
Break Up the Insulin Racket - prostoalex
http://www.nytimes.com/2016/02/21/opinion/sunday/break-up-the-insulin-racket.html
======
glenk
I've been type 1 for over 30 years since I was a toddler. I could stand to
lose a few pounds these days, but I am not fat, nor obese. Adjusting my diet
would do very little to change the increasingly high amount I spend on
insulin.

The cost of insulin over the last few years and as recently as the last few
months has skyrocketed. Not just the fancy fast acting insulin, but even the
regular stuff that you can buy over the counter without a prescription(R and
NPH) has nearly quadrupled in the last 12 years. It's not an increase in
manufacturing costs. It's price fixing by the two major players(Lilly and
Novo).

You'd think that with Lilly significantly raising their prices a few months
ago, that Novo Nordisk could make a killing, but no, they both did it at the
same time. Funny how that worked out.

~~~
e40
I have a relative that is type 1. A couple of years ago he went on a no carb
diet and at xmas he was telling me that he now uses a lot less insulin and
generally feels a lot better. He also lost some weight (he wasn't obese,
either, but he now looks very trim).

Have you tried something like that?

~~~
Eliezer
I know you mean well, but managing this sort of thing is something that's
extremely different from person to person, very hard to get right, and often a
source of great personal pain for people trying and failing. Please refrain or
be extremely cautious about enthusiastically telling everyone what worked for
your relative.

~~~
RHSeeger
While I agree it's worth being cautious about how you phrase any "advice", I
think the parent post was perfectly reasonable. There was something that
worked well for someone he knew, and he mentioned it in case it might help.

For context, I've been a Type 1 diabetic since around '85 and, as I get older,
I'm becoming more insulin resistant (Type 2) also. While I've been able to
keep my blood sugar mostly under control, I test my blood 4-10 times a day and
sometimes need to take insulin 5+ times in a single day (sometimes it just
doesn't "work" and I need to take more in smaller amounts to bring my blood
sugar down. I can't just retake the original amount in case the first shot
suddenly "kicks in").

------
narrator
I think the hardest thing for the American political system to grasp about our
medical system is that spending more money is not the answer. We already spend
16% of GDP, about double what almost all other countries spend on health care
and have worse outcomes.

I'm glad that there's some new thinking going on here that may lead to some
movement. Unfortunately, all the incentives are aligned such that everyone who
is making a ton of money off the system lobbies to make even more.

~~~
xlm1717
The insurance system is itself a racket. Putting even more people into the
insurance system only makes insurance companies richer, doesn't do much for
the average American.

~~~
CamperBob2
True, that.

If pressed to name the single stupidest concept I've ever encountered in over
forty years of life, I'd have to say it's the notion of selling "insurance" in
a market where you know perfectly well that 99.9% of participants will
eventually have to file expensive claims.

Communism is way up there, along with smoking, and religion, and then there's
the time that Circuit City tried to sell their own proprietary brand of self-
destructing DVDs. But none of them can compare, in terms of sheer forehead-
slapping stupidity, to the idea of "health insurance."

~~~
api_or_ipa
Briefly, since I'm on mobile, I'll explain why I think you're completely
wrong.

Insurance doesn't seek to prevent the inevitable. That's not why we buy
insurance. We buy insurance to insure against catastrophic risk. Would you
rather flip a coin and lose your house, or flip 10,000 coins where each toss
risks $100?

Humans are risk averse, and there is plenty to say about the value of risk
reduction. We buy insurance as a trade off: we know we're getting skimmed by
the salesman, but our preference for reduced volatility means we gladly take a
small certain loss instead of a possible huge one.

On the other end, insurance sales men don't just sit on their obligations.
They swap risk and find complementary risks: it's highly unlikely a hurricane
in Florida will happen at the same time as an ice storm in the north east.
Tally up all the insurance salesmen and you'll find they all aim to hold a bit
of each other's risk. They, just like us, prefer to take a small certain loss
than a possible disaster.

This is the purpose of insurance: to dilute the 'pain' of singularly
disasterous events across a large enough population so we collectively do
better off.

Health insurance is supposed to be the same way: you shouldn't need insurance
for buying aspirin at Walgreens. $5 ain't gonna kill you. What will seriously
damage you is an unforeseen large medical expense. As it stands, most people
don't really need much in the way of serious medical care- it's true to say
that a small population of people incur far higher medical expenses than the
rest of society. This is exactly the purpose insurance was designed to deal
with.

I leave my discussion here. I recognize that there is something deeply unfair
about leaving a population out in the cold. I agree, we ought to do something
for them, but this is not a critique of our social policies at large. I mean
to simply remark that insurance is exactly the financial vehicle that best
serves to smooth out the consequences of unlikely yet expensive occurrences.

~~~
true_religion
> Insurance doesn't seek to prevent the inevitable. That's not why we buy
> insurance. We buy insurance to insure against catastrophic risk.

Ideally, that would be the purpose of health insurance, but in the USA its
used to pay for essential health care such as regular visits to your dentist
or general practitioner, or to get the negotiated rate on prescription drugs.

When people talk about the inevitability of healthcare use, they don't refer
to heart attacks, an onset of cancer, or broken legs. They refer to chronic
conditions like arthritis, or high blood pressure that will plague the vast
majority of people simply because of their increasing age. These chronic
conditions are seemingly inevitable, and are factored into the cost of health
insurance.

------
dluan
How timely: this just dropped in the NYTimes today as well, "A Do-It-Yourself
Revolution in Diabetes Care".

[http://www.nytimes.com/2016/02/23/health/a-do-it-yourself-
re...](http://www.nytimes.com/2016/02/23/health/a-do-it-yourself-revolution-
in-diabetes-care.html)

Featuring the Open Insulin project. Many of the supporters of that project
came from HN.

~~~
roadnottaken
I'm a biologist who works in the pharmaceutical industry. I like the idea of
open source insulin as much as the next guy. But. I just took a look at their
website and it's a complete joke, frankly. It's basically a high-school
science experiment. The sort of thing that a single undergrad could do in a
few days. Compared to the thousands of man-years required to produce and test
a new pharmaceutical product.

I wish them luck, but c'mon. Biopharma is not IT where a smart kid can compete
from his garage. It just isn't.

The NYTimes article says "the hackers hope to be able to demonstrate the
technological feasibility" rather than manufacture a drug. But everyone knows
that it's technically feasible -- the challenge (and cost) is in the doing.

~~~
snewk
> Biopharma is not IT where a smart kid can compete from his garage. It just
> isn't.

It isn't today, but it may be at some point. We tend to underestimate the
effects of monumental shifts like we've had in IT. This project represents the
first steps in that direction.

> The sort of thing that a single undergrad could do in a few days.

Even if this were true, the OpenInsulin project doesn't have a large
institution's lab facility. Nor does the project have a government grant as
benefactor. They are operating only off crowdfunding. It's obviously not
enough to get through the FDA approval process, but IS enough to construct a
roadmap to that end and make headway on a functional insulin producing
organism. The project already has _E. coli_ making proinsulin. The
experimental focus has now moved to methods of purification. They are also
investigating the feasibility/cost of getting this through the FDA approval
process for biosimilar molecules.

I think the real magic of this project is its open nature, which I find to be
lacking in the scientific community. This is research that anyone can make
meaningful contributions to. Science (specifically biology) can learn a lot
from open source software.

~~~
roadnottaken
> construct a roadmap

I just don't understand what this means here. Cloning a gene and expressing it
in e.coli is something that has been routine for _decades_. Literally. These
simple experiments won't provide a roadmap to do anything that we haven't
known how to do for a long time. It's like a crowdsourcing project to raise
money to write a "hello world" program. Seriously.

Open-ness is great. But "meaningful contributions" are generally made at the
cutting edge of scientific research. The experiments described are nipping at
the heels of science that was worked-out in the early 80s, so I fail to see
how a meaningful contribution will be made here. Open source is great, but
making headway in drug discovery or development is a Hard Problem and this
doesn't strike me as a serious effort. Just my two cents.

~~~
dluan
I think you're being disingenuous for the sake of argument. There is a non-
trivial scientific challenge of characterizing both proinsulin subunits and
developing a protocol that works for public domain without adverse effects.
Specifically, getting the sequence right to get the folding right.

Yeah, it's been done before but with different variations. To do so in a way
that isn't locked up in IP is worthwhile. And it's a challenge that faces an
uphill battle in terms of incentive and payoff. The crowdfunding covers that
risk capital gap that would otherwise make this impossible. You could say
their approach is a road not taken.

~~~
roadnottaken
Fair-enough. I'm not an insulin expert so perhaps I don't appreciate the
particular challenges here. But the way it was described on the website didn't
make the task sound too impressive.

I was also struck by the money involved. ~$15k will pay for an experiment or
two, as they indicate on the website. It takes many thousands of experiments
to get anywhere in Biopharma.

So... it's a nice start, and maybe a worthwhile challenge, but it hardly seems
like a serious effort. And not everyone realizes that, so I thought it was
worth pointing out.

~~~
dluan
Yes, $15k would not be the same for a biopharma company, but they explicitly
do not have the same goals of a biopharma company, nor are they a biopharma
company, nor do their people come biopharma, nor are their users biopharma
companies. Biopharma companies do not benefit from this, so why does it even
matter what the status quo or state of the art of "doing science" is?

It's easy to be a cynic on HN, it's harder to think critically about why
someone else would believe that it could work. You don't really get rewarded
for empathy on here.

------
simonsarris
> In much of Europe, insulin costs about a sixth of what it does here. That’s
> because the governments play the role of pharmacy benefit managers. They
> negotiate with the manufacturer directly and have been very effective at
> driving down prices. In the United States, we rely on the private sector and
> a free market for drug pricing.

Cartels are an emergent phenomenon[1] and it is in the interest of a _fair
market_ to not be "free market," whenever it leads to rackets.

[1]
[https://news.ycombinator.com/item?id=3494224](https://news.ycombinator.com/item?id=3494224)

~~~
rayiner
The fact that drugs are cheaper in Europe does not mean the market there is
fairer or more efficient:
[https://en.wikipedia.org/wiki/Monopsony](https://en.wikipedia.org/wiki/Monopsony).
European governments have monopsonist power: through negotiating with
manufacturers directly, they drive prices below the efficient level.

~~~
chishaku
Is that a monopsony though?

The market for drug companies is global. If you were talking about doctors or
some type of medical provider that was limited to providing goods and services
within a single jurisdiction, you might have a point.

~~~
dalke
Even if it is a monopsony, the questions are 1) do they abuse its monopsony
powers, and 2) what factors go ino defining 'efficient' and 'abuse'?

~~~
chishaku
No, the monopsony designation is key to the comment I was responding to and
the point I was trying to make.

If there is no monopsony power, it's hard to make any claim of abuse on the
part of the government. Single payer governments are leveraging their
bargaining power like any rational market participant. Drug companies are not
required to sell to them. They do so of their own volition at a price
favorable to their bottom line, otherwise they wouldn't do it.

~~~
dalke
Most shareholders would be up in arms if instead of a 5% loss in profit due to
government monopsony, the company CEO decided to shut down the company and not
sell anything at all, so the statement "not required" isn't that relevant.

"They do so of their own volition". No. You are expressing the Panglossian
viewpoint that just because something happened it was the best choice.

We know from experimental economics that people make decisions different than
rational market theory would predict. The heads of large pharmaceutical
companies are not exempt from this irrationality.

Nor are all people in government short-sighted pennypinchers. The price
negotiations also include the reality that some of the profits are turned into
more research for future drugs. Hence the questions of what "efficient" and
"abuse" means, which go into the pricing negotiations.

~~~
nickbauman
I think the "monopsony==inefficient market" argument is a fig leaf for the
shibboleth that state economic actors are somehow "tainted" because they're
not "private" enterprises. If a pharmaceutical firm were "negotiated"
(tortured?) below their break-even somehow by state actors, they would simply
fold. The entire concept of "below efficiency levels" is questionable here.

~~~
harryh
"below efficiency levels" isn't some sort of moral statement, it's a
mathematical one. It's not a question of moving sellers below their break-even
point (you're correct that would obviously never happen). It's about
transferring producer surplus to consumer surplus and introducing deadweight
loss into the system.

[https://en.wikipedia.org/wiki/Monopsony#Welfare_implications](https://en.wikipedia.org/wiki/Monopsony#Welfare_implications)
explains it pretty clearly for the example of labor.

~~~
dalke
"A mathematical one" in a simplified analysis which assumes a rational actor
model which doesn't model what people actually do.

Or if you want to use the model, the deadweight loss in your evaluation can
instead be interpreted as the price that people are willing to pay for the
good feelings of knowing that everyone in the country has accessible and
affordable basic health care.

~~~
harryh
> assumes a rational actor model which doesn't model what people actually do

Sure, but in the case of drug prices in countries with national health systems
we don't really have any reason to think that the model doesn't reflect
reality.

> the deadweight loss in your evaluation can instead be interpreted

Yes, this is exactly my point! The science of economics makes no judgement
about the relative moral values at play here. That may very well be a tradeoff
people want to make. Or it might not. Economics doesn't comment on that
question one way or another, it nearly provides data on the practical outcome
of the decision.

~~~
dalke
Which is why I wrote: Hence the questions of what "efficient" and "abuse"
means, which go into the pricing negotiations.

------
ecobiker
A simple fix could go a long way - disallow really minor improvements and work
hard to get rid of evergreening.

[http://www.nature.com/news/indian-court-rejects-novartis-
pat...](http://www.nature.com/news/indian-court-rejects-novartis-
patent-1.12717?WT.ec_id=NEWS-20130402)

~~~
dnautics
How do you define "minor"? These insulins have dramatically different serum
half lives (for example there are fast acting ones for postprandial
administration, others that are optimized for pumps, etc) and so there is a
clear pharmacological difference. Moreover, discovering these variants is
nontrivial, as each insulin must be checked against igf-1 receptor cross
reactivity, lest it become teratogenic. Making matters worse, the exact
binding of insulin and igf-1 to their receptors is not known making this
endeavor especially difficult to predict.

What is not clear is whether these modifications are an over optimization over
"the original". For each patient the cost/benefit calculation will be
different and based on many variables.

~~~
ecobiker
[http://theconversation.com/explainer-evergreening-and-how-
bi...](http://theconversation.com/explainer-evergreening-and-how-big-pharma-
keeps-drug-prices-high-33623)

I'm not an expert and I can't comment on specifics. But I'm of the opinion
that a small enhancement is not the same as an invention of a drug and it
doesn't come anywhere close to extending the life of the patent - _unless_
that tiny change actually makes a big different in effectiveness.

Any good patent system should find a good balance between the two seemingly
conflicting goals of incentivizing companies to innovate and keeping the price
down for patients.

~~~
dnautics
These insulin changes are like the difference between a spanner and a torque
wrench, or a spanner and a ratcheting wrench. The torque wrench is definitely
more effective for certain use cases, as is the ratcheting wrench, both are
nontrivial, but 99% of the time the spanner would do just fine / maybe be a
bit more of a hassle.

~~~
DrScump
(for Americans: "spanner" -> "hammer")

~~~
ferrari8608
I believe you meant wrench.

------
brandonmenc
There are so many people on both insulin and government health insurance that
it's probably in the taxpayers' interest to build an insulin factory to supply
the low-end.

~~~
mikeyouse
I had a similar thought a few years ago that it would have been in the
government's interest to buy Pharmasset when they sold for $11B to Gilead
based on the future potential of Sovaldi (the infamous $1,000/pill, 12-week
treatment for Hepatitis C). The government through Medicare / Medicaid is
currently spending upwards of $4B/year on the drug and private insurers and
international buyers are spending billions more. It would've been an absolute
net-win for humanity had the USGov or someone else just bought the company
rather than giving Gilead billions in annual profits.

~~~
chishaku
When it comes to Medicare, there is a much easier win: just allow the
government to negotiate prices. The government should have massive bargaining
power.

> When Congress created the Medicare drug benefit in 2003, it specifically
> prohibited the government from negotiating prices with drugmakers.

[http://www.bloomberg.com/news/articles/2015-02-02/drug-
price...](http://www.bloomberg.com/news/articles/2015-02-02/drug-prices-
prompt-obama-to-call-for-medicare-bargaining-power)

Imagine making a deal with a company where you are one of their largest
clients but you are specifically prevented from negotiating any prices with
them at any point in the future.

~~~
coldcode
Hah, never happen since the people who would vote on this are all on the
Pharma take. Both parties, an equal opportunity bribery, which means nothing
will ever change.

------
zwetan
in France, in UK, and probably rest of Europe people with Type 1 and 2
diabetes are taken in charge 100%

that means whatever amount of insulin you need, you get it for free

and it's not only the insulin, it's also all the rest: test strips, glycemic
reader, etc.

I'm pretty sure the article is wrong about

"had Type 2 diabetes for over 30 years. She takes several injections of
insulin each day."

this more describe Type 1 situation

anyway, I'm pretty sure the price of insulin went up also in Europe, except
the government paid the bill, not the patient, a bit more civilised but still
the problem stay the same:

big pharma corporation are abusing the situation and make money from it, it is
disgusting and criminal

first, about the patent and why there is no generic insulin, read
[http://www.medscape.com/viewarticle/841669](http://www.medscape.com/viewarticle/841669)

second, most people are uneducated about diabetes, they think it concern only
fat people or other countries, and other BS like that

nope, it is worldwide major public health problem, many studies show the
amount of people with diabetes rising , for ex

[http://www.nytimes.com/2015/06/08/health/research/global-
dia...](http://www.nytimes.com/2015/06/08/health/research/global-diabetes-
rates-are-rising-as-obesity-spreads.html)

"reported a 45 percent rise in the prevalence of diabetes worldwide from 1990
to 2013"

finally, why it is disgusting and criminal for pharma corp to make ppl pay for
insulin ?

it as simple as that: if you don't take insulin you die, period.

It's not curable, there is no alternative diet, nothing, zilch, nada

and those big pharma corporation they made a business to profit from that, and
when profit is not high enough, simple, raise the price.

~~~
pascalmemories
Type 2 diabetics often progress to insulin treatment as their pancreas becomes
exhausted and ceases proper function.

The low insulin sensitivity in type 2 means the pancreas produces large
amounts of insulin in a futile attempt to reduce blood sugar. Initial
treatments focus on insulin sensitizing agents to try and assist the natural
insulin to be effective. Despite the amazing capabilities of the body, it
eventually becomes too much and people have to start insulin replacement
therapy at that point.

~~~
zwetan
no problem, it's like the honey moon period for a type 1 patient

I was saying "maybe", in general I see type 2 ppl who are just on pills and
have no need to take insulin, but yeah the diabetes can progress in different
way, no problem with that

------
forrestthewoods
Generally speaking companies "extend" their patent by making a slight tweak to
get a new patent. But that doesn't stop their old patent from expiring. And
the old formula from becoming open to a generic.

So why aren't there generic versions of old formulations? Who cares if it
doesn't have the latest tweak? The complain about such tweaks is that their
minor and unimportant. Meaning the previous version should be just fine.

~~~
CWuestefeld
Just one data point:

I have Crohn's Disease. Up until a few years ago, I took Asacol for this. This
is one of a whole class of drugs based on the active ingredient "mesalamine":
Asacol is specialized in that it's got a coating that keeps it from dissolving
until it gets to the colon. Somebody found that this coating (notice: not the
drug itself, just an enteric coating) might be a risk for pregnant mothers -
something that I will never be. So they stopped making Asacol, and came out
with a new "Asacol HD", which is still good old-fashioned mesalamine, but with
a slightly different enteric coating - and with a brand new patent.

Although I don't have any evidence to support the idea, it seems suspicious
that this revelation about the coating being questionable during pregnancy,
came to light not very long before the expiration of the patent on original
Asacol.

So there exists a small group of patients (pregnant moms) who might have had
trouble with original-packaging Asacol. Rather than putting these patients on
other mesalamine meds (like Pentasa or Delzicol) for 9 months, that was
parlayed into a need to discontinue the entire Asacol product and come out
with a new one.

In this case, it seems that a desire (or a pretense) to make something safe
for all sub-groups, even those that are small and easily segmented, becomes
the engine for renewing the patent, and thus keeping generics out of the
market.

~~~
roadnottaken
But as forrestthewoods pointed out, if the improvements in the new version are
so marginal, then you'd think there would be a booming market for the old
version if it was cheaper (generic). So what's stopping the generic
manufacturers from cranking out the old versions? Seems like there would be
lots of money to be made, unless patients (the market) actually did value the
incremental improvements and would likely chose not to purchase the original
formulation.

~~~
CWuestefeld
Well, in my example, it seems like the manufacturer hasn't just moved onto an
abstractly nicer formulation, but in the process they've left some FUD that
the previous version might be problematic (for some subgroup).

~~~
akavlie
I'm sure most people outside that subgroup would jump at the chance to get a
cheaper substitute.

Asacol HD is $600 - $700 for 90 pills: [http://www.goodrx.com/asacol-
hd](http://www.goodrx.com/asacol-hd)

~~~
CWuestefeld
You should see the other stuff I take, Entyvio[1], at around $25K/dose (which
is every other month). I don't know why they list it for various pharmacies,
since you can't buy it - it has to be administered by an infusion center. I'm
the reason that healthcare insurance is so expensive.

[1] [http://www.goodrx.com/entyvio](http://www.goodrx.com/entyvio)

------
lgp171188
I am tempted to believe that the pharma companies are more interested in
keeping their recurring revenues from diabetics than find a one time cure.

Here in India, the medicines and tools for a diabetic (particulary IDDM) is
still prohibitively expensive for most people who have it. The prices of
insulins and testing strips have increased by 10% or so many times in the past
couple of years. Things like CGMS, insulin pumps are not affordable even to
well-off people like me.

There has always been news of research from various government and government
aided organizations towards the development of low cost testing strips (at
about Rs. 5 per strip compared to Rs. 17 and above for the existing products)
but nothing has come out as a product. What's worse is an unknown healthcare
company has acquired the technology from ICMR (Indian Council of Medical
Research) a year back and till now their only product is a low cost sanitary
napkin. Wouldn't be surprised of the involvement of the big pharma companies
in the delay.

All this said, at least India doesn't have an insurance system like in the US
which has pushed up the prices repeatedly to help the insurance companies
(imho an unwanted middleman in most cases) make more and more money.

I am not very optimistic about the future.

------
feld
My mom just told me in tears today it cost her over $400 rather than the
normal $80-90 copay she was used to

------
venomsnake
Can anyone explain me the evergreening - even if new patent is granted for new
molecule the old molecule should be free. So why is nobody producing them?

~~~
mschuster91
Because no one is interested in spending billions to get a generic insulin
through FDA or other regulatory agencies.

Too much profit is to be made.

~~~
venomsnake
IIRC you don't need to spend billions to get it trough FDA. That is the whole
point of the generic. That the molecule is already approved and tested.

~~~
akiselev
You don't need to spend money on phase 1-3 trials for safety and efficacy of
the molecule but you do still need to spends tens of millions of dollars to
prove that the generic drug you are manufacturing behaves like the original,
within a margin of error, and that you can maintain that quality control in
the future.

------
EwanG
According to the article, Pharmacy Benefit Managers are as much to blame for
the increasing costs of drugs as the manufacturers. I suspect that's partly
true, but I also suspect the "percentage of blame" is being ignored here.

~~~
bcheung
A model that is more direct from business to customer sounds like it would
eliminate costs. Too many people trying to put themselves in the middle and
make a cut.

------
adenner
At least in some states you can buy a form of insulin over the counter. It is
an older formulation and apparently it is not the easiest thing to DYI figure
out the correct dose. NPR had a report on it a while back.
[http://www.npr.org/sections/health-
shots/2015/12/14/45904732...](http://www.npr.org/sections/health-
shots/2015/12/14/459047328/you-can-buy-insulin-without-a-prescription-but-
should-you)

~~~
skyhatch1
A fair enough statement: "The broader availability of [over-the-counter]
insulin allows patients with diabetes to obtain it "quickly in urgent
situations, without delays," the FDA says, and is intended to increase patient
safety."

However, it seems like there are no visible protocols in place to control use
in non-emergency situations like with the patient mentioned in the NYTimes
article. That's certainly risky for poorer diabetics who don't necessarily
know better, or are desperate enough financially to risk the long-term
consequences.

------
cfcef
Some previous submissions: [http://www.psmag.com/health-and-behavior/why-is-
there-no-gen...](http://www.psmag.com/health-and-behavior/why-is-there-no-
generic-insulin) [http://www.psmag.com/health-and-behavior/why-is-there-no-
gen...](http://www.psmag.com/health-and-behavior/why-is-there-no-generic-
insulin)

------
sparky_z
"This is true, in no small part, because the big three have cleverly extended
the lives of their patents, making incremental “improvements” to their
insulin."

Possibly dumb question: If the improvements really are that minor, what's
stopping other companies from using the original, "unimproved" formulation in
a generic? How would disallowing the "improved" patents change the situation?

~~~
dragonwriter
> If the improvements really are that minor, what's stopping other companies
> from using the original, "unimproved" formulation in a generic?

The fact that doctors won't prescribe the unimproved formulation when the
improved one is available.

------
pjc50
> Insulin has been around for almost a century

> In the United States, just three pharmaceutical giants hold patents that
> allow them to manufacture insulin

How does this work with patent lifetimes being 25 years?

Anyway, as the article says, in countries where chronic medical conditions
aren't seen as an opportunity for price-gouging, it costs much less or is free
to the user.

------
shade23
This project started a while ago[1].This could pretty much change the way
people approach medicine.

[1]:[https://experiment.com/projects/open-
insulin](https://experiment.com/projects/open-insulin)

------
tim333
I see generic Insulin is available in India:

Actrapid 40 iu, 10ml at Rs. 145, or about US$2

so the lack of availability would seem to be down to regulatory / patent bs.

There should be some way to alter the laws in the US to favour the US people
rather than the billionaires. Saunders?

~~~
known
[http://janaushadhi.gov.in/list_of_medicines.html](http://janaushadhi.gov.in/list_of_medicines.html)

------
patmcguire
What happened to Genentech? Wasn't this their first product? Didn't this
happen in the late 70's?

F. Hoffmann-La Roche AG is their parent now, not named.

------
msie
The cost to start a drug company to make generic insulin must be prohibitive
enough that we don't see any.

------
d6974
Check out Dr Bernstein's Diabetes solution and use less insulin.

------
abpavel
Shouldn't it be called patent extension racket?

------
tehwalrus
It's really weird to read this kind of article from outside the USA, where
healthcare is a public service.

(of course, here in the UK, the tories are doing their best to ruin the NHS,
but it's still _so much better than this_ ).

~~~
brandonmenc
Every time there's a health care post people chime in with the useless
comment, "this is really weird to those of us not in the USA."

Jeez, really? Wow.

~~~
remh
I agree with that. But, as a European, I also agree with the parent comment.
It is weird in the sense that we could never think of something like that,
things such as a "doughnut hole" where a few months a year you don't have an
insurance.

I currently live and work in the US, love it, love the country. I have the
chance to have a great plan thanks to my company. But i'm not sure how much
more I can keep tacitly approving this system.

~~~
maxerickson
The doughnut hole isn't that weird, a coverage was expanded, with a limit on
how far it was expanded. The limitation is on spending, not related to the
calendar beyond that:

[https://www.medicare.gov/part-d/costs/coverage-gap/part-d-
co...](https://www.medicare.gov/part-d/costs/coverage-gap/part-d-coverage-
gap.html)

Of course once the annual limit is reached coverage is reduced for a period of
time, but there will also be cases where the limit is not reached.

And while it doesn't compare favorably to a simpler to access program that
covers all expenses, enacting it didn't make anybody that ends up using it
worse off.

------
Frozenlock
> except the government paid the bill, not the patient, a bit more civilised
> but still the problem stay the same (...)

God I hate those moral high ground stances seeping everywhere in HN comments.

You think it's more civilized, I think it's barbaric to forcefully take
something from someone. Just like that, you made it that much harder for me to
take anything from what you've written.

> (...) second, most people are uneducated about diabetes, they think it
> concern only fat people or other countries, and other BS like that (...)

And the NYTimes article you linked immediately after starts by saying "The
prevalence of diabetes has been rising in rich countries for several decades,
largely driven by increases in the rate of obesity."

Are they totally clueless?

>finally, why it is disgusting and criminal for pharma corp to make ppl pay
for insulin ? it as simple as that: if you don't take insulin you die, period.

Well, gee, it sure sounds like food, water, vitamins, or a bunch of other
stuff that are sold for profit everywhere.

>It's not curable, there is no alternative diet, nothing, zilch, nada

Except that type 2 (the one that is the rise, by your linked article) is
preventable. There is a high correlation between type 2 diabetes and sugar
intake.

~~~
dang
We detached this subthread from
[https://news.ycombinator.com/item?id=11154983](https://news.ycombinator.com/item?id=11154983)
and marked it off-topic.

------
seivan
Just throwing this out there, I am not sure of this myself. But aren't there
studies where you could do without insulin shots if you avoided carbohydrates
while feeding on protein and fat?

~~~
mikeytown2
I believe this is the study you're thinking about
[http://ajcn.nutrition.org/content/early/2015/07/29/ajcn.115....](http://ajcn.nutrition.org/content/early/2015/07/29/ajcn.115.112581.short)

"The LC diet, which was high in unsaturated fat and low in saturated fat,
achieved greater improvements in the lipid profile, blood glucose stability,
and reductions in diabetes medication requirements, suggesting an effective
strategy for the optimization of T2D management."

I haven't heard of any formal studies where they got off of medication 100%;
I've only heard of n=1 studies (single person reporting) where that has
happened. The most remarkable n=1 is this from a type 1 diabetic:
[https://www.reddit.com/r/keto/comments/2rnn9b/doctors_can_su...](https://www.reddit.com/r/keto/comments/2rnn9b/doctors_can_suck_it_im_staying_on_keto_for_the/)
but in this case the person is still on it which isn't a surprise as they are
type 1.

~~~
ferrari8608
I don't know of any formal studies offhand, but for some pretty consistent
anecdotal evidence you may want to read some of Maria Emmerich's work. She's a
nutritionist who specializes in treating people's metabolic issues.

[http://mariamindbodyhealth.com/about-
me/](http://mariamindbodyhealth.com/about-me/)

~~~
sethrin
I don't necessarily want to suggest that when I see "nutritionist" I read
"witch doctor", but if there is any field of science which has made less
progress over the centuries, it is nutrition. I am not suggesting that any
particular practitioners are ignorant or incompetent (per se), merely that it
is a very hard problem to study. Among other issues, there is evidence to
suggest that glycemic responses are highly individual[1]. However, this is
also an area of political and commercial interest, and there are many actors
presenting shall we say "motivated" studies, demanding an exacting scrutiny of
any empirical results.

In short, not only are the self-reported anecdotes of a person with a
bachelors in nutrition not adequate evidence of anything, but even formal
studies are suspect. As far as my own opinions go I suspect that I would be
inclined to believe what she says, but truths that mesh with one's
preconceptions demand an even higher standard of evidence. Were I you, I would
not be promoting this person's work, and I feel it was inappropriate as a
response to the parent.

[1]
[http://www.cell.com/abstract/S0092-8674(15)01481-6](http://www.cell.com/abstract/S0092-8674\(15\)01481-6)

------
tosseraccount
The risk of diabetes is strongly associated with obesity, and even a modest
weight loss has been reported to substantially decrease the diabetic risk.
According to statistics from the US Center for Disease Control and Prevention,
55% of diabetic patients are obese and 85% are overweight -
[[http://www.sciencedirect.com/science/article/pii/S0899900712...](http://www.sciencedirect.com/science/article/pii/S0899900712000731)
]

Is it the drug companies or the sugary food makers running the racket?

~~~
pascalmemories
You're conflating a whole range of issues about diabetes into a single,
misleading, factor. I don't know if it's intentional misrepresentation or
genuine ignorance on your part.

Type 1 diabetes is not associated with being overweight and weight loss does
not help. Indeed, rapid weight loss is often an early indication of the
condition. Treatment with insulin (the only method available) typically
results in weight gain, as the body recovers due to the newly available
injected insulin. Often these patients start at normal weight range (i.e. BMI
< 25) and are often substantially below typical weights prior to development
of diabetes.

Type 2 diabetes has strong genetic factors and substantial evidence shows
these, combined with weight and some other factors of diet, lead to an
expression as diabetes. In these cases, some people have had significant
improvements in their conditions due to calorie restriction (leading to weight
loss but often it also means they've switched to a healthier diet in the
process and that also helps). The mechanisms here are believed to be due to
improved sensitivity to insulin which is still being naturally produced.

Various ratios of diabetes are quoted, but generally 1 in 20 of the white
european population has diabetes and 1 in 20 of those has type 1 (and the
other 19 type 2). Figures for Indian/Pakistani origin people are dramatically
different if they move to Europe or North America and research suggests this
is due to very different foods consumed [the 'western' versions being
significantly less healthy than those from origin countries]. Much higher
numbers of type 2 diabetes are found in these populations (reinforcing the
factors as both genetics and types of food are involved). Other population
groups differ too.

Treatments for diabetes typically create weight control issues as increased
insulin or sensitivity to insulin promotes body fat storage.

It's untrue (and frankly verging on offensive) to simply blame diabetics for
their condition because they are obese or overweight. Addressing and treating
the condition is significantly more complex and weight control may be one of
the few elements the patient has any input to, while many other factors are
entirely outwith their control and they bear no culpability for.

~~~
GirlProgrammer
The article talked about type-2 patients. Our NIH estimates that 60% of them
would be cured if they simply ate less:
[http://www.ncbi.nlm.nih.gov/pubmed/17227327](http://www.ncbi.nlm.nih.gov/pubmed/17227327)

