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"Outrageously" priced weight-loss drugs could bankrupt US health care (arstechnica.com)
45 points by psychanarch 28 days ago | hide | past | favorite | 94 comments



> A study by researchers at Yale estimated that drugs like Wegovy can be profitably manufactured for less than $5 per month.

Serious question: Why not just bootleg the stuff?

It's a very small protein, easy to make, and "research chemical" companies that sell structurally similar bodybuilding drugs and nootropics are a dime a dozen. Search online for "BPC-157" (a protein drug of only slightly inferior complexity) and you'll find a million places that sell it at $25 for a month's supply. Those vendors are legitimate far more often than not.

If Novo Nordisk won't sell to humans at a humane price -- instead preferring to gouge insurance companies and the gatekeeping medical bureaucracy -- I'd argue that there's a moral imperative to bootleg the drug and distribute it to those who would benefit from it at a fair price.

And, unlike many of the bodybuilding drugs (which are a big business,) these new weight-loss drugs aren't scheduled, so you won't get in much trouble even in the unlikely event you are caught.


These same companies that manufacture and distribute BPC-157 and bodybuilding drugs already also offer various GLP1 drugs, semaglutide, tirzepatide, retatrutide. Google around and you can find them available for much cheaper via grey market vendors.


Well, there you go, I guess.

So high semaglutide pricing won't end up "bankrupting" the US medical system. It'll push an ever larger number of patients -- and more than a few well-meaning doctors, who already recommend things like BPC-157 -- into the gray market. That this would further delegitimize the medical establishment and FDA would be a well-deserved outcome.


Where does one go to find these vendors? Are they the sorts of places that other sites prohibit links to?


They have patent protection and the US government goes to great lengths to defend intellectual property rights.

Technically, compulsory licensing is allowed under TRIPS (https://www.wto.org/english/tratop_e/trips_e/public_health_f...). But the US and others opted out of this (https://www.wto.org/english/docs_e/legal_e/31bis_trips_annex...).


I'm down for it or something similar. Not even joking.

A. The issue becomes creating a manufacturing and cold chain distribution system involving the fewest people with compartmentalized knowledge. I'm not sure how you'd launder it or keep enough of it a secret to not get eventually busted because someone would open their mouth. It'd probably be busted with RICO if any sort of profits were involved. Must pay taxes, for sure.

B. DIY chems home pharma kit is another approach.

C. Traffic from other countries like France at near cost prices.

D. Send patients to low-cost countries to buy up medications for their own personal use, and post or FedEx it back to themselves in bulk.

E. Hold politicians accountable and make the FDA and FTC set hard limits on price gouging so that Medicare, health insurance co's, and American patients aren't overcharged. You'd think health insurance co's would be right out in front complaining about the high cost of medications and lobbying for change.


> get eventually busted because someone would open their mouth

Aren't this what "corporations are people" prevent? Plenty of people doing shady, or outright evil stuff, get their way because they're behind a corporation.


It's more like conspiracies fall apart whenever there is more than 1 person. When there are 800, then it's over immediately.

Evil or shady acts must first be illegal to be potentially prosecutable crimes or be injurious to have standing as tort claims. And limited liability isn't unbounded.


> Serious question: Why not just bootleg the stuff?

Historically, the black market for medication has been vanishingly small. People don't as a rule trust drugs they get off of alibaba or wherever; even the viagra gray market is a small fraction of the prescription revenue.

And this doesn't treat something critical, it's a weight loss drug. To be blunt most people would probably choose to remain fat vs. buying an illegal generic.


>To be blunt most people would probably choose to remain fat vs. buying an illegal generic.

Wow, I think the exact opposite. Weight loss is a huge industry and people are desperate.


Fentanyl seems to be tainting a lot of black market drugs lately. I'd want to test anything if it came from unofficial sources.


Totally different markets. They are adding fentanyl to cut intoxicant drugs as a way to make more money. Nobody gets high on a GLP-1. Never heard of supplement/nootropic drugs being tainted and doesn't make sense that anyone would on purpose because they are sold by companies with web stores and credit card processors.


I don't think this is true. Look at the number of people buying Modafinil off Indian websites.


Well technically because India is not a black market, more like a grey market. They didn't pay for IP, Indians just copied the drugs, but they achieved their goal - selling affordable medicine with good enough quality to an average Indian.


They already are. Weight loss clinics will send the Rx to a compounding pharmacy.


>clinics will send the Rx to a compounding pharmacy.

I think you are confused about what a compounding pharmacy is -- at least if you refer to how it works in the US.


Not sure what you mean. You can sign up for compounded semaglutide from many online services (e.g. Ro https://ro.co/weight-loss/compounded-semaglutide/)

It's still expensive, but far cheaper than brand name with similar efficacy. Competition from these programs will likely drive costs much lower over the next few years.


Absolutely nowhere on that page is mentioned what you’ll actually pay for the compounded drug. Spoiler - $300+/mo


Yes, less than half the price of brand name, and competition hasn't even really started.

These are first mover prices.

What's the monthly health cost of being obese?


Semaglutide is still under patent in the US till at least Dec 2031 (say Wpedia).

Blockbuster drugs still under patent usually don't have alternative avenues of supply that are significantly cheaper than the main avenue. I wonder what law or regulation allows this alternative avenue to persist.


What is compounding? What raw ingredients do they start with? How is it possible?


They are compounding the useful, active ingredient which they are purchasing from some mass manufacturer with some pointless thing they happen to have on hand and that provides a legal fig leaf that the medicine was tailored specifically for you.

The reason compounding pharmacies are very useful in the US is not because the process of compounding is useful; it's that they have carveouts in regulations that make it hard for the FDA to control them. When there is a drug that is useful and safe, but not approved by the FDA for the purpose you want to use it, you can often get it from a compounding pharmacy.

Semaglutide is a GLP-1 agonist. There are many other GLP-1 agonists, of varying efficacy and side effects, and many of them which a compounding pharmacy can purchase in bulk at very reasonable prices. However, only Semaglutide has been FDA approved for the indication of weight loss, and being the sole approved product means they can milk their patent-granted monopoly for a ridiculous amount of money. Simply because without FDA approval, you cannot get the other similar drugs for the purpose of weight loss. Unless you go to a compounding pharmacy, which, for dumb historical reasons, happen to have loopholes in FDA regulation, so long as they are artisanally producing compounded drugs tailored to a specific individual.


Do they still require a prescription?


Many reasons. One of them being doctors won't prescribe an off brand drug and insurance won't cover anything related to it.

The other reasons are:

1/ Even the manufacturer doesn't know everything about how the drug was made. They characterize the final compound but the compound was made by some sort of living cells so each one has different properties. For the same molecule, one cell line may produce a drug with entirely different toxicology profile compared to another. You need a full manufacturing chain with different departments analyzing it at different stages to guarantee the desired effect.

2/ Patents make sure that the vanishingly few groups with the capability to do the above characterization would not want to risk their business doing it.

3/ For every one molecule that made it to market, dozens or hundreds of others were discarded. They all cost about the same amount to develop up to the point they were thrown away. Due to the amount of regulations in place, the cost to research is obscene and the final manufacturing cost is peanut compared to the price of the pipeline what the drug went through.


Utter nonsense, especially point #1. Drugs absolutely are not random mixtures. Semaglutide's molecular structure is completely characterized -- on its wikipedia page, in its patent application, and elsewhere -- and it's very easy to make identical molecules in the lab.

Novo Nordisk's patent -- US8129343B2 -- lays out the process, which is nothing more than Fmoc solid state synthesis. "The protected peptidyl resin was synthesized according to the Fmoc strategy on an Applied Biosystems 433 peptide synthesizer in 0.25 mmol or 1.0 mmol scale. . ." So they don't make it in cells, but by totally conventional peptide manufacturing techniques.

As for #2, you must be unfamiliar with the existing gray market for pharmaceuticals. Among others, both the bodybuilding community and the nootropics community experiment extensively with pharmaceuticals -- and they do drug synthesis and distribution in a way that's actually extremely cost-effective! (Necessarily, because their customers are humans who pay out of pocket directly.)

#3 is trite and overstated. It's a standard drug industry talking point, but it really has no bearing on this discussion.


> insurance won't cover anything related to it

If the grey market is cheaper than you would pay for the real drug after insurance’s contribution, who cares?


Patents?


When it comes to pharmaceuticals, the patents are ridiculous. Take for example Contrave[0]. It is a combination of Naltrexone and Bupropion, both of which are no longer under a patent. Put them both in the same pill and it's under a new patent.

[0] https://en.wikipedia.org/wiki/Naltrexone/bupropion


So buying them separately and mixing them in your mouth is legal? It's like combining 2 pieces of open-source software and selling them under one product.


Totally legal. You can have your doctor prescribe 50mg Naltrexone and 300mg Bupropion and you can take them at the same time every day. It's the same drugs in the same ratios. Contrave is not novel in any way. There's substantial prior art. And yet a patent was granted to cover this combination and prevent anyone else from taking two generic drugs and combining them into one pill.


> It's like combining 2 pieces of open-source software and selling them under one product.

That describes a decent chunk of the tech industry!


Interesting. I'm pretty familiar with both drugs in the context of addiction treatment and mental health (and seen plenty of people taking both as separate pills), but I've never heard of them indicated for weight loss.


I believe the most likely outcome is a price curve downwards as Novo nordisk is quietly forced info JV with US manufacturers under implicit threat of some one-off ruling akin to an IPR eminent domain action.

Nobody in government wants to accept IPR is broken but they'll find a way to bend it's ruling into a hoop, for the specific needs of the moment.


> Why not just bootleg the stuff?

because the US is largely responsible for the rich world's tyrannical patent and copyright laws?


> I'd argue that there's a moral imperative to bootleg the drug and distribute it to those who would benefit from it at a fair price.

Why not do away with patents and IP altogether if the standard is that as soon as someone makes something needed it can be stolen?


I'm not sure what the right solution is, but making 160x the manufacturing cost seems a bit obscene. Not sure what the total cost of R&D was, but at that rate of return those R&D costs have to be recovered relatively quickly and then it becomes a pure profit machine.


Do you similarly object to the insane gross margins on software?

Like in software, pretty sure the main expense is R&D.


The consumer costs are significantly lower for software. For example, the cost of ChatGPT is minuscule in comparison, while the R&D costs are still quite high.

The real difference between the two sectors is that for medicine, you have a captive audience. People are willing to give up their life savings for certain medical interventions. That same cannot be said for software.


The other real difference is that the addressable market for most drugs is quite small in terms of number of customers. The vast majority of people just don’t need a particular medicine, especially the life-saving variety. The more niche, the more you have to charge to make up for the large R&D costs.

There are, of course, also instances of gouging. But it’s not like these things should inherently cost $20/mo, or whatever, if you want to be able to pay biomedical researchers enough not to go do something else highly compensated like finance/consulting/whatever. Sadly, I had a lot of classmates in engineering school who went that route instead. We urgently need more nuclear reactors, but one of the smartest guys I know, a nuclear engineer, is doing healthcare private equity.

A lot of saas is more like $200+/mo for businesses, and chatgpt might be $20/mo for consumers, but there are companies paying $1m/mo or more for that api.


No one is mentioning the liability costs (and liability insurance costs) here in the US vs other western countries, which is playing into the costs of these new-to-market drugs. In 10 years or so, when there's an established history of non-issues with the drugs, premiums will be lower for the companies. Plus these initial versions will begin to lose patent protection and generics will flood the market.

Personally I'd rather have a system where these kinds of innovations are made and where they eventually become widely available than a system where govt or others forcefully take or force-price an innovation, thus harming future innovations.


>Why not do away with patents and IP altogether if the standard is that as soon as someone makes something needed it can be stolen?

laughs in anarchist don’t threaten me with a good time!

We also need to differentiate “theft” (actually taking a tangible thing) from “ripping off” (stealing an idea and making that thing yourself).

Theft is bad (depending in who you steal from and why), ripping off is only bad if you believe current economic models/practices are good. But

I’m only talking about conceptually since this doesn’t account for the consumer’s safety. In practice one downside to unregulated markets is they get exploited by bad actors for profit by making inferior products that harm consumers, unlike regulated markets that get exploited by bad actors for profit through regulatory capture.


Why not make an exception for life-saving patents/inventions?

The irony that, were it not priced outrageously, it could save the health care industry billions as these people with obesity will otherwise require epesneive treatments if the remain obese.


There are already exceptions for technical products that must be licensed on fair, reasonable, and non-discriminatory terms. (RAND or FRAND. See: https://en.wikipedia.org/wiki/Reasonable_and_non-discriminat... )

Why not carve out a new exception for breakthrough drugs that have the potential to add X% to the GDP or save X lives/annum?


> it could save the health care industry billions as these people with obesity will otherwise require epesneive treatments if the remain obese.

"Could" is doing a lot of work there. We don't really know what to expect for these patients 20 or 40 years out.

Long-term outcomes and population-scale polypharmacy risks are not really clear, and won't be for decades.

These drugs enable a valuable intervention for individuals at high risk of health hazards and it's fantastic that they're available, but the perspective changes when you look at outcomes for tens (hundreds?) of millions of people over long spans of time -- there are a lot of inescapable unknowns. One can't actually be sure that the benefits of fast, widespread use will outpace the costs, or at what scale.

Many genuinely effective drugs have gone through exactly this kind of hype cycle only to lead to regret, embarassment, and/or skepticism later on.

Good science, and the good public policy that's informed by it, moves slowly.


Liraglutide has been in wide use for 14 years and trialled for a decade before that; we do have a good idea of what to expect for patients 20 years out.

Semaglutide was approved in 2017 and been very widely used (>9 million people). That's been wide & long enough to determine that risks are either exceedingly rare or significantly slow acting.

OTOH the risks and costs of obesity are massive and well known. We're weighing massive known benefits against risks that are either rare (likely less than 1 in a million) or take decades to manifest.


Exactly. I’m old enough to remember the Fen-Phen fallout.

A truly harmless weight-loss drug is the white whale of the pharmaceutical (assuming it can be profitable enough to offset the losses that would go along with the decrease in needed treatment for problems ancillary to obesity). These drugs, so far, seem pretty good but some of the side effects should take the shine off for people who thing this is ”The Cure” for obesity.


check out the DES babies (0) or Thalidomide if you want to see how little we understand long term effects...My mom was a nanny and one of the girls she raised was born sterile due to DES her mom was given _to support pregnancy_ !

0) https://en.wikipedia.org/wiki/Birth_defects_of_diethylstilbe...

1) https://en.wikipedia.org/wiki/Thalidomide_scandal


If it can actually save the health care so many billions, you'd think it was worth paying high prices for it.


> Why not make an exception for life-saving patents/inventions?

This ain’t it though.


It's possible to believe that the best system of laws to operate in contains concepts like patents and intellectual property, and that the best thing for you to do individually is to take advantage of poor enforcement. This probably matches the attitudes of most people here about Piracy for example.


I'm in favour of doing away with patents entirely. Or maybe make them 3 years and not 20.


And what about the second order effect of nobody wanting to do billions of dollars worth of research and trials for the slim possibility of hitting a safe and effective drug, only to have exclusivity for 3 years?


The USA should nationalize the health care industry and all the pharmaceutical companies. Illness should not be a source of profit.


> The USA should nationalize the health care industry and all the pharmaceutical companies.

Novo Nordisk is a Danish company. Read that again: it is European.


Nationalized healthcare doesn’t stop at a pharmaceutical manufacturer’s borders. You think NHS or any other country with socialized medicine pays what the US does? With socialized healthcare the pharmaceutical companies pay what the nation dictates or it doesn’t do business with that nation. I highly doubt Novo Nordisk would write off the US if it went to Medicare for all.


Not really sure what that has to do with anything. It would be easy for the USA to keep Novo Nordisk from doing business within its borders and have a nationalized pharmaceutical company produce the drugs at cost.


I recall when we hiked to to Canada to get the same drugs at a fraction of the price.

No need to pirate, just kick in gear the Great White express.


Dallas Buyers Club needs to go north


I think there should be more competition, and one source of competition should be public health care and maybe publicly subsidized medical supply corporations or nonprofits. I don't know that nationalizing existing private companies is really necessary.


Going to leave a link here to a reddit thread I ran across recently for the curious.

https://old.reddit.com/r/unitedkingdom/comments/1cn8dy8/what...

Look at how many times NHS is referenced and how it is viewed by those utilizing the system. In my opinion, socialized medicine tends to fail as the overall demand for healthcare will usually exceed the available supply in most societies.

I'm sure there are counterexamples to be provided; however, I think the benefits of a capitalist healthcare system are underappreciated.


Your point is “we have too many sick people, let some of them die so the rich can keep their ease of access” and it’s gross.

That’s what “demand” represents in this equation. Not people who want faster cars or different colored Stanley cups, but access to life saving drugs and treatment. I’m not saying para-socialized systems are better (it’s capitalism with a wig) but the “benefits” of capitalism are nowhere near equally shared and in fact highly concentrated at the top. The benefits are in fact over-appreciated by those who have them and they will do anything to keep the dirt people away from their stash.

I don’t have a solution, but my point is praising mass death for the squalid masses is tacky and I personally wouldn’t do it on public forums.

*edited for spelling error


I am a physician, and I am also entitled to my own opinions. You can take a moral highground if your want. But, I feel I know more about healthcare than most people on this public forum. I tend to deal in practicality.

And where do you see me praising mass death?

Further edit: I would go far enough to say you lack any understanding of our current healthcare system besides meaningless feelings on how it should be in a utopian society. Resources are not limitless. There is a continual shortage of healthcare providers which there are no good solutions for currently. If you don't want to address this reality, there is really nothing to address at all.


A good start to fixing the shortage of healthcare providers would be to permit more medical schools, allow more students in per year, and reduce the cost of an MD. Because medical school costs so much, more and more graduates are going into specialties because they won't make enough to cover their loans and live comfortably as a family doctor or general practitioner.


> I think the benefits of a capitalist healthcare system are underappreciated

What benefits? The benefit of mortgaging your home to pay for cancer treatment? The benefit of having your access to healthcare directly tied to your employment (especially considering that many wage workers are kept from working more than 35 hours a week lest they become eligible for employee sponsored health plans)? The benefit of having folks like Martin Shkreli corner the market on generic drugs and raise the prices, not because manufacturing costs have risen but because they are seeking windfall profits?

Seriously, what benefits? We have this silly notion that capitalism provides us with choice, and that this choice is a desirable good in itself. Choice is overrated. Health care is a commodity. You walk into any doctor with a broken arm, diabetes, COVID, pneumonia, depression, or any one of hundreds of other maladies, and the treatment for those will be the same regardless of the physician or the hospital or the clinic.


It's not just choice but access. The access to see a specialist without waiting months. The access to see a different provider if you don't like your care. The access to pay cash for services. Choice is also underrated.

Those same people you say can't afford healthcare are the ones that are heavily subsidized by others through ACA, free community health plans, or Medicaid.

Healthcare is not a commodity despite your claim. It requires labor.

It seems most people are generally satisfied with their health insurance in the USA as opposed to the UK (see links below). In fact, the satisfaction from employer provided healthcare was much higher pre-ACA than it is currently. The middle class got shafted with increased premiums and deductibles to help subsidize those with low income. This has led to lower healthcare utilization rates in the middle class. The rich don't care since it's a marginal cost relative to their income/wealth. And, the biggest spenders (elderly) don't care since they are mostly on Medicare.

Most of the countries that report high satisfaction with their socialized medicine are both rich and have a low population count.

---

https://www.kff.org/private-insurance/poll-finding/kff-surve... Most insured adults (81%) give their health insurance an overall rating of “excellent” or “good,” though ratings vary based on health status.

https://www.nuffieldtrust.org.uk/news-item/public-satisfacti... Overall public satisfaction with how the NHS runs now stands at 24%


> Illness should not be a source of profit.

Exactly.

Let's take this further. Nobody should be making money off other people's suffering.

So.

Let's also zero out doctor's and nurse's salaries.

Hospital administrator's salaries.

This would also apply to all charities that try to alleviate any suffering. No administrator should make any money off other people's suffering.

The only profitable enterprise should be showing ads!


This is a very disingenuous argument. There's a huge difference between a doctor making $300k a year and a relatively small amount of people making millions (or billions) selling easily mass produced chemicals at prices that can't be afforded out-of-pocket. And you know this, but you think you're being clever. It's not clever.


This is a very disingenuous argument.

These same people are the ones who formulated a chemical that works, proved that it works, proved that it is safe. That same chemical improves the health of the population saving billions in costs and quality adjusted life years. So just describing it as just a manufacturing cost is disingenuous.

And you know this, but you think you're being clever. It's not clever.


Like education, government involvement only causes prices to go up. Why wouldn't they? The government has unlimited money. The education and healthcare industry beats the government like a money pinata.

Why would you suggest more government to a government created problem? Usually because people don't realize the government as the root cause in the first place. Get the government out, let people actually pay for their own health care, so they actually 'care' what they're paying. Use insurance for the exceptions cases. And social programs for the people who really can't afford it.

Capitalism actually works if you let it.


> Capitalism actually works if you let it.

Right. This is why drugs like BPC-157, mentioned above, go for $25/month. There's a lot of competition on the gray market, and often the only way for vendors to differentiate themselves from the pack is on pricing, so drugs rarely if ever sell for more than double their manufacturing cost.

In the world of legitimate patented pharmaceuticals, the manufacturing cost is not even a consideration. It is often -- as it is here -- less than a single percentage point of the sale price.


> government involvement only causes prices to go up

This is so hilariously wrong I'm not even going to address it.


Give me a break. Inflation, housing, healthcare, education, I can go on and on. You have no argument.

You either pay for things up front with taxes, or you pay for them later by way of inflation. There's no free lunch.

The government has chosen inflation. Really at this point they'd save money by shutting down the IRS, dismantling the entire tax system and just pay for things by printing what they need. Inflation is the ultimate flat tax.


> Capitalism actually works if you let it.

This argument is always that if the government would just step out of the way the private market would provide for everyone and there would be full employment. As though somehow things like minimum wages and OSHA are what keep capitalism from reaching its full potential. As though things were better in the 19th century.

I've read Friedman and Hayek. The world they wanted is a terrifying world indeed.


Nothing wrong with minimum wage and OSHA. When the government creates a level playing field, capitalism can flourish.

When companies stop competing with each other, and start trying to suck as much money out of the government that they can - that's when things fall apart.


No thanks, I'd rather not permanently destroy a productive and innovative industry with communist schemes.


Isn’t obesity responsible for massive healthcare costs? What about quality of life?


If you feel guilty encountering the pleasures of vice, then I am less likely to be expected to produce sons&daughters destined to become diabetes clinicians instead of astronauts.

Wrath brings Heart Disease.

Sloth causes osteoporosis.

Polygamy risks the manifestation of a malformed body&mind when your random scattered offspring begin dating each other years after your death (centuries before Birth Control "cured" pregnancy).

Sullen faces, hunched posture, double chins, pot bellies - evidence of a derailed populace convinced to open the floodgates of desire. Your curse is a Cattle Car Healthcare System.

Eat less, do more. Pain is Weakness Leaving the Body.

Lest the Fast Track sequesters even more useful talent.

The clergy knew this, but you would rather overrule judgement with surgeries and pills (clean-up crew salary&options).

Morality is about someone else's tomorrow, because you will not be abandoned (despite your folly). Citizen Upkeep described in the form of iambic pentameter and parable.


The Government could manufacture the drug itself under 28 USC 1498.[1] "Reasonable and entire compensation" to the patent holder is required, but previous cases indicate that does not authorize a huge markup.

The last time using 28 USC 1498 was proposed in the pharma sector, it involved ciprofloxin. The pharma industry panicked. Suddenly, ciprofloxin became much cheaper.

[1] https://www.law.cornell.edu/uscode/text/28/1498


This is silly because it doesn't take into consideration all the health issues that are alleviated when people stop overeating and get down to a normal weight


Which ones weren’t accounted for in the CBO report, which tried to take into consideration other health issues (from a financial perspective at least)?

It states that “at their current prices, [anti-obesity medicines] would cost the federal government more than it would save from reducing other health care spending—which would lead to an overall increase in the deficit over the next 10 years”


I know 10 years is the standard CBO timeframe but are we sure it's the correct one for a drug like this?

If you gave a vaccine 100% effective against cancer to 18 year olds it would probably look like a money loser on a 10 year timeframe but that's clearly not the window to measure.


> It states that “at their current prices, [anti-obesity medicines] would cost the federal government more than it would save from reducing other health care spending—which would lead to an overall increase in the deficit over the next 10 years”

… and that reason is because obese people have lower lifetime medical cost. Anything that reduces obesity will tend to increase long-term healthcare spending, because it’s cheaper to die of congestive heart failure at 50 than to live to 80 and incur a couple hip replacements and a bunch of expensive end-of-life care.

(technically it varies by country, depending on their particular allocation of end-of-life spending vs earlier care, but generally the expected cost of a 1-unit BMI reduction is more likely to be neutral or positive than an overall total reduction. And the US is even worse since we weight spending enormously heavily towards senior care due to Medicare - someone dying at 40 is a very cheap outcome for our system.)

> A one-unit decrease in BMI showed gains in life expectancy ranging from 0.65 to 0.68 year and changes in total health care costs varying from -€1563 to +€4832.

https://pubmed.ncbi.nlm.nih.gov/37222003/

Skinny people have been absolute bastards about the whole thing from the start, they don’t want to lose the ability to look down on and belittle a class of sub-humans, they want to smirk and tell people to eat less and work out more, and losing that underclass will hurt their own perceived social standing. So now that there’s a drug that helps people eat less, it needs to be argued against strenuously lest that eventuality come to pass.

That’s why you’re seeing the moralizing and “they should lose weight without medical assistance!!!” come out instantly yet again. It was never about actually wanting them to lose weight per se, it was about the ability to moralize to an underclass who that group argues deserves their status - the whole “my assholery is an incentive to lose some weight!” school of thought that is so prominent.

Semaglutide and the class of drug is overall extremely well-studied, well-tolerated, and effective at treating several different families of chronic medical problems around the reward system of the brain. And that’s frankly terrifying to a large group of people who are low-key bigots and are facing the loss of their favorite punching bag. Like what if there was a drug that you just took it and 90% of people lost significant amounts of weight? That’s terrifying to a group of people who without a subclass to look down on will now move down a rung on the social ladder themselves.

The black mirror with the exercise bikes nailed it. People want to toss soda cans at fatties forced to work menial subclass jobs and tell them to lose some fucking weight, that’s what it’s always been about in this discourse from the start. They just can’t quite get away with physical assault in our reality, but they’ll certainly endorse emotional abuse and unequal treatment, “for their own good” etc.

It’s just a shame that this sentiment has also hindered the ability to look into endocrine disruption or gut microbiome etc. There are lots of interesting things that skinnies were too emotionally vulnerable to allow research into, that have just been vaulted over by semaglutide.


Interesting, thank you for linking to that study and providing the quote! I agree that the "losing weight naturally" thing is ridiculous. Medication for mental health gets some of the same rhetoric ("nobody needs drugs, they should just go outside and exercise!"), but really it's all the same as stigmatizing toothpaste and then blaming people for getting cavities imo.


It explicitly does, as is noted in the article.


> If Novo Nordisk set its US prices for Wegovy to match the Danish price, spending to treat half of US adults with obesity would drop from $411 billion to $94.5 billion, a roughly $316.5 billion savings.

The solution to the drug price crisis is for the US to stop subsidizing the rest of the developed world.

The US should set a rule saying that it will not pay more than the price the drug company charges to any developed country.


My hot take on these GLP-1 drugs is that they won't work long term for most people. If the plan is to give the drug to as many obese people as possible and take a victory lap, thats going to fail.

I don't think its resonable for most people to continue taking GLP-1 antagonists all their lives. Its been widely shown that most people rapdily gain back ~2/3 of their weight after stopping semaglutide. This means that the people who lost weight did not build sustainable weight management habits during their time on these drugs.

IMHO a better solution would be to design individualized weight loss programs which would help people build sustainable healthy eating habits, and change their relationship to food while using GLP-1 as a tool to help the process and motivate people. I understand that is much easier said than done, especially at such a large scale.

Maybe the answer lies in a combination of various actions, some ideas include,

- Medicare and Medicaid negotiating to reduce the cost

- Possibly offering lower/higher dosages based on needs to better manage cost

- Offering incentives/discounts when GLP-1 is used in-combination with health coaching.

- Offering GLP-1 drugs with lifetime maximums similar to Orthodontic procedures such as braces or clear aligners, with some exceptions based on medical needs.

- Reduce food deserts, especially in rural and low income areas.

- Penalize companies which sell seriously addictive / unhealthy foods. We did that with Cigarettes! Unhealthy diets filled with addictive sugary processed foods cause similar harm to families, society, and future generations.


> I don't think its resonable for people to continue taking GLP-1 antagonists all their lives.

Why not? People take statins or beta blockers for the rest of their lives. Sure it's not that feasible at current US prices but they won't be that expensive forever.


> I don't think its resonable for people to continue taking GLP-1 antagonists all their lives.

But why? Plenty of chronic conditions require chronic medication (e.g. insulin).


While I 100% agree that GLP-1 antagonists won’t lead most to making actual changes to their behaviors with food outside of forcing them to not over-eat when actively taking the drug, I am not so sure about your hot take here.

A woman I know has been on this stuff for a couple years now and while she has plateaued for about 6 months, her current weight is now in a healthier spot.

It’s crazy what losing some weight can do to people’s mental health too. Like her home is more organized, she’s more active with walking (doesn’t hurt anymore), she just overall describes not fearing food anymore.

And now for the bad news, her insurance no longer covers it. It’s kind of insane but apparently this stuff has a black market, like she buys it from one of her coworkers like it’s some sort of street drug.

In summary I think we need more time to see but from what I’ve heard this does seem to be a long-term solution similar to insulin shots if you had to compare to something existing.


I agree that obesity can be a chronic condition for many people, especially when combined with societal pressures causing mental harm.

> And now for the bad news, her insurance no longer covers it.

This is one of the reasons why I think these GLP-1 drugs are going to be classified by insurance as a temporary tool to help people improve their health. Rather than a long term medical necessity like insulin.

> I think we need more time to see

I agree with this statement, we definitely need more time. We don't fully understand the long term effects of GLP-1 in large populations.

I'm in the camp of, if its possible to use GLP-1 as a ramp to building sustainable habits and then wean off the drug, then as many people as possible should be weaned off.


There is also a nexus with the reward system of the brain in general, and semaglutide definitely seems to have effects similar to ADHD medication in these respects. It also seems to help alcoholism for the same reasons - it helps reduce the underlying dysregulation in the reward system that keeps people in that loop.

Probably this will be the next patent-ever greening strategy pursued after the weight loss thing.

It’s an absolutely wild drug in medical terms. “The white whale” is an understatement here. It literally is a white whale for multiple whole fields of medical science.


Speaking of the effect in the brain, a rare but real side effect in many people is anxiety to the point where they have to discontinue the med. I wonder why.


The healthcare system in the USA is designed to make the people bankrupt first due to medical debt


The savings in reduced diabetes, heart disease and cancer would make up for it.




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