbitrary delineation of responsibilities in which the NHS is
free to wash its hands off of the matter and NICE has no incentive to hold the
NHS accountable - leaving patients with no choice but to pay out-of-pocket -
is exactly the problem. Meanwhile, PrEP has been generally available (and
essentially free) in the US for four years, thanks (ironically) to the
federation of power which forces insurers to remain somewhat competitive with
each other, and which permits the pharmaceutical companies to pick up the
slack when that fails.

If you want to point out that this approach has its shortcomings as well, then
yes, I'm right there with you. But it's wrong to imply that what NICE and the
NHS are doing is fundamentally different from the cost-benefit analyses done
in the US, and it's also wrong to ignore the problems with the DH.

------
rayiner
The idea that you can point to even one or two "whys" is patently ridiculous.
The goal is easy to state: how do you set drug prices at the level that
optimally balances consumer welfare (benefit realized minus money spent)?
Simply setting prices as low as possible is of course not the answer--a big
part of maximizing the benefit realized involves creating adequate incentives
for drug companies to create new medicines. But there are a dizzying array of
factors that make it hard to even understand what that optimal price should
be:

1) The potential free rider effect is huge. Drug companies would not invest
billions into creating new drugs if after six months on the market they could
be duplicated by a competitor and sold for a far lower price.

2) To avoid (1), we give drug companies a patent. But in the process, we make
it much harder to use market mechanisms to regulate drug pricing, since
patents inherently give drug companies monopoly power.

3) Moreover, in most of the developed world, we want to make a certain level
of medical care accessible to everyone. That results in systems like Medicare,
the U.K. NHS, etc. That too stymies market mechanisms, except in the other
direction. Single-buyer markets are monopsonies, and unchecked result in
driving prices _below efficient level._ (That is likely what has happened in
Europe, and is the reason why Medicare is prohibited from negotiating drug
prices.)

4) The pharmaceutical market is international, and thus rich in arbitrage
opportunities for national governments. So long as the American market is
willing to foot the R&D bill, other countries have enormous incentives to
drive prices local below the efficient level for their own citizens.

5) Conceptions of morality also complicate things. We ordinarily accept the
idea that companies are permitted to charge based on the value they create for
their customers. We accept Apple charging $2,400 for a Macbook Pro and
understand that people only buy it because they think they will get more than
$2,400 of utility from it. What's the value to the customer of HIV anti-
retrovirals? How much would you pay to extend your life by decades? Almost
certainly more than what those drugs cost. There is an impulse to try and say
"well, it's okay for Apple to charge based on value created, but not drug
companies." That impulse is surely well-intentioned, but is counter-
productive. It has the effect of driving talent and capital _out of areas_
that have the greatest positive impact on humanity.

~~~
maxerickson
The US seems to need better regulation. How did it take so long for
esomeprazole to be revealed as a marketing sham?

[https://www.quora.com/Is-there-a-significant-difference-
in-e...](https://www.quora.com/Is-there-a-significant-difference-in-
effectiveness-between-Nexium-esomeprazole-and-OTC-omeprazole-brand-name-
Prilosec-when-treating-GERD)

Not necessarily more regulation or less regulation, but better. I guess that
falls into easy to say hard to do.

I also wonder about things like the significance of the improvements made to
the Epipen (the related patents allowed Milan to push generics off the
market).

------
sigil
"Why can't we just control prices?" wonders a publication called The Economist
in the second graf.

This article doesn't meet the Hacker News bar for me. Why read a shallow,
dataless, meandering, "could the grass be greener" thinkpiece when you could
be reading and discussing a deep statistical analysis like:

 _High US health care spending is quite well explained by its high material
standard of living_
[https://randomcriticalanalysis.wordpress.com/2016/09/25/high...](https://randomcriticalanalysis.wordpress.com/2016/09/25/high-
us-health-care-spending-is-quite-well-explained-by-its-high-material-standard-
of-living/)

The two follow up posts on that blog (Random Critical Analysis) are also quite
good. So many surprising discoveries await us _in the actual data_ , but I
guess opining and confirming bias is more fun? If real journalism is going to
require active philanthropy to survive, I'm funding the kind of critical
analysis on open data sets that makes me think & rethink, not the kind of
stuff that makes me go "that's just, like, your opinion, man." This article
was the latter.

------
marcgcombi
The key challenge is that the government has so grossly distorted the market,
on multiple dimensions, that the actual levers within the pharma vertical are
opaque to all but the most embedded incumbents. (economists refer to these as
hidden externalities).

These market-distortions have all but eliminated the natural cost-competition
that one would observe in other sectors, such as commodities or manufacturing.
The best thing the government can do is back off completely and make those
pharma companies REALLY sharpen their pencils.

For those of you who believe MORE regulation is the way out, that's called
"trying to dig your way out of a hole" or "repeating the same nonsense and
expecting a different outcome." Please challenge your beliefs.

------
vowelless
> And it is illegal for Medicare to negotiate with drug companies

Why is this the case ?

Also, this is from September 2016.

~~~
whafro
It was politics from a couple decades ago. Medicare historically didn't cover
prescription drugs, until Part D was enacted during the Clinton
administration.

A tactic to get Republicans to support the measure was to pledge that Medicare
wouldn't interfere in the drug market by developing its own formulary –
Medicare Part D plan providers would compete for members and negotiate with
pharmaceutical companies themselves.

There has been a bunch of talk over the last decade about repealing that
particular restriction, but it's never made it over the finish line.

~~~
cowsandmilk
> until Part D was enacted during the Clinton administration.

???? Medicare Part D came into being in 2003, well into Bush's administration.
The whole rest of your post is based around the notion that it was proposed by
Clinton, when it was Bush....

~~~
whafro
Totally, and thanks. I was quick to write and submit my answer and was
remembering some debate during the Clinton era.

But the noninterference provision was indeed targeted at market-oriented
Republicans to get them on board. There were plenty who wanted to ensure that
Medicare wasn't going to be eroding the businesses of established payers.

------
abfabry
I work at Blink Health (www.blinkhealth.com) and we're working to solve this
problem and offer patients a fair price for their medication, often saving
patients up to 90% of list price. We negotiate with pharmacies and
pharmaceutical manufacturers to get the lowest rates and improve price
transparency in an opaque market. We have a kick-ass engineering team -- if
you're interested in these problems and want to help us fix healthcare shoot
me an email at alexander [at] blinkhealth [dot] com

~~~
maxerickson
Why is an account with you better than no account at GoodRx?

I assume you are pretty much just a PBM?

------
MrFantastic
The reason is that private health insurance companies suffer from the Classic
Agency Problem.

They want their costs to increase at a sustainable rate so that they can keep
growing their Net Income.

Historically, private health insurance companies earn ~ 6% of their total
revenue as profit. To justify an increase in their premiums they have to
"miss" their payout ratio slightly every year.

Drugs that patients will take for life are a great way off locking in that
increased cost in a "controlled" way.

------
WallWextra
My father recently passed, and a month or so afterwards we got a bill from the
nursing home pharmacy who, apparently, couldn't figure out how to bill his
insurance.

The price for 30 atorvastatin, whose out-of-pocket cost is about $20, was
$160. The same with other cheap generic heart medications.

Complaining about high drug costs is a red herring. Drug prices are a small
fraction of healthcare costs, and even if new drugs were made cheap,
healthcare providers would still overcharge for them.

------
faragon
In most European countries drug prices are negotiated at scale, because of
public institution negotiating directly with pharmaceutical companies (most
expensive drugs are the ones in international shortage, e.g. hepatitis C
drugs, etc.). So what happens in the US is that pharmaceutical companies apply
the "divide an conquer" rule, having a de facto monopoly.

------
AngeloAnolin
Answered practically in the first two paragraph of the article:

Despite the furor, drug companies continue to charge exorbitant prices in
America. Why?

THE SIMPLE ANSWER IS BECAUSE THEY CAN

There's no _quick_ fix to the insatiable greed on all the parties involved.
Profit over people's well-being.

~~~
mgrennan
I have never understood for profit medicine. There is a very fine moral line
between, selling a blue pill that gives someone a "fun time" and selling
cocaine for the same resin? Drug companies are making dugs and machines to
"extend life" to drain the saving of the elderly. I've seen who could not pay
for a "live saving" drug, give away everything they own so they can go on
medicaid to be "saved".

------
WalterBright
Sam Peltzman in "Regulation of Pharmaceutical Innovation" shows with
statistics how the 1962 FDA Amendments resulted in massive drug price
increases and a halving of new drugs being developed, with no net increase in
efficacy.

------
andrewla
> Private insurers do so instead, but the government binds their hands, for
> example by requiring them to pay for six broad categories of drugs, without
> exception

I'd like to understand more of this -- it seems like there is hand-tying at
multiple levels. In addition to insurance companies, why isn't it possible for
pharmacies, for example, to compete on price directly -- CVS, or Walgreens, or
potentially even Walmart, seem like they would have sufficient market share to
negotiate prices as well.

~~~
refurb
The largest pharmacies do compete on price. It's common for CVS or Walgreens
to get an additional discount on products.

------
caseysoftware
Negotiation is only effective if you can walk away from the deal.

The drug companies can't afford to lose their biggest customer. But since the
customer can't go anywhere else, it's not like they would. It's a detente
where neither side can really make a move because the other just says "Nope."

I think transparency - as in publicly available pricing - would be the only
thing to change the balance here. Even then, it's not a fix..

------
narrowrail
I searched all the comments and saw no mention of hospitals. I believe
hospitals[0], pharma companies, and insurance companies have colluded to set
prices for all healthcare which prevents the actual 'users' from price
discovery.

[0][https://en.wikipedia.org/wiki/American_Hospital_Association](https://en.wikipedia.org/wiki/American_Hospital_Association)

------
uptown
1\. Drug companies donate to politicians.

2\. Politicians promote drug-company-friendly policies.

3\. Drug companies earn outsized profits.

4\. Repeat

------
shakencrew
Previous discussion on Hacker News:
[https://news.ycombinator.com/item?id=12494927](https://news.ycombinator.com/item?id=12494927)

------
pc2g4d
To me this is why single-payer is unwise. The distortions of having a single
massive customer with various mandates are bound to cause distortions like
this. Government-subsidized HSAs for everybody is my pet alternative.

------
Overtonwindow
Please add (2016) to the title.

~~~
ThomPete
Done

------
known
Make in China?

