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The insulin racket: why a drug made free 100 years ago is recently expensive (prospect.org)
477 points by wallace_f 21 days ago | hide | past | web | favorite | 381 comments



This is an issue beyond insulin. I hope they don't just focus on insulin.

Generics do not work to lower prices on drugs because there is price fixing between companies. Price fixing is illegal in the US but does not seem to be enforced.

I discovered this because my sister in law has a rare disease and she depends on a rare drug called syprine. Her drug costs went from 177.00 a month to $8000.00 a month where it hovered there for a year, then it went up to $43,354.73 a month.

The US funds the manufacture and research on drugs for rare diseases but only while the drug is under patent. Once the drug is out of patent then there is no regulation. These are called "orphan drugs."

It turns out that Valeant (the maker of syprine) was guilty of price fixing and was under investigation by the federal trade commission. The case went all the way to the supreme court which came down against Valeant. The end result seems to be nothing.


> [monthly] $43,354.73

That's half a million per year. At that price, unless syprine's manufacturing process requires digging diamonds, one could probably save money by hiring a dedicated chemist (100k p/y or thereabout) and giving them the necessary money to make the drug just for one.

If I were an insurance company, I'd consider buying a small pharma outfit and target it at these orphan drugs just to save money.


If I were an insurance company, I'd consider buying a small pharma outfit and target it at these orphan drugs just to save money.

Here is why you'd rethink that position.

By law, insurance companies have to spend 80-85% of their revenue on patient care. Which means that their potential profits are limited by medical expenses paid out. As long as they have properly projected and accounted for the medical expenses in their business model, they therefore have a financial incentive to let expenses be high.


Yes, insurance companies are not on your side. They want all prices to rise so their competitors pay the same... and we wonder why there is price fixing?


But then their rates wouldn't be competitive and people would switch insurance.


That might be a decent argument for another discussion.

Spending $43,354 for something and getting a $30 copay in return will never be a part of any clever scheme to fleece anyone.


The pharma company is a standalone subsidiary, the insurance company is the only customer. The profits they keep go to the shareholders, bypassing the 85% rule.


Interesting point about insurance companies saving money that way. I know that some insurance companies are starting to run medical practices and pharmacies, I wonder how far away them making their own drugs is. Unfortunately, I fear that that's the direction of further distopia.


Chiming in as someone who works at an insurer in clinical analytics.

There's a few ways we can pay less for a compound where there are generics/biosimilars. We could contract with a hospital group saying we will pay a small % markup on the cheapest drug to treat each condition - i.e. they can use the cheapest generic/biosimilar and make profit, or use a more expensive one and make a loss. They naturally shift all volume to the cheaper one. That then makes demand very elastic to price, and so encourages a lower price from manufacturers. We do see some compounds all sit at the same lowest price and not shift - that does suggest collusion - potentially tacit collusion though. An alternative is to contract with one pharma company to get a rebate if we push volume to their drug. We could then mandate to providers that we'll only pay for that drug.


So why not do this? Seems low risk, and these drugs are regulated to be identical. Plus you aren't the govt - you are allowed to pick winners.


They do that, or contract with companies (like PBMs) to do so. That's been the way this works forever. Asymptotically no one pays the ~$40k+/mo list price.


You mean no one that has insurance pays that price. Those without insurance don't have anyone making these agreements and are SOL.


Not necessarily true. I know a diabetic who gets her insulin for free through hardship programs she qualifies for with the drug manufacturers.


You just have to live in poverty, one way or the other.


Its also the same direction government funded healthcare would need to go. Ultimately if one or two companies captured the entire market like this, then we socialized medicine by having the government pay these companies, I'm actually curious how that's practically different than government owned entities doing the same thing.


The large mountains of cash that gets smoke screened as "profit" to be redistributed as campaign contributions, executive compensation, and "research and development" costs; like researching how hiring ex strippers as sales reps increases sales of drugs.

Games theory is pretty clear about how this all ends... Badly.


Right, because the government official is corrupt so the private entity gets to be a bad actor. But if the private entity is instead also a corrupt politician owning a government controlled entity... why would that be different? (to be clear, I'm not arguing private is better or worse, I'm actually curious if there's any reason to believe it would be meaningfully different either way).


If they are competent at making drugs, would they simply be competition? How would it be more dystopic?

If they manage to undercut gouging, that should lead to lower insurance costs and put pressure on the rest of the industry to control costs too...


I think this is just extending the HMO model a bit further. So yes, they'd be competition.


> I know that some insurance companies are starting to run medical practices and pharmacies

They are? Where is this happening? This could be a good thing, but I doubt it since the regulations on such entities will likely be warped in their favor.


Kaiser Permanente is doing that in California. I was very happy with their healthcare when I lived there.


Kaiser's cool until you try to get mental health treatment through them. Then they become a comedy of cynical errors.

First, they make you get evaluated by one of their psychs. Take depression for this example. Unless you're having suicidal thoughts, according to Kaiser, you don't have depression. So no, therapy is not covered.

So, you say "no really, I am demonstrating every symptom of depression other than suicidal tendencies, I just want a therapist." ok fine we've got a troublemaker over here demanding the healthcare they pay for, stick'm in a room with 10 other patients and an unconcerned therapist, call it "group therapy," done.

"But I don't want a room full of random people to know about the shit I go through in my life or my past abuse. I have depression, I want therapy." Fine, you have overcome the requisite 3 months of phone calls and bullshit that filters out 90% of our insurees, so you get to be on the waiting list for one of the five Kaiser approved therapists in the bay area. Next appointment: 2021.

Of course, you could always just pay out of pocket, between 100$ and 200$ a session...


The backend of this isn't any better.

They've been outsourcing significant amounts of this to secondary companies (e.g. Easter Seals, BHPN), which then outsource the work to smaller agencies. This turns into the smaller agencies fighting for basic services on behalf of clients.

There are regular mandatory meetings (monthly I think) where execs from Kaiser and the intermediaries announce breaking changes, or straight out berate the group of providers for doing their job, or for not doing things that aren't their job. They like to change coding rules without telling people and then blaming them for not coding properly. They also like to force companies to follow rules, especially when it doesn't particularly make sense (like carrying insurance for injuries to customers when customers aren't allowed on-site).

Then after all of that they'll arbitrarily hold payment as long as the possibly can. A couple of the smaller agencies in our area have gone under because they couldn't pay staff while they waited for checks. We've seen them delay payment by over a year after services were billed.

The only real strategy in this case is to spread out your customers by insurance provider. Unfortunately that means turning very needful customers away, because you can't become too reliant on any one funding source.

Source: I provide support to a mental health services agency in my off time.


> Unless you're having suicidal thoughts, according to Kaiser, you don't have depression.

Which is insane. Even I know that the DSM's definition of major depressive disorder includes numerous other criteria besides suicidal ideation, and I ain't even got a psychology degree (I did ace my AP Psych exam, though). That actual licensed psychologists/psychiatrists (and/or the representatives thereof) would pretend otherwise is surreal.


Yeah the issue is that therapy is very expensive compared to medication and mental health is so common it's hard for insurance to pay for it without raising rates even higher. I currently spend ~$800 a month on my wife's therapy. It's basically impossible to get insurance to pay for and the condition has a very high mortality rate(for a mental health condition) and has no drug options for treatment.


That’s a shame. Therapy can be such a useful tool for anybody.. mild to serious symptoms. I suppose their issue must be one of supply though because finding therapists in SF taking new patients on a more typical insurance plan was also a pain.


As well as Colorado where, to my understanding, use a hospital to house their own doctors and their own pharmacy (not sure if they own the hospital).


Same in Georgia. I loved Kaiser (but my current employer doesn't offer it).

It was great being able to go to one facility to see a doctor, a specialist, get tests, and fill a prescription.



Rite aid is currently piloting RediClinic which will be basically a mix between yoga classes and urgent care.

Essentially they want to get you having more than your blood pressure checked and enjoy some other things they can throw at your insurance.


It could be a bad thing, since their in house medics have an incentive to avoid necessary but expensive treatments.

Better to remove the profit motive from most of the healthcare economy rather than move it around.


Healthpartners, an insurance company in Minnesota, runs their own pharmacies, as well as Virtuwell.


CVS owns Aetna, for one.


The pharmacies aren't the point where price is inflated. It's the pharmaceutical companies, which make the drugs, not the stores that sell them.


Actually it's both. As well as pharmacy benefit managers, doctors, hospitals, and insurance companies. They all inflate prices. See http://truecostofhealthcare.org/conclusion/ (scroll to the "Where is all this money going" section)


The idea is their pharmacy can negotiate with drug companies. "Give us a good deal on everything or we get generics instead of you for everything we can get elsewhere" (that is but one type of negotiation)


Sadly it is not about how much manufacturing and research costs.

But about how much they can profit from it.


I agree, I was just noticing that such a ridiculous margin should allow for other actors to step in at lower price points. Maybe maire's sister does not have half a mil lying around to kickstart the experiment, but with these numbers, sooner or later someone likely will.


The disincentive to new entrants is that the existing market participants can always drop prices enough to make the new entrant unprofitable. If you're in a control of a monopoly or oligopoly, you monitor for signs of new entrants, and when they begin to raise or deploy capital, you offer to buy them out or drop your prices to unsustainable levels and wait for the new entrant to run out of capital.


I'm sure there are other barriers as, if what you are describing is complete, one could earn a pretty riskless profit by some combination of (a) 'threatening' to become a new entrant in the market for an expensive drug; (b) stockpiling the existing entrants drugs when they drop their price to try to drive you out of business.

I remember reading a book about the history of some (famous) chemical company in the U.S. – Dow? Dupont? – doing exactly what I described to compete with the at-the-time existing German chemical company cartel.


For more regulated classes of drug the FDA doesn't just control the conditions under which it is made but also assigns production quotas to different manufacturers. The prime worry, I believe, is that if too much of a controlled substance is produced and it isn't sold then it might end up being sold illegally. There are also issues where allowing people to produce a drug willy-nilly would stretch the FDA's inspection capacity and allow the possibility of defective drugs being made.

Plus there's the issue of whether a drug can remain safe to use after long periods of time at all.


>Maybe maire's sister does not have half a mil lying around to kickstart the experiment

The set of people with the condition probably does. I wonder if a kickstarter for generics would be successful?


Wouldn’t a profit maximizing capitalist just invest in these unregulated pharmaceutical companies as opposed to starting an unprofitable pricing war?


It depends on how much profit will be generated by investing the same amount of capital in the two activities. Say that half a mil in pharma shares return you 5% yearly; if you can generate more than that with a price-competing activity (also pricing in the risk to your capital, of course), you should do that instead.

In this particular case, there are actors for whom the profit would not be directly generated by sales of goods, but by the amount they save elsewhere in their operations - which, depending on various factors, might actually be multiples.


You can't really invest, because the investment opportunity is controlled by other profit maximising capitalists who will charge an arm and a leg for the opportunity.

You could find a profit maximising capitalist who would be happy to enter the market and compete for a fraction of the outrageous profits - that would make a lot more money than paying to invest as is more usual. In theory there only needs to be a handful or so and that would be enough to bring the market back down close to cost of production.

However, it seems likely that government regulation would disrupt that process somehow, otherwise it would have happened by now.


In that case, why aren't there rules to limit profit margins on live saving drugs?


culture and ideology basically. Capping drug prices is the norm in free market havens like Singapore to Scandinavian welfare states.

It's not just prices as well. The US stands also out as being one of three countries that allows direct consumer drug advertisements.


And the only one that allows prescription drug ads.



Once drugs are not protected by patents, competition should reduce prices. Unless competition is not working because of price fixing or something else related.


That's not how competition works.

How do street drug dealers compete with each other? Not by lowering prices. No. They actually attempt to monopolize their territories by either eliminating or merging with their competitors, until a stable state is reached.

They then set their prices to maximize margins and profits. This continues until something happens to destabilize the market, at which point there is some kind of struggle or even war, which stops when another stable state is reached by eliminating or merging the competitors.

Without regulation to prevent the creation of monopolies and cartels, this happens in legitimate businesses just as much as street drug dealers.

Competition by lowering price does happen, but when it does, it is part of the unstable phase that ends when another stable monopoly or cartel forms, at which point margins go right back up.


> ... monopolize their territories by either eliminating or merging with ...

The elimination part of that is important though. If companies were allowed to round up a group of the boys and go break some kneecaps when the boss didn't like something then it is true there won't be a lot of competition.

But in civilised country that isn't an option. Nobody wants that level of deregulation - basic policing of physical safety is something of a given. People are somewhat protected by law in their attempts to compete.


Companies eliminate each other all the time. Maybe--and I only say maybe--physical assault of executives is not an option.

But companies do things like dump product to drive a competitor bankrupt, and then raise their prices back up. After that happens a few times, people get the message that there is no money to be made competing with them.

Or they play patent games and litigate the competition either out of business, or strongarm them into joining a patent cartel.

The tools may be different, but without specific anti-monopoly and anti-cartel regulation that is enforced aggressively, companies will ruthlessly drive markets towards monopolies or cartels.


Very interesting perspective, what has informed it? I'd like to read more.


This is one model of free-market economies I hadn’t considered. Thank you for the mind shift!


It's so much more lucrative to just slice the orphaned drug catalog up in a cartel structure.

You charge robbery rates for drugs A, C and F and I'll take B, D and E.

We both make lots of money and don't have to worry about each other.

Competition assumes sellers don't collaborate and negotiate but they do all the time.


More pointedly competition only works when it exists.


It's hard to do because the upfront costs are so high you'd drive out manufacturers.


Tell me more about the upfront costs of Insulin.


The upfront costs of building out an insulin production facility and getting it FDA approved are quite high. Especially because insulin and insulin-analogs are large molecules that are hard to prove are biologically equivalent to their patented versions. Which is made even more difficult by a large number of patents surrounding the manufacturing process the brand name company uses to produce it.


Honestly? Free Market Evangelists who think that price controls on medication is socialism (but coal subsidies for outdated jobs in West Virginia is "American").


I'm no chemist but the stuff doesn't look too complicated. And noting the stuff used to cost far less ...[1]

[1] https://en.wikipedia.org/wiki/Triethylenetetramine


Translation of https://en.wikipedia.org/wiki/Triethylenetetramine#Productio... (with some personal remarks):

It's not easy to put that Nitrogens in the middle of the chain. Moreover, the method to produce it is to mix some smaller chains that have the Nitrogen in the ends of the chain and make them combine in a longer chain.

This produces a mix of a lot of similar chains with different length and number of Nitrogen. They have similar properties, so it is difficult to separate them. They use distillation. But at high temperature that Nitrogens like to burn, so heat the mix carefully.

Also, the mix you produce have a lot of compounds with the same "2D" formula, but they have a different shape in "3D". Some of the versions may have totally different properties, like been very toxic. So you must separate them too, and again, it's difficult.

Note: I studied a Chemistry specialization in the Secondary School, so I have some general knowledge about this, but I'm far from an expert in medical drug production.

Note 2: If you like this kind of things, I recommend to see the Nile Red channel in YouTube https://www.youtube.com/channel/UCFhXFikryT4aFcLkLw2LBLA It's nice to see some easy and not so easy projects, and he explain the reactions, and the problems and pitfalls he found. (I don't understand everything he does.)

---

Anyway, the difference of the cost of the medical drug and the chemistry drug is annoying.


As a chemist you won't even bother to do the synthesis. You just order it from Sigma-Aldrich. Currently it cost about 300$ for 100g.


Not a chemist but in NL S-A shows 33,50 eur/100g (ships today!)

https://www.sigmaaldrich.com/catalog/product/aldrich/132098?...


As I'm sure you know but so that others understand, that's technical grade, not pharmaceutical grade.


Interesting! However on Sigma-Aldrich website it says: technical grade, 60%

How do you get from 60% to 99%? Do you have to (for pharmaceutical grade)?

What are the remaining 40%? poison? harmless byproducts?


You can buy the 97% version. Then a quick analysis (IR specter, NMR) will give you an idea of the contaminants if they are not specified by the manufacturer. Based on that you can take additional step to purify the product (extraction, chromatography, etc.) to the required level. The yield may not be perfect making overall cost a little bit higher, but this is really basic organic chemistry.


Is there any law as to purchasing/producing unregulated drugs in the US? If not, I'm surprised some budding pharmaceutical chemist hasn't swooped in and started producing these sorts of drugs. You know, free market capitalism and all that.


All drugs are regulated by the FDA, even if a drug patent is expired you need to get FDA approval to sell a generic version, which would cost millions. The only way around this, is if you market your product as not for human consumption or make some obscure research drug and market it as a health supplement.

Of course the latter two eventually will get you in deep shit with the FDA.


But could you make it for yourself?


...or at least meet the legal definition of making it oneself? Like the "build your own AR-15" kits where 99% of the work is already done, but for insulin?


You can produce the drugs but very hard to get anyone to buy it, as your product is not recognized by pharmacies and insurance companies as legitimate. Drugs doesn't get bought in the US unless it is carried by pharmacies and pharmacies won't carry your prescription drug unless insurance covers it.


So it sounds that the solution to the problem is to establish an online pharmacy chain and make sure that you gain a good reputation?


I'm sure Amazon will manage to sell you counterfeit insulin.


All I'm thinking is that there's likely some very desperate people out there looking very hard for these drugs in a cheaper form, and with a bit of viral marketing magic from the pharmacist I don't think it would be a massive stretch to match the two.


It wouldn't be hard except for FDA regulations around manufacturing/selling drugs intended for human use.

Ah, so we should just get rid of those regulations and let the little guy compete!

Not so fast. Maybe the first new market entrants are motivated by altruism as much as by profit. They do everything carefully but charge prices closer to cost. Patients pay less and there are hardly any downsides, except to the financials of legacy pharma companies.

But by year 3 there are people who have learned that you can buy barrels of technical-grade active pharmaceutical ingredients off of Alibaba and make pills from them without any quality control in between. Sometimes the products are contaminated with carcinogens. Sometimes they vary widely in potency across lot numbers. In the absence of regulations, fraudulent and shoddy products become widespread. It would be like the supplements industry, except that people actually die if they don't take real prescription drugs they need (this is less common for people who are sold fake herbs.)


I assume you can't just manufacturer unpatented drugs and sell them as drugs.

You likely need to prove that you are producing a clean product, etc.

Similar to how there is regulation of you make food at industrial scale.


I don't believe so. There are foreign online pharmacies of various reliability that a good number of people use. Folks near the border go up to Canada as well. None of that is legal, but it's not enforced. I imagine the outcry would be too great.


> unless syprine's manufacturing process requires digging diamonds In a way, it does. Diamonds also have inflated value due to forced scarcity.


> If I were an insurance company, I'd consider buying a small pharma outfit and target it at these orphan drugs just to save money.

I've looked into it but the regulations get in the way. It's a crock of bologna - if you hire an American Chemist and set up an American chemical plant, you have to build the facility and wait for FDA inspection before you can start manufacturing and in some cases, you have to pay for a trial to prove that your medication works. Or you can just import the drug from China and India and the FDA will let you act like a compounding pharmacy and repackage the Chinese / Indian active ingredients.

Then you have to pay the licensing fees which are borne equally by all manufacturers. If you make 100 doses/yr, you pay as much as your competitor who makes 1 billion doses/yr.

There's a reason the market for easily-produced medication hasn't been disrupted yet, if you make affordable high quality medications in a way that doesn't defer to the FDA's stupid system, you can and will go to prison.


So TL;DR, prices are high because of poorly done / too much regulation?


You might not need to hire one if a compounding pharmacy can handle it


Compounding pharmacies don't make drugs, they mix them.


The real manufacturing cost is of course lower than the old $177/month cost.

These cases from the last 1-2 decades are always because of FDA regulations. The drug is out of patent, any manufacturer is allowed to make it, but the FDA regulations for actually starting up manufacturing are so difficult and time consuming that whoever is left as the only manufacturer of a rare drug can crank up the price from $177 to $43k, and ride on that profit wave for a few years while FDA processes competitors applications.

More sad detail here: https://slatestarcodex.com/2015/09/24/the-problems-with-gene...


So you're imagining the insurance companies aren't somehow benefitting from the high cost of healthcare?


This is something pharmacies did in the past.


> The US funds the manufacture and research on drugs for rare diseases but only while the drug is under patent. Once the drug is out of patent then there is no regulation. These are called "orphan drugs."

This is exactly the opposite of the case. The FDA wanted to encourage manufacturers to conduct new safety and efficacy trials on drugs (that can be out of patent) to treat 'orphan conditions', which are conditions that exist in rare populations, which could be currently off-label indications. Because it is outside of the scope of the FDA, the FDA cannot incentivise you to help this class of underprivileged people by extending your patent monopoly. What it can do, is to give you the exclusive rights to advertise your drug, which, in the US, is a de facto monopoly. Of course, this regulation is highly abused.

https://www.spectrumnews.org/news/drugmakers-manipulate-orph...


Lobbyists are a lot like genies. You ask for something that sounds perfectly reasonable, and when you get it you wish you'd never met them.


Why isn't there a list with alternatives distributed, say, by the federal or local governments ?


Because it would undercut profits.


Because that would literally be against the spirit of the law. Moreover, why would anyone make an alternative when it will not be advertised much?


My SO takes a drug that also varies wildly in cost [0]. Some insurances will price it at ~$3/mo, while others will price it at ~$10,000/mo. Yes, really. I've had to turn down a fair few job offers due to this issue with insurance. Once, after I told them that I had to turn down the offer I was told: "Don't throw your career away". Like, dude, it's the health of my SO, I have no choice, get better insurance.

The funny thing is that this drug is given to horses in their feed. Like how we just put Vitamin D in our milk or Iodine in our salt, they put this drug in horse feed. I've tried to buy it this way, but you need a vet's license in this state to buy it wholesale. If things get bad, I'll try to buy it off of farriers or something and then dilute it down.

So, to be clear, my SO takes a drug so cheap they literaly toss it into horse feed, but some insurances will try to charge us ~$1000/gram for this.

[0] It's not really a drug per se, it's more of a supplement in that it does not cross the blood-brain barrier. It interacts in a more digestive sense.

P.S. I've written before about the issues with CU-Anschutz and vaccinations here and it may be interesting to you: https://news.ycombinator.com/item?id=19760317


Have you looked into the nootropics community? /r/nootropics is the one I frequent but there are other sites out there. They're pretty good at finding ways to order drugs and supplements not designed to be sold for human consumption, someone might know how to order it from another state or country.


Good call! Thank you very much!


Lookup the CAS number and search for it on lookchem.com


Holy shit, it's ~$100/metric ton wholesale from China, and they'll ship individual kgs for ~$3 + shipping.

Oh my God, we're free!

THANK YOU! You've saved us!


> I've tried to buy it this way, but you need a vet's license in this state to buy it wholesale.

Your SO should become a horse owner.


Haha!


The downside, you might have to cook your own dinner...


> Valeant

I know that name. Valeant doesn't do any r&d. Their entire business model is to buy up rights to, or manufacture drugs that are supply limited, and ratchet up the prices to the maximum that the market will permit. They typically end up selling these drugs at 100k-10m times higher than the cost to manufacture. They've also ceased manufacture of several life-saving drugs because the profit margins weren't high enough for their model.

I am anti death penalty, but I would make an exception for the people who run the likes of Valeant. Profiteering off people with rare diseases belongs in a lower ring of hell than serial murder.


Oooh,

That named sounded very familiar to me (no being from the USA) and I just remembered why:

https://www.gq.com/story/netflix-dirty-money


>I am anti death penalty, but I would make an exception for the people who run the likes of Valeant.

Amazing how many times on this forum I've read people suggesting people should be killed for what are, at this point, nothing but alleged crimes.

Where does such an inhumane mindset come from? Hypocrisy?


Moral thought experiment: who do you think deserves a greater punishment - a drug addict who stabbed your child during a high, or a CEO who knowingly prevented your child and hundreds of others from being able to afford the only life-critical medicine available in order to maximise their profits, even though the cost to manufacture that medicine is 1/100000th of what it was being sold at?

This isn't hypothetical, GP is talking about a treatment that went from ~$200/mo to ~$43k/mo simply because a bunch of heartless assholes figured that was the point of max profit even if it ruins the lives of a bunch of people and kills a bunch more.

Is my viewpoint hypocrisy? I don't think so. Your comment seems to be centred around the alleged part, and I also strongly oppose the death penalty because of the false-positive rate of convictions. But take an hour out of your life to study Valeant and its leadership, and come back and tell me that you believe that there is room for error in their motive or the outcome of their actions. These are people who have found loopholes in the law and have grossly crossed any imaginable ethical boundaries. The only contentious part of my viewpoint is that I believe ethics supersedes law, and the heads of Valeant have technically complied with the law despite falling to the lowest low of ethics. These people are gaming the system at a level that most hard convicts wouldn't consider.

I upvoted your comment, it is a good avenue of discussion.


>who do you think deserves a greater punishment - a drug addict who stabbed your child during a high, or a CEO who knowingly prevented your child and hundreds of others from being able to afford the only life-critical medicine available in order to maximise their profits, even though the cost to manufacture that medicine is 1/100000th of what it was being sold at?

First, you can look at intent. If a person stabs someone, then it usually means that they intended to directly hurt someone. If a CEO raises the prices of a drug, then it usually means that they intended to make more money. The harm it causes is collateral damage rather than the main intent.

Second, a CEO controls/owns the production of the drug. They are not responsible before the public for the public having access to the drug. Private property means that they don't have to share if they don't want to. If this wasn't the case then where would you draw the line? We can all agree that asking for $43k for the treatment is outrageous and scummy, but where do you draw the line? $10k? $5k? $1k? $500?

Another question: if they had stopped producing the drug altogether then would that have been morally better in your opinion?

Obviously these price increases are ridiculous and unacceptable, but I don't see how you fix this without the government requiring that a drug company must supply a certain drug that they started making for X amount of time and in Y amount.


>These are people who have found loopholes in the law and have grossly crossed any imaginable ethical boundaries.

I think in my country there are laws against (translation: "racketeering"). It is selling goods/services to people in distress/danger for an unreasonable high price. There is no death sentence here, but also no loophole.


"I hope they don't just focus on insulin." is a great point.

One way we have gotten into this mess is going at healthcare in a piecemeal fashion. First we have a program for the seniors, then for the veterans, then for the poor, then we get COBRA and "you can keep your children on your employer's plan until they are 26", then there is Obamacare which can be good sometimes and bad other times.

(When I am between jobs I have a $20 premium and a $15 copay. When I am making moderate money I my premium is similar, but I get high deductible "junk insurance" where I pay more like $150 for a visit. I could buy low deductible insurance but the price difference is about the same the deductible)

Each time they add a new piece to the system, you are left with the remainder that is more intractable. If they do something special for insulin that will somehow cost the government a lot of money and then next time it will be some other drug.

If they really wanted to save money they would start dismantling parts of the system. For instance, eliminate the tax deduction for employer insurance and herd everybody onto Obamacare. "Medicare for all", something like that.


> I discovered this because my sister in law has a rare disease and she depends on a rare drug called syprine. Her drug costs went from 177.00 a month to $8000.00 a month where it hovered there for a year, then it went up to $43,354.73 a month.

This is nuts! $43000+ per month is insane!

1. I did a quick check and in India Syprine is available for Rs. 1.5 lakh / pack (which is roughly 2100$ at current exchange rate (Rs. 69 = 1 USD)): https://www.indiamart.com/proddetail/trientine-capsule-sypri...

2. Another brand (non-Valeant; same chemical composition as Syprine) is available at even cheaper rates of Rs. 20000 / bottle (which is roughly 300$ at current exchange rate): https://www.indiamart.com/proddetail/trientine-capsule-250mg...

Is it possible to import the drug from India instead? Or is this market highly regulated?


> Is it possible to import the drug from India instead?

It is, and in my experience it's as simple as just placing an online order.


> Price fixing is illegal in the US but does not seem to be enforced

Those companies are too powerful. There have been many investigations, but you never hear anything back.


It's also that the insurance and medical care markets don't work properly as markets because of a whole host of factors, eg who has the time or knowledge to comparison shop drugs (if there's even multiple drugs that will treat your condition!) and even for the few people that do have the knowledge insurance disguises the true cost for most people. Combine that with the difficulty of becoming a drug manufacturer and the fact that there's only a handful making each drug we don't even have to have coordinated price fixing, if you competitor raises their prices there's very little reason to not raise yours as well because there's either a) no substitute to that drug or b) patients and doctors are shopping by effect not cost for 99% of the time.


In order to fix a price with your competitor, the only thing you need is an information channel with them.

The price in itself carries information, so, I would not be surprised if in many cases not conversations are happened between the parties, but all the necessary information exchange have happened through the prices. That would be very difficult to police.


This works for competing gas stations. One raises the price by a penny, the one across the street sees this and does the same thing.



Generics do work to lower prices, at least over time. I've been on two medications that, when started, their patents were about to expire. They still cost a small fortune, $700 to $1000/month on retail cost without insurance. Over the course of about 6 years, the generics were introduced and were also initially very expensive, but the competition gradually lowered prices and they're now sub-$100/month for the generic, and maybe 3x that for the Brand name (still expensive for the brand, but significantly cheaper).

The problem with the astronomically escalating drug prices tends to be those where there's a bottleneck of a single producer. Two manufactures would help this, and syprine is an excellent example:

According to NYTimes [0] Syprine was about $21k when Teva introduced a generic, which was priced around $18k. In the roughly 2 years since though, the price has dropped significantly down to about $11k [1]

I suspect it will continue to drop as the two manufacturers gradually undercut each other over & over again. It's a slow process, and it could be much, much better, but it is one avenue of attack against these abusive pricing tactics.

[0] https://www.nytimes.com/2018/02/23/health/valeant-drug-price...

[1] https://www.goodrx.com/syprine


It always saddens me of how goverments deal with consumer injustice.

Time and time again an issue is left to fester until it becomes fiscally or pr fashionable to do something about it. Then they end up cashing in with a big fine upon the company involved. Goverment gets a nice payout, consumers who have been shafted for years - just end up paying for the shafting and then in many cases, indirectly end up paying for the fine.

I'm certainly a bit of a cynic in my age, but I does kinda feel like governments use consumer abuse as a revenue stream thru fines.

The only consumer alternative to get financial justice always falls down to class actions/private cases more than not and in process's that takes forever.

Frankly I fail to understand why their is no consumer protection as any price increase of over X% in any field should always be investigated. More so the entire drugs industry. Even if that trigger was 100% in a period of a year, it would be a start in preventing such abuse. Which it is blatantly more than not.

It's as if such companies are aware of what they are doing, not even illegal drug dealers push their prices up that much upon a captive market. That certainly puts some perspective upon such activities in the legal drug industry.


Is it not possible to get it from another country like India?



Every year we have celebrities helping raise millions for various medical research projects.

Maybe we need someone to set up a nonprofit pharmaceutical company to look at treatments (including vaccines) for chronic illnesses instead of treating customers as cash cows.

A partner like this funding university research would be amazing.


"...made free 100 years ago..."??? What?

> Insulin from cattle and pigs was used for many years to treat diabetes and saved millions of lives, but it wasn’t perfect, as it caused allergic reactions in many patients. The first genetically engineered, synthetic “human” insulin was produced in 1978 using E. coli bacteria to produce the insulin. Eli Lilly went on in 1982 to sell the first commercially available biosynthetic human insulin under the brand name Humulin. [0]

This process—programming bacteria to generate complex human biomolecules for our consumption(!!)—was a crowning human achievement. It did not occur 100 years ago. Insulin is not simple [1], and making it in the current pharmaceutical form that we expect, at the scale we need, is not some simple, 100 year old thing. We can't take these things for granted.

No comment on how much makers should charge for insulin.

[0] http://diabetesstopshere.org/2012/08/21/the-history-of-a-won...

[1] https://en.wikipedia.org/wiki/File:InsulinHexamer.jpg


As far as I know, current clinical evidence shows that modern porcine insulin isn't actually any better or worse than synthetic human insulin overall. However, it's also not any cheaper these days either - in fact, I think the NHS pays slightly more for it than human insulin. Sure, managing to program bacteria to produce complex human biomolecules was a major breakthrough, but the tech is old and refined enough that companies can churn the stuff out relatively cheaply.


> churn the stuff out relatively cheaply

The marginal costs (per unit) are relatively cheap but the fixed costs, especially regulatory costs, are very much not cheap; which is one reason why there's so little competition.


Can we use synthetic biology to create an open-source bacterial strain that produces insulin, then distribute the incubators and purifiers to diabetics? Something akin to 3-d printers but for home-brewed medications.


We can. But its not realistic. You need purified water, media, etc to grow the strain, you need waste disposal for when you purify the harvest. And the biggest bug bear - maintaining sterility for all the pieces of equipment, and the environment to. I suppose you could design it to be a single use, closed system. But even then, the challenges are enormous. I work in pharma and producing vaccines in a clean-room is challenging enough. The FDA can shut you down for a single OOS/OOT. I would never in a million years inject myself or anyone I know with something made from a DIY kit like that.


I feel that this statement sets the perfect as the enemy of the good. If your alternative is to take this or die due to not being able to afford the proper medicine you need, what is your choice? What solutions do you put forward for fixing the pricing problems?


I'm not proposing a policy here. I'm giving my reasons why something is A Very Bad Idea.

>If your alternative is to take this or die due to not being able to afford the proper medicine you need, what is your choice?

I don't view it as "an alternative". Just like drinking battery acid is not "an alternative" to treating esophageal cancer because it happens to kill off cancerous cells.

>What solutions do you put forward for fixing the pricing problems?

I don't know of a market based solution that would do that. But you can have the government provide a single-payer system, and negotiate the prices. That's one sensible option IMHO.


As "bad" of an idea as it is, it's still better than "give up and die".


It isn't, really. That the entire point. Just repeating that it is without actually making a _science_ based argument is plain silly. If you inject yourself with non-sterile material, there is an extremely high chance you will now die from two things (or more), instead of just one. Depending on the organism, an untrained person attempting to grow bacteria outside of a lab might create an even bigger problem, for e.g. if they improperly dispose of it, the organism (or other metabolites/proteins/etc) could leech into the soil and cause further damage, or worse.. contaminate the water supply. Heck the city won't even let you install a sprinkler without making sure you're not sending the water back into the supply. And you guys are thinking about growing bacteria at home. I don't think I can make my case any clearer. This is a terrible idea. But OK, you do you...


> The price of his insulin had apparently gone up again to $1300, which was more than he had in his bank account.

> Five days later, he was dead.

I don't mean to sound insensitive here, but... last I checked it's possible to pick up insulin (without a prescription) for $25 a bottle. Sure, it's not the same insulin he was probably on, but it does work (I was on it for many years). A little bit of searching on the web would have turned of this information; so why is he dead instead of on a different insulin?


I'm guessing it was because people are more scared of taking unknown drugs than stopping taking their known-good drugs.

IMO, we've gotten to a point in our society where there are risks we used to take routinely that we no longer think are acceptable, even when the alternative is complete failure. Prescribed medicine and other healthcare-related areas are some of those things.


Also keep in mind that messing up an insulin dose can kill you pretty quickly, so I can see why it would be particularly frightening. Not that it’s worse than certain death.


Yes and no... https://www.snopes.com/fact-check/insulin-walmart-vial/

There are other articles available that describe the situation.

tl;dr - Yes, you can get a vial of insulin for $25. But, it's not the same kind of insulin most diabetics take. They are typically prescribed insulin analogs, which still require a prescription. The $25 version could likely keep them alive, but the dosing/usage/effects are not as consistent.


The original article is pushing the narrative that those new, fancy insulins "offered minimal benefits" compared to that older insulin, that they're just prescribed because of "aggressive marketing campaigns" by the evil big pharma, and that this is what's pushing up insulin prices. The fact that you can buy the older stuff off the shelf with no prescription for $25 is definitely a problem for its narrative, and the fact that there are genuine disadvantages to doing so is an even bigger one.


The newer insulins are definitely better. Just the fact that they act faster allows one to take insulin reactively (blood is high, take a bit of insulin to bring it down). This is a large QOL boost in that it allows more flexibility in eating.


Exactly. This whole narrative here sounds like "walking was invented billions of years ago, and was free. Why are cars so expensive today then?".


But it does work. I was on 70/30 when I was a kid and, while not as flexible, it will keep you alive. You have to be VERY strict about your diet and exercise regimen when you're older, while doing blood sugars on the regular, but you don't fucking die. (Well, far less likely, I should say)


I was on R and L for 15 years or so (it's been a while, so I may be off by a bit, but it was a long time). Sure, it's not as good (as noted by others, you need to be more strict with your diet because it takes longer to work in your system and you can't take it reactively), but it _does_ work. It's certainly better than being dead.

justin66 21 days ago [flagged]

> I don't mean to sound insensitive here, but... last I checked it's possible to pick up insulin (without a prescription) for $25 a bottle.

You don't sound insensitive, you sound ignorant.


Ok, but please don't break the site guidelines: https://news.ycombinator.com/newsguidelines.html

If you know more, share some of what you know so the rest of us can learn something. You can also downvote and/or flag bad comments. But please don't post one yourself—that doesn't help.


From the article:

"Walmart sells an old version of human insulin for $25, but as Lipska explained, it doesn’t work for all patients and is incompatible with many new delivery devices."


It's much worse. The big thing with insulin is being shelf stable vs fast acting. The insulin your pancreas produces is really fast acting, but the Wal-Mart stuff is slow acting. With the fast acting stuff you can manage your blood sugars to a tighter degree. This might not sound like much, but over a lifetime it adds up to many fewer medical complications. It's true the Wal-Mart stuff will work in a pinch (if you know how to use it), but issuing it long term will likely take years off your life.


Maybe the Red Cross should parachute Insulin into the US like in any other war zone. It is a war zone, the owners of the health care system have declared war on their customers it seems, they are only now becoming aware of it.


Why hasn't Amazon declared war on their customers? It doesn't have to do the market, and it certainly has nothing to do with capitalism. It has to do with rent seeking on behalf of lobbyists are the corruption of government. Imagine a world where drugs go off-patent in 5 years (or if you really want to be radical, no patents at all) and every drug was available without any prescription whatsoever. I guarantee you prices for pretty much all drugs would be 10-100x lower. How do I know this? Because I moved to a country (Tanzania) in which no one has health insurance and there are practically no controls on any drugs at all.

Medications that had costed me $500 with insurance per month in the US I can buy for $20/month. One of my friend's father is diabetic, and he spends maybe $40/month on insulin.

The patent system in the US combined with the 3rd party payer system has created astoundingly bad incentives for every party. And the result of all of this is sky high drug prices.

People seem to think that the defective US healthcare system is an indictment on free-market capitalism. But there's nothing free-market at all about our system. What it's really an indictment on is cronyism, corruption, and rent-seeking.

The question becomes, what do we do about it? The tangled and corrupt web of healthcare will be almost impossible to undo. I'm a staunch neoliberal but even I don't think it's going to be possible to go back to that in the US. It pains me to say/think this, but maybe the only solution for us is single-payer.

Single-payer has pretty terrible incentives too, but probably not even as bad as the current system.


>Why hasn't Amazon declared war on their customers?

They're still building up an unassailable position.

Wait until they are firmly embedded in critical supply chains to where it is almost unthinkable to remove them and see how they behave. There's a reason they have been operating for most of their existence at break-even yet their stock continues to rise -- investors expect for them to begin to leverage their dominance very, very soon.


In general I agree about corruption being a primary reason for that, but small correction - lack of access to insulin is not due to patent system, but due to combination of companies evergreening these patents, doctors being a gatekeepers when deciding which product to use, FDA being a gatekeeper deciding which product to allow to sell. All of these come from (ab)use of government power, so the core of your message is right - with these three things there can be no free market. You can't pick "old" version of insulin and just inject it yourself using regular syringe. You have to use whatever doctor and FDA approves only in the name of the safety of patients.

https://www.hopkinsmedicine.org/news/media/releases/why_peop...


There is an even more fundamental blocker to a free market in healthcare: free markets don't work when one of the parties to the transaction has their very life on the table in a transaction.

It's a minor miracle and a testament to the moral standing of health-care industry execs up until recently that the market has worked as well as it has for most of the last hundred years.


> ... free markets don't work when one of the parties to the transaction has their very life on the table in a transaction.

So why is food so cheap? Why is water so cheap? We need both to survive but nobody is jacking up rates for them.


Water is a publicly managed resource (for this very reason).

If T.Boone Pickens has his way, the rates will be jacked up for water.

As for food, there are lots of options. If I charge too much for corn, you can buy lima beans. Plus, there is time to explore options. When that becomes untrue, people do gouge for such things. The more immediate the need, the more extortionary it can become. Medicine tends to be fairly immediate.


If the only way to eat was to buy food insurance (offered as a benefit by your employer, of course) and get a prescription for one specific brand of that food, and the only foods available were those screened by the FDA for a decade and cost the food company $10 billion to bring to market, I predict three things:

1. Food would be extremely safe. Nobody would die of food allergies.

2. Food would be far more expensive than it is today.

3. More people would die of starvation.

If you ask any economist why the prices of certain drugs are so high, they will point out the lack of competition, the onerous and costly approval process, and consumer inability to comparison shop. They will not say it is because drug company execs are selfish bastards. The benefit of competition is that it doesn’t matter if people running the companies are purely selfish. The system forces them to provide a compelling product or they go out of business.


>They will not say it is because drug company execs are selfish bastards.

Because that is a given. Dealing with a selfish bastard is ok as long as you can walk away from a transaction if it is not to your liking. People bargaining for their life don't really have that freedom.

I can buy a watermelon from a guy selling it out of the back of his pickup on the side of the road and be pretty confident that it won't kill me. You won't ever be able to say that of medicine. Many of the regulations are there for a reason.

There will never be as much competition in medicine as there is in food (unless it is in the 'Uh, oh, a handful of companies own all of the farms' direction). So, even if we eliminate all regulation it still wouldn't solve the problem of competition.

So, we will have few players in a market that is difficult if not impossible for your average consumer to understand selling items that are essential for people to continue to live no matter which direction we go. So the only question is: would the threat of government forces keep these players in line better or worse than self-policing under the fear of market punishment if what they do goes badly?

My thought is that the government is going to have the resources to effectively go after bad actors where the surviving relatives of individuals harmed will not. And there won't be enough market players in any case for those trying to make a decision based on what news they get of such bad market behavior to effectively stop them by spending their money elsewhere.

It's the difference between being able to pump the brakes on a bad situation or relying on coasting to a stop.


I think you're making a false assumption here though, particularly with this line:

>There will never be as much competition in medicine as there is in food (unless it is in the 'Uh, oh, a handful of companies own all of the farms' direction). So, even if we eliminate all regulation it still wouldn't solve the problem of competition.

This may be true, we don't necessarily need that level of competition and a lower level, but still competitive market can handle this. Rather, we're at the other extreme, where regulatory barriers are heavy enough essentially prevent competition, effectively ensuring monopoly.

A good example here would be the list of off patent drugs with no generic alternative. In particular the infamous case of Daraprim, where generic Daraprim could be made, but would have to go through the FDA approval process.


Water is fairly heavily regulated as a utility in the United States to prevent such price gouging and prevent a corporation from getting an agree-or-suffer-and-die unequal negotiation. Medicine is not that.


It’s not going to remain that way.

The modern marketing campaigns against meats and dairy are designed to move food production into even more vertically integrated, easy to control and high margin businesses.

As climate change impacts California, you’ll see more upward price pressure on produce, which will drive more business to alternative manufactured food.

Basically, you’ll see that what happened to water happen to food.


high insulin prices are about companies using a chronic disease treatment for cash flow.


> People seem to think that the defective US healthcare system is an indictment on free-market capitalism. But there's nothing free-market at all about our system. What it's really an indictment on is cronyism, corruption, and rent-seeking.

That might be because those corrupt rent-seeking cronies have been selling their behavior as "free-market capitalism" for decades.

I agree with you that corruption is the real problem with the US healthcare system, but I'm not sure I agree that an unregulated free market is the best solution. It seems to me that it would work very well for regulating the prices of popular treatments and procedures (insulin, vision correction etc.) but it seems to me there would be no incentive to do the same for rare or difficult conditions.

For instance, treating some types Leukemia require teams of dozens of caregivers over months-long hospital stays. It seems to me that there's no way a market would make that affordable to the average person, and it seems inevitable you would end up with a two-tiered healthcare system.

> Single-payer has pretty terrible incentives too, but probably not even as bad as the current system.

What's so terrible about single-payer? It seems like it's pretty effective at bringing costs down where it's implemented.


> For instance, treating some types Leukemia require teams of dozens of caregivers over months-long hospital stays. It seems to me that there's no way a market would make that affordable to the average person, and it seems inevitable you would end up with a two-tiered healthcare system.

I think that's a pretty good and fair point. Clearly the healthcare system in Tanzania is more primitive and leads to worse best case outcomes. Or in other words, the best care you get can here doesn't even get close to the best care you can get in the US. In fact, the US probably has the most advanced care in the world.

The downside of this is that it creates a system in which everything is expensive. Doctors only consider the efficacy and quality of treatment, instead of making trade-offs based on efficacy and cost. I think this is a largely a culture issue, though the Hippocratic oath and the litigiousness of American society are certainly contributing factors as well.

> What's so terrible about single-payer? It seems like it's pretty effective at bringing costs down where it's implemented.

Single payer systems result in inflation of costs and creates individual incentive to pursue inefficient options. If my healthcare costs are amortized through payment from primarily other people instead of myself, I don't care how much money anything costs. From an individual perspective, it would make sense to have doctors spend another million so I can live another month.

Moreover, it incentives risky behavior (smoking, getting HIV, etc) because I personally will not have to bear the financial burden of those choices. The only way to get around this would to to institute caps on lifetime medical credit. And if that happened, people would be screaming about "death panels" and such.

I find it hard to imagine a simple and clear single-payer system that would a) provide individual incentives to maintain health b) not impose exorbitant costs on the majority by the few c) fairly allocate healthcare resources to people who would derive the most benefit.


> Single payer systems result in inflation of costs and creates individual incentive to pursue inefficient options. If my healthcare costs are amortized through payment from primarily other people instead of myself, I don't care how much money anything costs.

I think this can be somewhat mitigated thorough co-pays. It's been shown that even if you make a doctor's visit cost a few dollars/euros then people will treat it as something of value.

Also there's nothing that says a single-payer system has to cover everything the patient wants carte-blanche. In Germany, which is a hybrid system where a vast majority of people are on the public plan, the state insurance is somewhat judicious about what is covered, and it's possible to get elective treatment out-of-pocket. I think this is a reasonable incentive structure.

> Moreover, it incentives risky behavior (smoking, getting HIV, etc) because I personally will not have to bear the financial burden of those choices. The only way to get around this would to to institute caps on lifetime medical credit. And if that happened, people would be screaming about "death panels" and such.

I have a lot of problems with this reasoning. First of all, I think it is probably a tiny minority of people who only value their health because of the threat of financial ruin. I think there's a strong intrinsic incentive to avoid things like HIV and lung cancer.

Second, not all health issues are the result of bad choices. I have relatives who are or have been affected by conditions like MS, dementia and cancer through no discernible fault of their own. This argument seems to imply that it's more important to punish callous smokers and people who have unsafe sex than it is to care for innocent people who are the victim of circumstance.


All of those problems with single-payer exist with the current system in the US, at least for those of us with excellent insurance. High deductible plans are an attempt to correct those problems, but I'm not convinced they work as well as one might hope.


The free market is very good at reducing prices in some areas but then it would also not serve other areas where there is no profit. So in a free market health system you would see cheap prices for some stuff but people with certain diseases would just be left to die. You would also see a lot of bad drugs that kill people.


Also, the free market can't co-exist with heavy regulations - you can't just make insulin product and start selling it - you have to go through FDA first, and then market it to doctors who is an ultimate gatekeeper for the drug.


Of the drugs in Tanzania, how many were invented there?

It's typically US companies that take the brunt of the R&D costs to develop novel drugs. Then once they're developed, it's easy for them to spread to other countries for cheap.

That said I do agree the healthcare system is pretty messed up, and patents are part of the problem. But you have to recognize that R&D in this space is not cheap, and companies need some incentive to spend billions of dollars


>People seem to think that the defective US healthcare system is an indictment on free-market capitalism. But there's nothing free-market at all about our system. What it's really an indictment on is cronyism, corruption, and rent-seeking.

Isn't the allowance of 'cronyism' etc, what makes the market "free?"


If you believe that then the billions of dollars corporate interests spend on think-tanks to produce messaging is probably working.

The original concept of free-market economics, as envisioned by Adam Smith, was defined in opposition to entities governments and guilds using their power to impose artificial rules in the market to subvert natural market forces like supply and demand. Pharma companies use regulatory capture to do exactly that: they set up a legal landscape for their own benefit and everyone else's detriment. Rent-seeking is anything but free-market.


>...They set up a legal landscape for their own benefit and everyone else’s detriment.

So if I’m understanding correctly, the problem is not a lack of willingness to break up/regulate this monopoly, but instead the regulations and lobbying that explicitly facilitated its creation?

Are there any inherent facets of a free market that prevent such abuses?


The inherent weakness of any and every society is always going to be the government. As the entity with the monopoly on force, the corruption and influence on government from interest groups will necessarily be the weak point in the system.

It's incredibly hard to generate the political will of many people who will slightly be hurt by something against the will of the few who will be significantly hurt even if the aggregate damage is far greater for the many than the few.

Almost all legislation follows this sort of calculus: zoning laws, tariffs, minimum wage, etc.


> Are there any inherent facets of a free market that prevent such abuses?

No, there's nothing about free market which will automatically mitigate this issue. Markets are very good at certain things, like delivering goods and services efficiently if certain conditions are met, but they are not some panacea which can magically solve every problem.

There are certain cases where markets are not very good at serving a majority of people: for instance in the case of monopolies, or when there are negative externalities which are not priced into the market (for instance it can be profitable for a company to burn a lot of fossil fuels to produce products cheaply, and everyone else suffers the environmental costs).

Strict libertarians will disagree with me, but markets alone are not enough. In every example of what we could consider a well-functioning society, the government plays a role in guiding and constraining the market where necessary.

Regulatory capture does represent a problem, and is an example of bad government, but that does not negate the need for good government.


Given that 'cronyism' means private business inducing government officials to use state force to benefit said businesses, no, it's certainly not what makes the market 'free'. The use of force by the state to entrench the position and profits of a particular business - whether by suppressing competition on threat of violence, or by straight up taking money from people via the tax system and handing it to the business - is not only not part of the "free market" ideal, but antithetical to it.


> The use of force by the state to entrench the position and profits of a particular business

This is a natural and obvious end following from the foundation of capitalism, which is the existence of private property ensured by the state.


This thread is fun. The problems are X, Y, Z but not A (even though A results in X, Y, Z). Do people think lobbiests and corporations are somehow operating outside of capitalism?


I believe "cronyism" here refers to government interference on behalf of certain companies or industries, driven by lobbying etc. It may be a common failure mode for capitalism, but it's hardly "what makes the market free".

https://en.m.wikipedia.org/wiki/Crony_capitalism


This looks like a case study of what is wrong with the US healthcare system.

There isn't much discussion of why it's expensive in the US specifically. In other countries insulin prices haven't risen in the same way and are still affordable. So why is the price gouging only happening in the US?

As a T1 diabetic in the UK, where the wonderful NHS covers all of my insulin costs, this is one reason why I'd never be able to move to or work in the US.


> As a T1 diabetic in the UK, where the wonderful NHS covers all of my insulin costs, this is one reason why I'd never be able to move to or work in the US.

I'm a T1 Diabetic in the US and I consider myself very lucky to work in software. I have good insurance, so my medication only costs me about $200 per month. That's just an additional cost I have to pay to be alive, on top of all the other stuff everyone else has to pay for, too. If I had a lower paying job, or a job with less good health insurance, I can see how I'd be priced out of living.


I'm sorry but I find that horrifying.

I'm in Australia, my brothers recently diagnosed as a T1 diabetic, he's currently taking a career break to spend time with his family and get his health and medication all sorted out. Thats all fine here because the costs are reasonable, I see these reports form the US and can't help but wonder when it will get here, most 'innovations' do, fortunately the US health system doesn't seem to be getting a foot hold here.

It seems to me, as an observer, that the health system along with the cost of education have been set up to produce a slave class, I could be wrong but its definitely something that I fight to keep out of here. Five years or so ago I was regarded as a socialist, but with how things are going, most people I speak to no longer argue about it, so it seems the battle is being won here. I find it hard to understand how there aren't marches in the street over there about this.


It's bad, but it's not all that bad. Most jobs, such as mine, provide health insurance that makes costs at least manageable, if not reasonable. I live a happy and comfortable life, despite the $200 monthly tithe to the CEOs of the insurance and pharmaceutical companies.

And there is progress being made. The ACA passed under Obama was a very significant step forward, and public perception is shifting in favor of more government involvement in healthcare[1]. As with most things, the problem is money in politics and media. Republicans resist any attempt to slow the accumulation of money into the hands of the ultra-wealthy, and also own the most popular news channels, so they've convinced a significant chunk of the population that making the wealthy wealthier will somehow help them. A good chunk of Democrats are also paid to oppose changes to the current healthcare regime. But there's a growing number of Democrats actively campaigning for single-payer and other sane systems, and support among voters for single-payer is also growing[2].

There's hope. The situation isn't so bad that violence is the answer, yet.

[1] https://www.pewresearch.org/fact-tank/2018/10/03/most-contin...

[2] https://thehill.com/policy/healthcare/339247-poll-support-gr...


> Most jobs, such as mine, provide health insurance that makes costs at least manageable, if not reasonable.

Hope you don't lose your job for some bullshit reason.


I wasn't advocating violence - peaceful marches work, look at the recent events in Hong Kong


It was touched on - there's the "official list price" (which has gone up) and the "price actually paid by large providers" (which has gone down).

My best guess is that the price rises were to bring in some immediate profits in the short term ("this quarter isn't looking good") and them these were shortly followed by the compensating discount you have to give to your pissed off customer.

Problem was that nobody gave a toss about the profit margin on the lone guy paying $1000 a month (or $1300 a month) at retail.


The reason is that there is demand for the newest drugs and insurance will pay for it. In the US, doctors quickly switched patients from vials to pens, from Lantus to Tresiba, etc. The price goes up because insurance/PBMs negotiate large discounts. Most full-blown diabetics have two insulin prescriptions and after insurance pay $50-100/mo in out-of-pocket costs, so the increases are hidden from them—hence the need for articles like this one.


>In other countries insulin prices haven't risen in the same way and are still affordable. So why is the price gouging only happening in the US?

The price hasn't really risen in the US either. Or at least not as much as the article implies. The list price has gone up but the corresponding discount given to insurance companies via PBM has gone up about the same. For most people it doesn't make a difference because they buy through insurance. For people like in TFA they get screwed because they have to pay list price. Theoretically, the number of people in that situation should be 0 post Obama care but obviously there are cracks.

Unfortunately, the guy in the the articld fell through a crack. Mostly because he didn't realiZe that buying through insurance would save him a bunch of money. Or maybe he was at the wrong pharmacy to get a huge manufacturer discount.


And this is a good illustration of how the system is completely fucked up. No part of what you wrote is sane (I'm not implying anything about you, just the system). The corporations have gamed the system where it's now normal to suggest that you are responsible for determining and getting discounts, in this instance that it was on the subject of the article to figure out the system, the system that was supposed to be helping him.

Being in an employee-owned company, I'm very aware of how much the company pays for insurance. It never goes down, it always goes up. The company has to switch to plans where employees pay larger and larger deductibles, just to keep the insurance cost increases down in the 10% per year range. Usually the reason costs go up is because we "use it too much", people need to use generic drugs, etc. Of course, it's hard to determine actual costs in such a convoluted system, but orders of magnitude cost increases for medicines obviously plays a significant role.


> The corporations have gamed the system where it's now normal to suggest that you are responsible for determining and getting discounts

It's not really that difficult. You just buy insurance or get on Medicare/Medicaid and you get the discounts. That's not to say that the system hasn't been grossly perverted. Just that the hoops aren't difficult to jump through for pretty much everyone.


> Just that the hoops aren't difficult to jump through for pretty much everyone.

The hoops are incredibly difficult, just at random.

My son was just diagnosed with T1 diabetes as a juvenile. The insurance company denied coverage for the ER visit and in-patient overnight stay after being admitted. They stated since he was not yet hyperglycemic and in acute stress that it should have been an outpatient procedure.

So what sounded like a $50 co-pay because he has good insurance, turned into a $20,000 bill out of the blue that must be fought.


It's worth noting that this isn't about the type of insulin either - the NHS generally prescribes the new, fancy insulin analogues to type 1 diabetics as their first choice because they provide actual clinical benefits, despite this article's claim that they're a giant con that only exists to line the pharmaceutical industry's pockets. In particular, Lantus used to be the recommened long-acting insulin of choice for new patients until they switched to something even newer a few years back.


And a great reason for why you wouldn't want to.


It's because the US healthcare system is a nightmare combination of extreme government control & regulation, and corporatism. They socialize the cost and privatize the profit, to the benefit of a small percentage of the population that works in those fields or invests into them. It's a very large, regressive wealth transfer. You can only do that with the intentional, direct assistance of the governments (federal + state governments) as enablers that protect the healthcare cartels and worker guilds.


$1300/month is absolutely crazy. In Sweden, a whole year’s worth of injection insulin is about $600 (actual cost to the government, including the disposable injectors) and $0 to the end user.


Another person commented on a different thread that he was buying some kind of auto-injection pen that fetched a premium to the bottled stuff. It seems he was not aware that he could’ve used the regular bottle stuff and saved a LOT of money.

The pharmacist should’ve given him a better consult and told him options for cheaper stuff. I had a pharmacist and a tech search for 30 mins several times for a rebate that brought my cost to $0. They will suggest another medication if the one you are getting isn’t covered. They will even call you doctors to get a new script.

It seems there were failures on multiple levels. He should’ve been aware of better options. The pharmacist shouldnt have let him leave when he couldn’t afford it.


The primary failure is that healthcare is considered an "industry" in the US and that health "insurance" is incentivized to keep prices (and profits) high.

Health insurance by private companies is just a scam. In combination with "not-for-profit" hospitals, medical practicioners loaded with college debt, lobbying to government to enforce ongoing rent-seeking (eg "Medicare D is specifically not allowed to negotiate drug prices").

The entire US health system needs an enema.

It should not be up to the patient to "be aware of better options". It should not be up to the pharmacist to stop him leaving when he couldn't afford it.

What should have happened is that a doctor prescribed the appropriate medication, and a pharmacist supplied that medication, both ensuring the best outcome for the patient.

The cost of the medication should be absorbed (not totally perhaps, but within the bounds of reality and the minimum wage) by the government.

That forces the government to negotiate the best possible price with the suppliers and to remove inappropriate IP "rights" when they no longer "promote the progress of science and the useful arts".


How well has negotiating drug prices worked for Medicare?[1]

[1]https://www.forbes.com/sites/johnwasik/2018/08/10/why-medica...


Still, auto-injection pens are not rocket science. In Sweden, maybe they'd double the cost to $1200/year, though I doubt they'd do that if mass-produced.


I still have a hard time believing the articles numbers. Heres one example that quotes the vials at $137.50 and the manufacturer gave the pricing.[1]

Note the guy died in 2017 and my link below is from this year. It looks like a small amount of progress has been made since his death.

[1]https://www.google.com/amp/s/www.usnews.com/news/best-states...


Here in the Netherlands my insulin costs including all other medical necessities are about 1600 euro/year. Do note, this can differ substantially per person.

edit: the cost to the end user is the required 385 euro.

Here it is happening as well: Novo Nordic set the cost of the - the new - Tresiba insulin higher than the covered amount, it simply wasn't offered as there were fortunately enough alternatives available though the stuff actually works better. A few years back they finally gave in and now it is still sold at the premium price but the apothecaries get back the amount not covered by insurance from the distributor (and I guess thus Novo). Which basically tells me they can offer it for that price but don't want to and hope the covered price goes up (not likely).


And the crazy thing is you also need strips at least, many of us pumps and CGMs because of being super sensitive to insulin. That is easily 100k per year even in Europe. And due to the mandatory insurance, not that much for the user.


Easily 100k, just for testing strips or a CGM?!

I'm not sure where in Europe you are, but it's nowhere near that in the UK - testing strips are around 0.20 each, (which TBH I think is expensive, but plainly no going to cost 100k/year!).

For CGM, if you're lucky enough to get the NHS to pay for it (unlikely), it costs them around 1k for the monitor, and around £1,500/year for sensors.

Finally, insulin costs the NHS around £400/year for a T1 diabetic.


Pump, insulin, Dexcom sensors and transmitters, pump infusion sets with the tubing separately, pump cartridges, strips and so on. It'll add up quite fast. Depending where you are it can be very expensive or not. In many European countries paid by the insurance.


But I accounted for all the things you listed there?


In India, it is around 330 USD (3 cartridges of Lantus, around 650 INR -> ~ 10 USD each), which again can be claimed.


Is this the traditional insulin that Walmart sells or newer versions that are so expensive in the US?


In the UK, the newer insulins cost the NHS £30-£37 for a box of 5 x 3ml disposable pens. Diabetics don't pay any charges for the prescription.


In areas the mafia doesn't exist (an analogy the title makes by calling it a racket), the cost of paying the mafia is $0. So it might be £30/vial no mafia fee in the U.K., and the same + $10,000 mafia fee in America.

However, doesn't some of that mafia fee go toward R&D? (Developing new drugs)? Why isn't the price to the NHS slightly higher, also in part to fund research? It's hard to imagine $10,000 just gets pocketed by Don Carleone, without any of it going back to the laboratory.

Is the analogy really sound?


> Why isn't the price to the NHS slightly higher, also in part to fund research?

The NHS (via NICE) sets a standard amount that it is prepared to pay for any treatment based on the QALYs (Quality Adjusted Life Years) it results in. So really a non-generic manufacturer can charge whatever they like, so long as the end result is worth it. In a sense we don't eliminate the mafia, just set the terms of engagement under which they have to justify their pricing. Whether they take that money and spend it on R&D or dividends is the vendor's decision.


I'm trying to figure out if the cost in Sweden (or UK NHS) is using the older recipe so the a valid comparison. If so the US Walmart product isn't so different. I'm trying to compare like with like.


>So he made a rational decision: He’d go uninsured, save the cost of the premium, and just pay for his meds out of pocket, while racking up work experience that could serve as a springboard to a better position with health insurance.

He did not make a rational decision. This is the most upsetting part. I looked. You can buy an insurance plan in Minnesota with a $750 deductable $6000 out of pocket max for $350 per month.

It is not possible with that plan and a few more like it to spend more than 1000 per month. If you are planning to spend that much anyway it is irrational to pick anything else.

What seems to have happened is he was using expensive autoinjector pens while on good insurance and then didn't adapt when he lost it and didn't get the right advice for purchasing his own insurance or the right education to be able to pick an appropriate plan.


At that point, he should just book a trip to Mexico or better yet China, and buy at less than 10% of the price.


As someone living in Mexico, I am always frustrated when reading horror stories from people in the USA about medicines. I have always been 100% willing to help getting any required medicines if needed.

And here I am today in the USA (visiting for 1 week of work), with what appears to be a stomach infection, and I'll have to just survive it maybe with Pepto, until I go back to Mexico, or otherwise pay a lot of money to see a GP to give me a receipt for a something that will cost me $6 USD back in Mexico ( https://www.angloinfo.com/blogs/mexico/mexico-city/more-adve... )


> He did not make a rational decision. This is the most upsetting part. I looked. You can buy an insurance plan in Minnesota with a $750 deductable $6000 out of pocket max for $350 per month.

What did you find exactly? Are you sure it’s something that was available to Alec? That price sounds surprisingly low, and sometimes there are cheaper plans for temporary work gap transitions that aren’t available to someone with a job permanently. The article said he was looking on the healthcare.gov marketplace, which doesn’t have plans anywhere near that low. I was using healthcare.gov for a few years while I ran a startup, and the prices went up so fast and so high I don’t know how normal or poor Americans can even afford them. We looked outside the marketplace and only found the same plans for the same price being offered privately.


I lived in Minnesota for a decade and bought individual insurance on the state exchange for a couple of years. I went on the same exchange today and searched for insurance plans available for 26 year old single men (the same situation I was in a few years ago) and found two $750/$6000 plans for $328 and $368 per month. There was also a $1000/$5000 plan for $375 and a few others in the neighborhood.

When I looked outside the exchange a few years ago I found a plan I liked more than my other options which I chose (didn't look today).

Quirks and or better management in MN gives it relatively favorable prices.


Thanks for the additional detail; you know more about Minnesota healthcare than I do. Looks like I'm wrong about the prices there. I guess maybe I'm reacting more to the idea that Alec's decision wasn't rational. I agree with you about how extra sad that decision was, if it was avoidable. But I might also give him some benefit of the doubt, especially since this exact same story isn't that uncommon, of people choosing against insurance because they don't feel like they can afford it, and then paying a much greater price.


Are you sure the base insurance price for a healthy person is going to be the same insurance price a diabetic would pay? I'm not so sure about that.


Yes, a significant part of the ACA was pre-existing condition protections.

You can only be charged rates based on location, age, and tobacco use.


Those pens allow for accurate dispensing.


Personally I'd say there is no difference; I've stuck out on syringes in the uk for ages just because I found them lightweight and convenient; but recently moved to pre-filled pens. The cost to the NHS for prefilled pens vs syringes is pretty negligible.

Syringes were fine for me, pens might be less embarrassing to use in public maybe?


are we talking the same thing, I am thinking of the pens I used to use that you would dial the dosage in and then push the plunger. In Canada, those pen fills costed about 70 vs 36 for the vials, but they also had 15mL of insulin vs 10mL. So about 1/3 more with the syringes and needles being about the same price.

The problem isn't their choice of insulin delivery, it is that there are no price controls and an incentive to increase prices without any significant loss in sales. This is an area that government need to be all over.


Who wouldn't choose to learn how to use a syringe well instead of paying a third of their income for auto pens?


I've seen a friend with Type 1 diabetes quietly and quickly go from someone who practices law competently to someone who can barely manage to stab herself when she realizes she's having a blood sugar issue. Dosage is hard when you're crashing.


If you’re crashing (low blood glucose) you don’t take insulin, you drink juice or call an ambulance (My partner has had to do this, unfortunately). If you’re so high that you’re having trouble using a syringe you need to be in a hospital.

Source: Type 1 diabetic.


To help people understand low blood sugar episodes, I think it's good to watch these three videos.

https://www.youtube.com/watch?v=pC_0CI9jV6A https://www.youtube.com/watch?v=Bv4HIci1Qtc

https://www.youtube.com/watch?v=TidRyyrTz4k


One thing I forgot was a Glucagon injection to revive someone who has passed out.


Yes, but generally you're not going to be injecting yourself with glucagon, as if you're lucid enough to do that, you're lucid enough to eat/drink some carbs.


Looking at what a good friend of mine has to put up with, I'd say someone with severe diabetes. You have periods when you cannot think very straight and it is easy to fuck up with standard syringes. Auto injectors should not cost a third of your income, they are not complex devices.


They shouldn't.

But you also have a tiny mass produced machine that is life and death for people. Insuring quality is expensive and the cost of mistakes is extreme.

If you want cheaper medicine you have to also have cheaper mistakes and there aren't many people arguing equally loud for both. (Just one issue of many)


The mistakes are not cheaper. The result of mistakes is a high risk of death in both circumstances. And measuring insulin into standard syringes while not being able to think straight is dangerous as hell.


By mistakes I was referring to manufacturing defects of medical devises and the levels of financial liability coming from them.


I'm referring to which course of action is least likely to result in the death of a friend.


So how much do you want to limit and punish the accidental death of a friend?

Higher numbers for the previous two will increase cost and death to people who can no longer afford the treatment.

"Least likely" means infinite quality control and is not possible. Failure rate is not zero, you have to pick finite regulatory requirements and financial consequences for failure.

You have to assign a dollar amount to a human life. It is uncomfortable for many people to think big picture thoughts but you're contently using things made by people who have to.


Not sure if this is the same issue, but apparently the cheaper insulin syringes are thicker and cause more pain and bruising. From my understanding, these are shots that need to be administered several times a day in perpetuity. The savvy consumer's options are chronic physical pain or poverty. With that in mind, would you still suggest that people go with the cheaper option?


Most diabetics, not pumping take two kinds of insulin. One that provides a basal dose that covers the glucose your body produces. One to two injections a day for that. In addition, there is the bolus dosages that are taken with any carbohydrates. So most people on average, eat 3 meals a day, plus any snacking. We are up to about 6 a day here.

The cheaper insulin in the US is garbage and should not be used. period. The problem is the companies are have no pressure to reduce prices. the customers are captive and must pay or die. They make money in other countries that have price controls on the same product.


Most importantly, the consumer should decide what is the best option here. If you are poor and the only available option to stay alive is injection multiple times through the day using thicker needles, perhaps it is still better then die? Or maybe not. I do not want to decide that for anyone.


Life sucks, diabetes sucks, and poverty sucks. More than people who don't experience it can understand.

But you do the best with what you have, and that means picking your pain.


The article seems to blame the Bayh–Dole Act and similar events that allowed Universities to sell government funded research results to the pharmaceutical industry. I don't believe this is the problem--the Bayh–Dole Act incentives new drugs. This explanation doesn't explain why off patent drugs have gone up in price.

I suspect the problem is market collusion and the FDA shutting down competitors on drugs where patents expired, which I believe is what happened during the epipen crisis.


Also forced non-competition... You simply can't make a generic version without your company being bought and/or litigated to death, preserving the just-barely-isnt-a-monopoly goal.

This happens in the garbage collection industry, people make competitors and offer 30% discounts on going rates, Waste Management or similar megacorp loses an entire county or region... Then they buy the company and slowly raise prices back up.

There's non-competes in the contract, but the owner doesn't care, they pocket 10 million and take a 1-year vacation then repeat the process. Only customers and employees are hurt (as there's less need for employees when the companies merge)

Same with pharma... Though I imagine there's extra pressure on the factories to not serve "little guy" as part of their contract with big pharma. So even if you have all the necessary process and expired patents, the industry stacked agreements and laws to make it nearly impossible.

Like many American industries, this is the kind of behaviour that caused Roosevelt (a Republican) to leverage the Sherman Anti-Trust Act... The key point being that mega corps were exploiting the populace and the only solution was to break up these giant monsterous companies that effectively created monopolies. He specifically targeted companies that used this power for ill, jacking up costs to consumers.

Now we are back at this point, but the public unrest hasn't reached a critical point while we are upset over other political issues, so big business continues to shovel buckets of money at Republicans to try and maintain the status quo until enough Americans get upset that politicians fear loosing their seat over the money (and right now, thanks to gerrymandering, enough politicians need 10% or more of their loyalty base to convert to the other party for that to be an issue.

In reality, this is a genius system that is perfectly legal... On the surface.


In the case of insulin, I think it has more to do with the FDA's processes than corruption.

It would be very difficult to make a profit on generic insulin because it's a biologic drug, which means a generic manufacturer wouldn't be able to bypass the FDA approval process by proving bioequivalency.

EDIT: Upon further reading, there is a pathway[0][1] for "biosimilars", but it seems to have higher requirements than chemical generics.

[0]: https://en.wikipedia.org/wiki/Biologics_Price_Competition_an...

[1]: https://www.fda.gov/drugs/biosimilars/biosimilar-and-interch...


The generic insulins that are out of patent protection are also significantly worse than modern, patented insulins. Here's a good article on the topic: https://www.webmd.com/diabetes/news/20150318/why-isnt-there-...


Some big hospital chains are starting a nonprofit generic drug manufacturer, Civica Rx. This seems like a promising step forward. For those more inclined to direct-action, there's Four Thieves Vinegar [1].

[1] https://fourthievesvinegar.org/


Why not just import it from foreign manufacturers for a fraction of the price?


The FDA won't allow that unless those manufacturers go through its approval process.


Sounds like a fixable problem.


If you’ve read the stories on some of these foreign manufacturers, you might reconsider trying to bypass the FDA inspection requirement.

Here’s just the first hit I saw on Google, there have been quite a few exposés on the topic.

https://www.npr.org/sections/health-shots/2019/05/12/7222165...


Exactly. Instead of spending 10Bn on R&D, spend 10Mn on lobbying.


How exactly would you fix it?


One key take away, Wal Mart sells a lower priced version along with supplied for testing. Well that is all and fine, they do list some reasons it isn't ideal but they leave out the big one. Most people under insurance or government provided health insurance are not permitted to use it.

Throw in over regulation besides limiting which types are available also can interfere with refills of both insulin and testing materials and even require periodic confirmation by a medical professional you are still diabetic.


When you say they aren't permitted to use it, do you mean it disqualifies them from insurance for other diabetes care or do you mean that the insulin isn't covered by the insurance?


They sell a $25/vial of Regular insulin; its an older style, and can be fairly dangerous to use, as it has quite the different action as the newer 'fast-acting' insulins.

With that said, if tight on money, its certainly better to use it, and monitor it closely, than not be able to afford the $225+/vial novolog or humalog.


It’s not “fairly dangerous to use”. Unlike aspart, Regular is less potent and has a slower and longer activity profile. If you have poor food absorption after a meal, take the wrong dose, or have any other event that would change your insulin requirements, you will find yourself in much sooner trouble with less time to react from aspart versions.


Monitoring is expensive. The strips can be 1-2 euros per one.


Walmart sells their own brand for about $0.20 each, the "name brand" ones are about $0.60-80 here. I have a diabetic friend whose insurance will only pay for 2 strips per day and he buys the remainder from walmart (and has 2 meters because the insurance-provided one is a different model that doesn't work with the walmart test strips).


Not sure where you are in Europe, but they're £0.15 - £0.30 each in the UK. TBH, I still think that's too expensive, but it's nowhere near 1-2 Euros


They are generally $0.15-$0.25 without insurance, and only rarely over $0.6, in the U.S. where this took place.


What's left out of most conversations around insulin.

- The incidence rate for diabetes has skyrocketed over the past 25 years. It's estimated that 100 million Americans are now living with diabetes or prediabetes.

- Most of the patents for the newer insulins are mostly on manufacturing processes. Read up on Lusduna if you want to see how difficult it is to bring an insulin to market in the US.

- Biosimilars are significantly more costly to bring to market than generic drugs.

- Alex Azar, and every other secretary of HHS have had the ability to allow legal importation of drugs from Canada since 2003. We actively choose not to. While IMO the risks are worth the benefits, I will concede the other side does have a valid argument against importation.

- The price difference is with fast acting insulins. These insulins offer a higher quality of life relative to the older insulins. The clinical benefits of using a fast acting insulin versus something like Novolin 70/30 (aka Walmart insulin) are negligible, while the price difference is substantial. (Talk to your physician before switching insulins) From the people I've talked with, fast acting insulins are a godsend if you have diabetic children or can't keep a regimented schedule.

- All of the companies that manufacture insulin are public and you can read through their financial statements to verify that what they are saying is true.

All that being said...

I'm surprised that an enterprising Canadian has not exploited insulin arbitrage.

You can buy insulin over the counter without a prescription in the USA and Canada. Canadian law does not prohibit exportation of drugs to the United States.

Theoretically you could set up an escrow service that connected Canadians who wanted to make a buck with American diabetics. The service could offer insurance in case a delivery was not made and you needed to buy insulin in the US.

Obviously this would complicate things with your insurance. No insurance company is going to cover bootleg Canadian insulin when it comes to your deductible.


> It's estimated that 100 million Americans are now living with diabetes or prediabetes.

Holy cow - that's like 1/4 to 1/3 right? That seems insanely high!


It's doubly tragic because (T2) diabetes is preventable, and even reversible in some cases. And I've read that T1 is also much better controlled on a low carb/ketogenic diet.


Prediabetes is broadly defined, it catches a lot of people who aren't necessarily going to become diabetic.


Let's not conflate Type 1 diabetes with Type 2 diabetes.


T1 is rare compared to T2, but those figures are still shockingly high.


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