
Why treating diabetes keeps getting more expensive - mhb
https://www.washingtonpost.com/news/wonk/wp/2016/10/31/why-insulin-prices-have-kept-rising-for-95-years/
======
bruxis
As a type-1 diabetic of 17 years now, I can confirm that the price of Insulin
has been steadily rising over the years.

I can also state that the majority of my medical expenses go to insulin pump
supplies, not insulin itself. On average, I'm paying roughly $250/mo out of
pocket, after 90% insurance coverage for the whole diabetic kit-and-kaboodle.
I would be quite troubled if I were to lose my job and/or medical insurance.
Thinking about the future, it's definitely a fear of being in a circumstance
where I will be without supplies for any amount of time.

As another commenter noted, and got down-voted instantly, a large cause of the
insulin usage increase (and therefore pump increases) is due to a dramatic
increase in the diagnosis of type 2 diabetics.

Depending on where you're treated, many type-1 diabetics are given a rather
thorough crash course on the disease (and it's symptom-based-cousin, type-2,
for comparison). In my opinion at least, I don't feel like many type-2
diabetics are given as much information, or are potentially more reluctant to
absorb it.

It's a broad generalization, but not necessarily inaccurate, to state that
most type-2 patients rely on medicines to treat their symptoms and will not
adjust their diets even under the worst case scenario. Type-2 in many ways can
have it's symptoms reduced/resolved by something akin to a keto diet. That
said, sugar _is_ ridiculously hard to quit.

~~~
soneca
I think the reason the other comment about the effect of increased type-2
diagnosis on price was downvoted was that it stated a simple and direct
causation between growing demand and prices.

I agree that type-2 patients should receive better orientation in terms of
dietary treatment, but this growth in demand could (should?) also lead to an
economy of scale, especially for pump supplies, and a price drop. I have the
impression that it is not the free market (through demand growth) that is
increasing the prices, but rather a lack of free market (through cartel).

------
rbultje
“I don’t think it takes a cynic such as myself to see most of these drugs are
being developed to preserve patent protection,” said David Nathan, a Harvard
Medical School professor. “The truth is they are marginally different, and the
clinical benefits of them over the older drugs have been zero.” -- quote from
article

And there you have it. I have seen this myself. One year ago, the insulin I
was on was removed from the pharmacy, and coverage by my insurance company was
also voided. My only choice, I was told, was to switch to a new insulin (which
- as article states - was only marginally better, if at all), but which had a
fresh patent and thus ensures new profits for another 20 years to come.

And so the wheel keeps churning. Patients are not given a choice, because we
are not humans. We are merely a commodity to pharmaceutical companies' profits
and shareholder value.

~~~
marvin
I always thought that when patents expire, a generics company will duplicate
the drug (or treatment mechanism) and the prices will plummet to close to
marginal cost due to competition. I get the impression that this happens in
Europe, given the generic options that I am encouraged to choose when I’m
picking up a prescription at the pharmacy. They are invariably cheaper.

What is different for diabetes, or the United States, to cause this to not be
an option? Seems almost like a human rights violation, or at least deeply
unethical.

~~~
pja
Generics still require FDA approval, which costs on the order of single digit
$millions to obtain. Plus you’ve got to set up the plant to create the drug,
which costs more $. Would you invest $millions in a product when a competitor
(who probably already has plant capacity from when they made the drug while it
was under patent) could come in and undercut you at a moments notice?

Obviously not - so the system ends up in a metastable state where one monopoly
producer can charge high prices for a drug & no competitor will enter the
market because they know the producer can and will undercut them the moment
they try and do so.

This one of the reasons why the health care system in the US is completely
borked.

~~~
shadowtree
Only true for rare and ultra-rare diseases.

~~~
pja
As far as I’m aware, all generic manufacturers must prove what the FDA calls
bioequivalence:
[https://www.fda.gov/Drugs/DevelopmentApprovalProcess/HowDrug...](https://www.fda.gov/Drugs/DevelopmentApprovalProcess/HowDrugsareDevelopedandApproved/ApprovalApplications/AbbreviatedNewDrugApplicationANDAGenerics/default.htm)

------
glassesquestion
From the article:

> There have been few efforts to create a cheaper insulin. Walmart, for
> instance, sells Novo Nordisk's human insulin under the name ReliOn for $25 a
> vial. Eli Lilly is expected to release the first copycat insulin analog, a
> chemically altered form of insulin, at the end of this year.

You can buy this product right now, it is the same formulation you would have
taken if you were diabetic in the 1990s. [https://www.walmart.com/ip/Pharmacy-
Relion-Humulin-Insulin/1...](https://www.walmart.com/ip/Pharmacy-Relion-
Humulin-Insulin/167672445)

I am amazed by how many diabetics and GPs don't know this exists.

~~~
Zimahl
As the husband of a type-1 wife, I just wanted to add that there is a
difference in insulin that isn't just long-acting or short-acting. Different
people can react differently to different insulins. My wife used the ReliOn
brand for both for a while, and even though the short-acting was fine, the
long-acting was way too inconsistent (some very non-deterministic lows and
highs). Switching to Levemir long-acting smoothed those out.

That said, nothing inherently wrong with the ReliOn brand if that's all one
can afford. My wife forgot her short-acting insulin for a long weekend trip
one time and it was nice to know what we could simply buy some insulin out of
pocket and not get gouged to death.

> am amazed by how many diabetics and GPs don't know this exists.

I've noticed that GPs don't know enough about diabetes, one needs a specialist
to really get control of it.

------
kakoni
Whats up with those US prices, Humalog more than $250 per vial? In Europe
(Finland) non-subsidized price is $34.

~~~
kgwgk
Drug pricing in the US is complicated. Humalog list price has doubled in the
last few years, but the rebates have increased faster and the average net
price is actually going down. The average discount is 75%!

[https://www.bloomberg.com/news/articles/2017-06-29/the-
crazy...](https://www.bloomberg.com/news/articles/2017-06-29/the-crazy-math-
behind-drug-prices)

~~~
tonetheman
I am not sure that it is complicated so much as, they gouge anyone they can in
the US.

Not complicated at all, insulin keeps people alive and our shareholders need a
return on their investment.

~~~
kgwgk
They gouge anyone they can, but the fact is that they cannot do it as well as
before with the “old” products because their sales are going down (in dollars,
despite an increase in volumes). And the “new” products are often not good
enough to justify higher prices.

Edit: By the way, we’re not talking about insulin (which has been keeping
people alive since the 20’s) but about insulin analogues developed in the
90’s.

------
Angostura
Interesting, the response in the UK has been to address this by attempting to
pump money into programmes to to try and prevent type 2 diabetes or at least
reduce its growth. Still too early to see how these efforts will be.

~~~
HarryHirsch
The UK is the second-fattest country in Europe after Malta, and obesity (BMI >
30.0) puts you at risk for type-2 diabetes. It's a public health issue.

Interestingly, the other thing that's a risk factor is lack of sleep. Huge
commutes put you at risk for type-2 diabetes. Who'd have thought?

~~~
AjithAntony
> obesity (BMI > 30.0) puts you at risk

BMI>23 if you are South asian

[https://www.diabetes.co.uk/south-asian/](https://www.diabetes.co.uk/south-
asian/)

------
nunb
Dr Fung's article [1] is a good complement to this one and explains how the
market for insulin has been deliberately increased. As other commentators
mentioned, once you can have carbs with insulin, why bother changing and
looking for an alternative? Dr Fung treats patients with fasting protocols,
where compliance is harder, but costs lower. FTA I just learned that Dr
Banting is famous for both insulin and the original (proto) Atkins diet.

[1] [https://medium.com/@drjasonfung/the-diabetes-
payroll-291649d...](https://medium.com/@drjasonfung/the-diabetes-
payroll-291649d0e0d2)

------
kylell
Insulin is just like when you have performance problem in a monolithic app and
you throw more hardware at it, but at some point you can't upgrade your server
anymore.

Not sure if there's much you can do while diabetic, but cut bread-like and
sugary foods, these spike your insulin the most and your body becomes insulin
resistant and so you need more and more insulin, more that you can make.

~~~
bruxis
As a type-1 diabetic, your body no longer produces any insulin at all. This
means even without eating any carbohydrates, your blood glucose rates will
elevate every hour until you eventually succumb into a coma and shortly after,
perish. I use about 34 units of insulin per day, excluding any carbohydrates
-- this largely depends on body type as well, some people use much more.

A type-2 diabetic on the other hand, depending on how far their disease has
progressed, could potentially ween themselves off insulin entirely if they
were to completely abandon carbohydrates. These diets are _extremely_ hard to
maintain, especially indefinitely, however.

~~~
kylell
Yes, sorry, I was thinking at type-2 diabetes, I have a relative with type-2
and doctor told her to cut alcohol, sugar, carbs, etc, type-1 is entirely
different, the immune system attacks the pancreas.

~~~
Kayou
Thanks for the apology, but you got me quite irritated with your first
comment. It was like saying to a paraplegic in a wheelchair to man up and hit
the gym because there is only so much you can do with a wheelchair...
Dreadful.

~~~
bruxis
Just to add a bit of a positive spin on this: even type-1 diabetics could take
measures to both improve their health and reduce the amount of insulin they
require.

I consider myself moderately overweight at this point (maybe 10-15kg). If I
lost weight, I could reduce the baseline amount of insulin I need every day,
thus reducing the amount of insulin overall that I need to pay for.

I also fully acknowledge that, upon getting an insulin pump (16 years ago), I
instantly became aware that I had much more freedom to eat _what I want, when
I wanted_ and thus, put little effort to cutting back on sugar outside of
switching to diet drinks. If I were to switch to a low-carb diet, or no carb
(which is admittedly very hard, I've tried), I could further reduce my insulin
costs.

Personally (keep in mind these numbers depend highly on each individual), if I
got my weight down 10kg, and ate < 100g of carbohydrates per day, I could
theoretically only require ~35-40 units of insulin per day. At 40 units, I
would only need ~1.35 vials of insulin per month. Ballparking, I'd say my
current rate is likely around 2 vials per month.

~~~
Kayou
You still need to have carbs in your diet, it wouldn't be healthy otherwise.
Especially if you practice a sport.

I eat whatever I want (mostly pasta usually) and I need 20 units a day at
most. (100 units/ml dosage).

~~~
theorique
There's no dietary or metabolic need for carbohydrate. The human body can
survive and thrive perfectly well with only fat and protein as macronutrients.
Practically speaking, doing that is challenging and complicated because most
foods are a mix of all three macronutrients.

~~~
Kayou
But do you need sugar? Or you don't need either sugar nor carbs? It seems
strange to me. EDIT: it seems that if you use only your fat, you'll end up
producing too much Ketones which leads to Ketoacidosis. Doesn't sound good.

~~~
mizzack
No, ketosis doesn't lead to ketoacidosis unless you completely neglect to
manage your insulin.

------
a_c
I wonder if there is open-source equivalent in pharmacology

~~~
aristus
[http://openinsulin.org/](http://openinsulin.org/)

------
IdeaHamstir
I am not sure if any of these programs are still around, but older, generic
forms of insulin are available for free or greatly reduced price at many
pharmacies to qualified applicants.

[http://www.needymeds.org/](http://www.needymeds.org/) Is a non-profit group
that helps provide free/low cost meds.

Many pharmacies listed offer free/reduced price insulin.
[http://www.freediabetestestsupplies.com/free-diabetes-
medica...](http://www.freediabetestestsupplies.com/free-diabetes-
medications/4506/)

------
tallanvor
The title should be updated to reflect that this article is from 2016.

------
flipp3r
> Why treating diabetes keeps getting more expensive

Because there's a "type 2" diabetes epidemic, and instead of doctors telling
people to stop eating for a while, they sell them insulin.

~~~
mschuster91
> and instead of doctors telling people to stop eating for a while

People won't stop eating (and especially drinking) high-sugar stuff unless
they're on their deathbed. The stuff is addictive as hell.

------
dingleberry
i reread the china study. chapter 8 is diabetes. it claims animal protein, not
carbs, causes diabetes.

------
loverofthings
Number of people suffering from diabetes has risen exponentially, demand goes
up, so do the prices.

It's going to stabilize as years go on.

~~~
michaelmrose
Demand has gone up it hasn't risen exponentially. The manufacturers have
colluded to raise the price. There is no reason for it to ever come down.

~~~
loverofthings
We live in the age of globalization and capitalism. There's bunch of cheap
stuff coming from all over the world. Collusion on that scale is not possible.

There's just more people suffering from diabetes T2 than ever before. Someone
is just profiting off of large demand.

~~~
mschuster91
> There's bunch of cheap stuff coming from all over the world.

Said cheap stuff from everywhere cannot be legally mass-imported into Western
countries (and that for good reason).

> Collusion on that scale is not possible

Oh it certainly is. The "old" insulin may be produced as a generic but the new
varieties (as described by the article) are patented by a few companies.

In addition insulin production is extremely expensive compared to simple pill
pressing as you need bioreactors and GMOs to produce it. Many generics vendors
opt out of that complexity.

