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.
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?
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.
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.
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).
> 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'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...
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.
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)
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.
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.
Once drugs are not protected by patents, competition should reduce prices. Unless competition is not working because of price fixing or something else related.
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.
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").
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.
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.
...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.
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 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.
> 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.
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.
> 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.
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.
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.
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.
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.
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.
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.
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.
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.
> 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.
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.
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.
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.
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.
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.
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.
"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.
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.
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.
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.
> 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.
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".
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 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.
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.
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".
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.
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.
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.
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.
> 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.
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.
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.
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.
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.
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.
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.
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.
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].
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.
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).
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 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.
"Big Pharma" isn't really the issue here. I mean, it is, but going around "Big Pharma" is a high hurdle to jump over, if you can jump it, and it isn't such an issue in other countries - which leads me to think this is a regulation problem.
First things first, though, simply "bypassing the big pharma" means you need to jump through regulartory hurdles. You need to produce insulin in a manner that won't kill folks, test the finished product for strength, and get it to the patients safely without the product spoiling. You'll need to invest in logistics. To get it to the final patients, you'll either need to hire pharmacists and support and send insulin directly to the patient, making sure you keep records as the FDA requires. Or you'll need to make sure that you can supply pharmacies with your products. This will often be shipping your product to warehouses.
The second one is more difficult to control costs, but the first option - direct to consumer - means you hire more folks yourself and have more risk.
None of this stuff means your insulin will be used instead of the more expensive ones. This is likely especially true if you are using an older version of the drug - though I doubt one would bypass using bacteria to produce and use animals instead.
And then, after all this investment, why in the world would you, the new insulin maker, charge a reasonable amount for your drug when your competitors are charging outrageous prices?
But again, this isn't the issue. Really. From the article:
" The three pharmaceutical companies that manufacture insulin—Lilly, Novo Nordisk, and Sanofi—rake in billions in profits annually from insulin sales alone, with the U.S. market accounting for 15 percent of global insulin users but almost 50 percent of its worldwide revenues. Insulin ranks among each company’s top-selling drugs; one BMJ study showed that prices could be slashed considerably and the drugs would still be profitable."
US patients are paying a lot more for the drug. This is, in part, because of the fragmented health care system and I'm guessing it is, in part, regulation. In a small way, it might be patents, but at one time, folks were shy to enter the market since there wasn't as much being made. Seriously, this calls for a legislative fix instead of "bypassing the big pharma". Sure, they raised their prices but only because the legislative environment allows it to do such things.
It isn't just in the US, by the way, as folks in some parts of Africa pay more for basic, not-as-effective medicines, but it seems to affect the average HN reader more. And it isn't like this is something special to "Big Pharma" either - other countries gouge folks on any number of things and take advantage of folks.
The article and title start with a false premise. The insulin made free 100 years ago is very different than the insulin you get today. It’s faster acting, etc. nothing is stopping someone from manufacturing the circa 1992 version (or even the very good versions developed in the 1990s). But so long as doctors prescribe, and insurance companies are willing to pay for, the newer stuff, there is little market for the older versions.
Ironically, the heavy subsidization of health insurance is what’s actually causing the problem. When there is no reason to control costs (especially under the ACA, where insurance companies cannot increase profits by doing so), there is a huge incentive to keep pumping out marginally better versions of a drug, because you’re not competing on price with the old, out of patent versions.
The state, not private interests, should spearhead production and research of pharmaceuticals, it should be part of basic developed-country infrastructure, like transportation and education.
* at every stage third parties (public, private, or both) bidding on time boxed rights to license drug and carry drug thru remaining stages;
* licensee paying royalties.
Earlier involvement in the most promising drugs is incentivized by allowing third parties to license earlier, taking on more of the risk, getting a better deal.
Orphaned drugs can still get some love by do gooders. In fact, government can pay (subsidize) third parties when there's no profit.
I'm a total noob, and have zero idea if this worldview has any merit.
Also, prohibit advertising and all forms of payola.
We sort of have this system, but in reverse. You're suggesting to default to government, and we currently have a default-to-private system. The US government funds basic research, basic development, and clinical trials for projects it deems important enough that will not see adoption by corporations due to a lack of profit.
One example of this is ebola vaccines. If I remember correctly, the incidence of ebola is incredibly (even internationally) low, but there is a public health justification for keeping a working vaccine available. The government, mostly through NIH, will sponsor the development of these kinds of projects.
This also happens sometimes with orphan diseases. The government funds more research further up the chain until it's enticing to private companies.
Im not so sure about that, people who finished college or high school in my country are in minority. Im sure this is also the case in most modern countries. I also think that considering voting as a valid way to influence politicians in an age of corpo-corruption is pretty silly. Sure you can pick politicians but if there are like 4 major parties which all sellout to highest bidder, voting is pretty pointless because result is always the same. Creating new parties is out of question because you need vast amounts of funds to accomplish it.
This is a unnecessorily long article where the central message gets lost. My understanding is that there were two major insulin manufacturers and in past, they competed which kept prices down. Then suddenly they realized that if they stop wasting their resources in competing and instead cooperate then they can get arbitrarily high profits. With this internal understanding, one would raise the price and soon other would match that high price. They did this over and over to their great surprise that customers are just eating up the higher cost. This was the much better and shorter path to huge profits!
I have a general theory that in any two-party system where rewards are potentially unlimited and at the expense of someone else, the parties would sooner or later learn that its better to cooperate instead of competing. We have seen this movie in cable industry, cell phone industry and so on. I expect this to happen also in political parties in US, UK and elsewhere. In those scenarios, parties will soon learn that if they cooperate then they can acquire unlimited power, funds and control at the expense of resources (i.e. people) and divide these spoils between themselves which will be much higher than if they tried to compete with each other.
"the Toronto team sold their patent rights to the university for $1 apiece in an effort to protect its integrity from greedy commercial enterprises"
"Eventually, Banting and his team reluctantly agreed: Lilly was granted exclusive rights to manufacture and distribute insulin in the United States for one year"
This makes no sense to me! If they were not interested in making money, as to donate their patent rights, why not letting it be public? Why selling it to a university? Then why get shocked that an academic organization does a poor job on scaling up production and on other non-academic related things? Oh, and the cherry on top, why did it have to be manufacturing exclusive rights?!
We need to hold these people accountable for their actions. Life sentences or if necessary capitol punishment sentences for the players and actors who are responsible for hiking up prices on drugs for no better reason than increased profit margins, enough is enough. It doesn't matter if its diabetes, ms or cancer if the the drugs aren't affordable then the people producing the medication should immediately be taken to court and if found guilty of price gouging should be punished accordingly.
As long as future citizens can hold people like you equally culpable for the predictable result, sure.
Here is my prediction; no one enters/stays in the high risk drug market because whack jobs want them dead for getting a return on R&D.
In fact, I would take this one step further. You my dear comrade, since you don't work in the field trying to invent drugs and lower drug prices, are obviously part of the problem. Since you rent your labor elsewhere for your own benefit you artificially distort the market and keep prices high.
Since you seem to believe capital punishment is an appropriate sentence, I only ask that you put a little skin in the game and mark your beliefs to market.
The high risk drug market? What are you talking about there's nothing high risk about the drug market. Their profit margins are enormous, absolutely gigantic. If you are under the impression that the people setting drug prices are good people trying to make an honest living then you are very, very confused.
The industry is thick and rife with corruption and greed. Their paying off politicians and doctors left and right. Have you any idea the kind of people your defending? Go discover a cure for cancer tomorrow, you will be dead by Monday. They will pay to have you killed, that's the kind of people your defending.
Skin in the game? Anyone who is dependent upon drugs to live already has skin in the game, I already have skin in the game. If they so choose any one of us who is depend on these drugs to live could be dead within the year, how's that for skin in the game?
Lots of comments focused on having a good paying job with comprehensive benefits (insurance). I don’t think that is even the solution here. The main problem is that lifesaving medications have prices spiralling out of control to the point where it becomes unaffordable for people to get it.
Not everyone will be lucky or capable enough to have a job that will allow them access to the medicines they need through some benefits or financial salary.
Will regulations work such that medicines categorized as lifesaving will be capped at a price that is affordable for people? Or is a solution based on ensuring patents are used not as a leverage to gouge prices but to protect the intellectual property and not financial commodity?
Solutions abound but when the greed of a few is being upheld, then it just becomes a reality that people becomes the bearer of bad news and in turn have to swallow the bitter pill of unaffordable medicines.
I think there is a very good argument to be made for nationalizing drug production in the USA, at least for generics. The idea that private companies have the power to gouge people just for the privilege of staying alive, in the name of profit, is reprehensible.
I dont understand why there aren't more generic competitors. If 20 years ago companies were profitable selling at a much lower price, surely a new biotech company could do the same now?
We're all looking for startup ideas with subscription models, this looks obvious.
As European and T1 diabetic - my monthly insulin dose is covered l in the poorest European country - Bulgaria. Even if I need to pay it it is still way much afordable - around 130 dollars.
Looks there are many troubles over the ocean...
One more thing - I get quality insulin that is latest tech and improves my life much. Much better products than I was getting for example 15 years ago and probably the same or better than than my fellow Americans are getting for there.
But I bet the corruption is so high that if I want to import the same products from Europe there will be a law against it.
If nobody has yet started one, sounds like an opportunity for patient-owned collectives to manufacture and distribute off-patent drugs for chronic diseases.
I'm thinking similarly to what was done for medical marijuana, but with more a credit union-type feel.
So long as legislation clears the hurdles to such organizations, it wouldn't cost taxpayers, and seems more in-line with the spirit of patent expiration.
For what it's worth, there seems to be a silver lining for some diabetics today, separate from the issue of insulin pricing -- the technology available now for continuous glucose monitoring, that takes a lot of dangerous guesswork out of day to day living.
It is another ongoing cost, but, it seems, not quite as devastating as what is going on with insulin.
That explanation of the economics and poor regulatory choices that led to all this certainly makes a lot more sense than the explanation in the other aricle. Unfortuntely, it's also less condusive to thinking that it's all the fault of mass-murdering villains running pharma companies who should be harassed for every second of their lives, and that anyone who even thinks this is worth discussing wants people to die. So I guess it's not surprising those comments are up top and this is languishing near the bottom.
They exist (most insulin produced today is rDNA biologics), and are about $25 at Walmart. Of course, the same thing at CVS or Walgreens is $100+. I know b/c I switched back to using them after needing to travel internationally for more than 1 month at a time... my expenses went from $2500+/mo to under $200/mo, including the extra testing supplies required to support this regiment. At the same time, I take up to 7 shots a day and am definitely now a "Medical Tourist". Yes, I can go to Europe or Canada and buy supplies (at retail cost) for less than the US, including travel. But - that's actually MORE FREEDOM for me. YMMV.
If we didn't let the rich get richer, would they then figure out other ways to enslave the poor and make their lives ever more miserable? It seems humans have a built in need for win-lose scenarios (schadenfreude?) and winning races by ever increasing margins. Cant we make a logarithmic scale for money so that 10x more money is only double the buying power?
Patent ownership does nothing to encourage innovation. Most of the innovations are based on prior research, and most are done in publicly funded labs that would do the research regardless of the profit motive. Allow full competition to work or you end up with a corrupt version of capitalism.
Why is there no exact pricing regulation for such widely needed drugs?
Capitalistic models don't work for everything, it certainly does not benefit this type of drug in an oligopoly... there is no competition and there is no need for it, the research is ancient history. Price fixing is not the problem, it's an inevitability, which is why the government should do it for them:
1. Regulate exact price, zero flexibility.
2. Require production of specific drugs as requirement for access to _any_ government research grants. Alternately to avoid production issues entirely: production is simply the cost of _being_ a pharmaceutical company selling any drugs to your country.
3. Meet demands through responsibility proportional to net profit. Make more money? great, but it has to benefit availability of basic drugs.
I must say, the lack of ... rage ... on this article surprising.
I would expect there to be a leaked list of names of the executives responsible for this, with pictures and home addresses. I would expect people protesting in front of their homes 24 hours per day. And covering their cars with rotten eggs when they went out.
That's the kind of thing that would have happened in France.
From what I understand, the US culture is one in which it is generally considered the fault of someone for being unable to pay for their own healthcare and living circumstances. Because there is the sentiment that it is possible to not be oppressed through one's personal power, cleverness, and considerate behavior, the people who claim to be oppressed are actually lazy, stupid, and inconsiderate.
You can see this whenever someone claims that they individually were able to climb out of poverty but know other people who, through their own stupidity or ignorance or bad luck, were not able to- and therefore less sympathy should be garnered to the whole of impoverished americans as there exists a subset that is comfortable leeching off the extremely poor social safety net that exists.
In short, a poor person egging a rich person's car would be seen as an aggressive, unprovoked action on the poor person, and the poor person should focus their efforts on being less poor instead. That the egger is focusing instead on protesting is an evidence of their screwed up priorities.
> From what I understand, the US culture is one in which it is generally considered the fault of someone for being unable to pay for their own healthcare and living circumstances. Because there is the sentiment that it is possible to not be oppressed through one's personal power, cleverness, and considerate behavior, the people who claim to be oppressed are actually lazy, stupid, and inconsiderate.
That is not "US culture". Those are the beliefs of an unfortunately sizeable minority. Even then, it is generally only directed at "the other" and is really veiled racism. Do not take the rhetoric of certain political factions at face value or as a representation of "US culture".
I agree it's probably a minority who would put it in such harsh terms as the comment you're responding to, but the underlying sentiment is more a part of American culture than many other places.
For instance, the values of meritocracy and self-determination are deeply ingrained in the US mythos, beginning from "All men are created equal" and "the pursuit of happiness" in the declaration of independence.
Since moving to Europe, the difference in the concept of individual credit/responsibility is one of the largest cultural differences I have felt.
indeed there are the stories of people who have managed to raise themselves from poverty and gone on to be CEO, and it is possible if all the dominoes line up, there will always be the exception where this occurs, in general the odds are not in your favour. I can't help but think if the line from the hunger games - may the odds be ever in your favor.
This is absolutely the story of the American ideal. We're a nation of Horatio Algers -- the quintessential "rags to riches" story.
Poverty, in the US, is a personal shame, not a systemic failure. The successful end result of centuries of propagandizing in favor of the Individual, and against organizing. We're a fractured people, to our detriment.
Exactly. Capitalist societies take what was considered a public good, and attempt to forcefully privatize it to every individual. And then, when the individual is bad at doing it because of institutional forces against them, they are blamed individually for the failing.
> You can see this whenever someone claims that they individually were able to climb out of poverty
Oh yes. Horatio Alger (0) stories are commonplace within capitalist societies. It's one of the bedtime stories we tell each other, that with enough hard work, and some luck, you will succeed... Except for that mound of people whom worked till they died. We'll just ignore them. They were, uhh, lazy, and didn't deserve to live with the fruits of their labor.
> ...but know other people who, through their own stupidity or ignorance or bad luck, were not able to- and therefore less sympathy should be garnered to the whole of impoverished americans
Yep. Nailed it. Because there's a person who with combination of hard work, community/friendship networks, and luck, was able to climb out. So everybody who isn't, is just lazy and dumb and doesn't deserve to be helped.
> as there exists a subset that is comfortable leeching off the extremely poor social safety net that exists.
I'd also argue that the very "poor social safety net" doesn't even accomplish helping people. It only maintains a very sad, horrible, brutish life. And given its tremendously regressive practices, also enforces either illegal actions OR keeps people down in poverty.
exactly: "Socialism never took root in America because the poor see themselves not as an exploited proletariat, but as temporarily embarrassed millionaires." - John Steinbeck
The story Radicalized in the recent Cory Doctorow collection of the same name is about a forum on which victims of insurance shenanigans get radicalized. When I read it the biggest surprise to me was that it hasn't happened yet. I've never had any issues with health care or insurance, but can easily imagine the impact it must have on someone.
> I would expect there to be a leaked list of names of the executives responsible for this, with pictures and home addresses. I would expect people protesting in front of their homes 24 hours per day.
That's how you end up with dead people. It's the difference between journalism/civilised discussion and cesspools like twitter/fb threads, we should present facts, not opinions or call for violence.
No matter how fucked up these things are you don't want to lower yourself to their standards, you'll lose all grounds for discussion.
What does "losing all grounds for discussion" mean? Discussion with who? The decision makers responsible? How are we discussing anything with them now? Nobody knows their names, or at least not enough people do. What is the value of discussion with them anyway? Are we going to talk them out of being absolute bottom-feeding assholes?
To be clear I am not advocating vigilante mobs of any sort. I would like to see these people's homes with protesters in front though.
I think we agree on the goal, not on the methods. It took decades for these companies to become what they are. If you listen to some people you should just burn them to the ground and go personal vendetta mod on their executives.
What I'm saying is that we should be careful about how we do it, because in fine the "how" is as import as the "why". Things don't happen in a vacuum, you have to deconstruct them and get to the root causes, otherwise you're just rushing to another failed system. Let's say you manage to get the execs out, what do you think will happen ? The new ones will turn everything 180 degrees and sell drugs at loss ? No, why ? Because the whole system is tweaked for profit.
Every time health pops up on HN, the majority of Americans defend their system and criticise the European way. There is a bit of a cognitive dissonance here, people can't expect a private/for profit company to do the right thing when it comes to public health. On top of that the demographic of people who voted Trump very much intersects with the one needing cheap health care, it clearly indicates that people are voting against their own interests in term of health, that alone would hint that there is a much bigger thing going on than "greedy execs control everything".
I think there's a lot of room between "we can't know their names lest any of them get inconveniently shamed" and "burn them to the ground".
But yes, I agree with the rest of what you're saying at least partially. Root causes are important, I just think there's a danger of going from that principle to never actually doing anything because we're looking for one more link in the chain and ignoring the assholes right in front of us.
It's the civilized discussion of the past that has created this problem, and you're right, dead people are the result.
The only solution that works every time is for enough of us get angry and voice that anger in concrete ways that shame and vilify those captains of industry (and henchman politicians) who blithely choose to harm other people because there's more profit in it than giving a damn.
Herein lies a big problem I have with the current culture in the US. We celebrate our independence (July 4th is right around the corner) but we do not celebrate the choices that led to it. A person can barely even hint at the cost of such social change without crossing the lines of what society now deems acceptable discourse.
I am having a hard time to see how I can tell people who can no longer afford lifesaving medicine due to profit maximization to value a civil discussion culture higher then their survival. Or differently put to value my principles higher then their survival. And that is the current situation, a decades long discussion about how the right to profit trumps peoples survival. And that situation has a running tab in the form of people dying so that people profiting on that misery and despair are not confronted with the consequences of their actions. All of this not even touching the problem of neutrality in a life or death situation of out powered people. Desmond Tutus mouse and elephant come to mind.
> I am having a hard time to see how I can tell people who can no longer afford lifesaving medicine due to profit maximization to value a civil discussion culture higher then their survival.
Tell them to act in a civilised way and to not vote for Trump who clearly stated his stance on public health.
The individuals might not survive that long. Or might not quietly accepts the situation if the majority votes for Trump regardless. I understand that dying quietly would be less of a hassle but dying on easily preventable causes rarely is friction less.
I would also suggest asking yourself why you view protests outside of peoples houses less civilized then them condemning people to death to make a bigger profit.
If you haven't ever done so, please go and read 'Letter from a Birmingham Jail', by Martin Luther King, Jr. I won't try and quote any relevant sections here, as it is far better to read the whole thing;
Yes, it works where the protest culture is already in place. You can't ask Americans to do the same, someone will inevitably bring a gun and it'll go south very fast, as it happens almost daily in all sort of public demonstrations, peaceful or not, in the US.
There is no points of comparison between the US and France when it comes to protests. LA riots, black panthers, vs may 68 and yellow jackets...
Regarding LA riots, black panthers, vs may 68 and yellow jackets, there's a world (an ocean?) of differences between the reasons which lead to each of the events, with the situation of blacks in America having nothing to do with the situation in France today and the same with the start of the LA riots vs the start of May 68.
>No matter how fucked up these things are you don't want to lower yourself to their standards, you'll lose all grounds for discussion.
This is the classic centrist liberalism argument that we have to maintain civility at all costs.
The time for civility was back when the drug companies were doing things like pushing bad legislation (that didn't directly hurt people) or the like.
The time for civility is over. People are dying because drug companies are too greedy and unregulated. The only way to get them to stop being utter vacuous wastes of oxygen is, in the long term, regulation. But in the short term? Harass the fuck out of them. I have exactly zero sympathy for the pharma execs that are profiteering off human misery.
It looks like you've been using HN primarily for political battle. That's not what the site is for. Worse, it destroys what it is for (curiosity), so we ban accounts that do it. If you'd review https://news.ycombinator.com/newsguidelines.html and use HN as intended, we'd be grateful. There's more explanation here:
I mean it depends on the context, right? I just mean that generally speaking, when there is nothing forcing people to be decent, it is clearly not simply enough for "wow this is morally reprehensible" to be a deterrent.
For profiteering off generic medication, I think some sort of subsidized natural monopoly producing and selling generics would work. Clearly, there isn't enough profit in the generics to make money off them without acting in a malicious anti-competitive manner, so incentivizing it otherwise must be necessary in a market system.
Alternatively, have a purely nationalized "company" that's funded by taxpayers and "sells" generics at cost. I think the value to society of cheap, readily available generics make this worth it even if it's not something that could survive in the market.
I work in biotech/pharma, and not all of us are greedy sacks of shit as some people seem to think. I'm not an exec and cant speak to their ethics broadly, but like any industry where people make big bucks you have greedy asshole-y people here too. But coming back to regulation, the FDA's primary mandate is the safety of the populace, its not to create economic incentives or disincentives. The FDA has been slowly increasing the standard required for compliance, which in turn raises the operational cost to ensure safety/efficacy/reliability/etc (obviously a very good thing IMO) but that in turn has also increased both the incidence and the cost of failure. When one product that sucked up a cool 10-50M of capital fails, the company has to recoup the cost elsewhere. Of course nobody wants to take a haircut themselves, so they just bump up the prices. I think a lot of this has to do with the ways companies in general pretty much have to absorb market risk to give a false sense of stability to their workforce. Maybe if our corporate system were structured where it was OK to fail, people might be less inclined to mask the failure on the balance sheet to please Wall Street.
>Alternatively, have a purely nationalized "company" that's funded by taxpayers and "sells" generics at cost. I think the value to society of cheap, readily available generics make this worth it even if it's not something that could survive in the market.
Well, maybe.. I'll keep an open mind but when has the government done anything cheaply or efficiently? They will have to sub-contract at-least some parts of it out just like they do with weapons or infrastructure or other projects. Government contractors are going to milk the system with their '$100 screwdriver' invoices.
> This is the classic centrist liberalism argument
Is this the step 1 of the identity politics game ? Paint someone as X Y Z and be done ? In what world being civilised is constrained to "classic centrist liberals" ?
All politics is identity politics. Putting "identity" in front of it is a weasel word to deflect, as you've just done.
My point still stands. Remaining civilized at all costs in the face of incivility is as insane as trying to calmly debate someone as they are in the process of murdering you.
"I would expect people protesting in front of their homes 24 hours per day. And covering their cars with rotten eggs when they went out."
Honestly that would be letting them off too easy, they need to be dragged in front of a court and be made to explain their behavior to the loved ones of victims that had died from this. They also need to be sentenced to a few thousand hours of first hand volunteer work that directly deals with people impacted by this. Seeing first hand the cost of their greed might knock some sense in to these people, if that won't I'm not sure what will.
I work for one of the companies mentioned in the article.
I too am troubled by the increasing burden on those unable to pay for their insurance, and feel that something must change, and quickly.
However, I’m shocked when I read articles like this one that manage to miss the crux of the issue so badly (though, to be fair to the author, most articles on the subject make the same mistakes). Perhaps it’s because I work in the industry and have more insight that I take for granted, or perhaps I’m simply blinded by personal biases and I’m the one off base, but the issue driving insulin price increases seems to be obvious: to he insurance system in the US is irredeemably broken. A few facts, considered together, support this:
1. The number of diabetics in the US has skyrocketed in the preceding decades.
2. The list price for insulin has also skyrocketed in the last 20 years
3. The amount of money the main insulin makers are paid per insulin fill is actually down during this time
So you have an increasing demand for a product, combined with an increased price, but less money per unit being made by the parties allegedly jacking up the price for profit. So where is the excess money going? Middlemen.
Insurance companies in the US have enormous leverage over just about every other party involved in healthcare: the patients, the providers, and the pharmaceutical manufacturers. This is even more true for medications like insulin, where there isn’t much difference in efficacy between brands. In a normal market, these companies would try to compete on price. But for insulin, price continues to rise. This is because insurance companies, and their negotiators, Pharmacy Benefit Managers (aka PBMs) have a vested interest in prices rising.
PBMs make their money by negotiating prices with pharma companies to secure discounted prices for insurers, and in doing so, create the insurers’ “formularies”, which are basically the list of all the medications an insurer will cover, the prices they will pay, and the conditions that must be met. PBMs get a cut of the discount they negotiate with the pharma company. If drug A has a list price of $200, and they negotiate it down to $150 for their insurance clients, they take home x% of all the savings that are made at $50 a pop.
This creates a perverse incentive however: a PBM stands to make more from a drug that costs $300 and is negotiated down to $150 than a drug that is $200 that is negotiated down to $150, even if everything else is the same. That means you are more likely to get better insurance coverage for your drug by starting high and giving deep discounts. And for drugs like insulin, where similarities between products are so small that the only place you can compete is price, how well you are covered by insurers compared to your competitors will make or break your business.
Insurance companies themselves also love drugs with high costs that are then discounted deeply, because when they charge a patient coinsurance, it’s based on the list price, and not the price the insurer is paying. So even though they’ve negotiated the price of insulin down by over 50% with the pharma company, they are still going to charge you y% based on the full price. So if they continue to get insulin from manufacturers for $Y per unit every year, they continue to charge you 20% of a cost that continues to rise further and further away from $Y, meaning they are actually paying less and less as prices rise. They will claim to be using the reduced costs to lower premiums, but if reduced costs are only the result of increased costs for the sick, then all we’ve done is create an insurance system where the sick are subsidizing the healthy, which is entirely backwards.
So now we have a system where manufacturers raise prices year after year, only to also give ever increasing discounts to insurance companies and PBMs, in hopes that it actually increases the number of patients who can afford their products (i.e. those with decent insurance). But those left holding the bag are the individuals without insurance or those with high deductible plans (which are becoming increasingly common).
It’s also important to note exactly how much power these middlemen have. It’s a common narrative that Big Pharma is able to get away with bad practices because of their power. But in reality, only a single pharmaceutical company is in the Fortune 50, and none of the insulin makers are. In contrast, 80% of the PBM market is controlled by 3 companies, 2 of which are Fortune 50, and the third is a subsidiary of United Health, which is an insurer and is also Fortune 50. In fact, 10 of the Fortune 50 companies are middlemen (insurers, PBMs, or drug distributors) in the healthcare industry.
Again, maybe my view of the issue has been entirely skewed by my personal biases. Also note that this isn’t necessarily the cause of all price gouging in the pharma industry. There are certainly bad actors that are jacking up prices simply because they can. But it seems to me like the true issue at the heart of the insulin pricing problem (the insurance system in the US) is being skipped over to focus on the symptom because the idea of rich pharma companies reaping in profits from price gouging because it is a simpler narrative.
Those poor, poor drug companies, it is not their fault they acted like utter cunts. After all, they were allowed to act like utter cunts, so they just had to. So lets solve this by removing all regulation that stops them from acting like utter cunts in other interesting ways, that couldn't possibly backfire.
>... or make more regulations, fewer people will sell drugs - at a higher price.
Which just doesnt happen in countries with stricter regulated medical markets. Quite the opposite, it happens in the US, thats what this article is about. Its a nice theory but not something that can be observed in reality.
>It only seems uncalled for if you don't believe price gouging on critical drugs to point of financial ruin and death is utterly evil.
It's naive and simplistic to actually believe that the price-gouging isn't far more nuanced than "evil" people sitting in a board room discussing how to screw over poor diabetics. But whatever works for you, I guess.
The system is broken, but at some point, people are sitting in a room deciding exactly that:
"Yes, some people will go bankrupt and some have actually died, but we need to strike while the iron is hot! After all, it's not our fault they can't get health care and we owe it to our shareholders to maximize profits"
It's naive and simplistic to actually believe that evil isn't far more nuanced than people sitting in a board room discussing how to screw over poor diabetics.
As far as I am concerned, the people engaged in price gouging for insulin are essentially committing mass murder for profit. It is so far outside of any kind of moral standard, that I have no problem in categorising it as just straight up evil.
This is not a coherent position. By this logic, every single person who is _not_ making insulin (people like you and me) are also guilty of committing mass murder.
There's clearly something very, very, very broken here, but unwinding the tremendous weight of bureaucracy and regulations that prevent an interested investor in setting up shop making insulin on the cheap is the root of the issue. The regulations need not even be a negative; I don't have a reason to believe that recombinant engineered bacteria produced insulin is really that easy, and the regulations may be all that's keeping a tide of ineffective or harmful varieties of insulin from flooding the market.
“This is not a coherent position. By this logic, every single person who is _not_ making insulin (people like you and me) are also guilty of committing mass murder.”
This is ridiculous. Pharma companies, unlike you and me, have the ability/equipment/expertise to manufacture insulin. Many people need insulin to survive. These companies could make insulin for relatively cheap and still be massively profitable, but they choose not to, and people suffer because many people who need insulin can’t afford the artificially high prices.
Acting like this price-gouging is caused by anything other than corporate greed is naive and misleading.
What about the pharma companies that do not produce insulin (like GSK or TEVA). They have all the necessary expertise, ability, and equipment to manufacture insulin. Many people need insulin to survive. These companies could make insulin for relatively cheap and still be massively profitable, but they choose not to, and people suffer because many people who need insulin can't but it from them.
Of course it's corporate greed -- even if they sold insulin for relatively cheap and were massively profitable, they would only bother to produce it because of corporate greed.
No one is talking about the other companies. Here is a hot take: companies which are currently selling insulin are ripping people off. People are suffering as a result.
Whether or not other companies could conceivably produce insulin is irrelevant. The parent commenter and I are talking about the current producers’ shitty behavior. If someone falls out of a tree because I easily could have but chose not to grab them, that is wrong. Other people could have possibly helped and didn’t, but that doesn’t make my shitty behavior any less shitty.
I glad we can agree on the impact of corporate greed, though.
>This is not a coherent position. By this logic, every single person who is _not_ making insulin (people like you and me) are also guilty of committing mass murder.
I don't think that is a particularly coherent position on my position.
The way that I read what you wrote was that "charging too much for insulin is morally equivalent to murder". How much do you charge for insulin? Would they be less culpable if they stopped producing insulin completely? If another company (say GSK or TEVA) has the technical ability to produce insulin, but doesn't, are they murderers?
For many diabetics, insulin is about as vital as water. If I have somehow ended up with an effective monopoly on water, would it be murder to price out all the poor? Would it be murder to stop all access to water? Am I allowed to point to other people and say, well they are not producing water? Or am I morally culpable for my own actions, regardless of the actions of others?
This doesn't make sense. Only an entity out to make a quick one-time score would literally kill their customers or potential customers. If anything, you'd want to bleed your customer for as much as you can, which is closer to what they actually do, e.g. provide 'discount programs' for people with less wealth or income to obtain drugs with high 'sticker prices' for much less.
Remember that, generally, if anyone is paying these high prices, it's insurance companies, not private individuals.
Think of it as the 'Apple' strategy. The most money for the least effort is to have a high markup for the middle class and up while ignoring the bottom of the market entirely. If you release cheaper things for the bottom of the market this gets you much less profit for your spend and also many of your existing customers will opt for the cheaper versions. In medicine this is exacerbated by the fact that you do not have a nice range and market segmentation, you are selling the same product to everyone.
Killing all your customers is clearly a bad market strategy. But I expect that to truly maximize profits, you'd aim to price the drug a little higher than what some patients can possibly pay. Sure, a few people will die as a result, but your higher profit on the others will more than compensate for that lost income. It shouldn't be too hard to set up a nice little model to compute exactly what percentage of patients left to die will pay off most.
Obviously this is awful, gross reasoning. But I think it's pretty solidly what pure economics would lead you to, and I expect that's what the term "mass murder for profit" is referring to.
Some of the big states should just use preferred sourcing laws to bootstrap manufacturers or contracts to just make things like insulin and shut these companies out of Medicaid.
The casual disregard for humanity and their largest customers should result in severe consequences for the companies and the investors in them. In short, they should be ground down and driven out of business.
Utter nonsense. That kind of deregulation fixes everything always assumes a perfect market with perfect information, ie consumers who can actually judge the quality of the product their receiving. Drugs most definitely do not fit into this category, how do I tell if the drug I'm taking is actually working? Would I feel worse or be getting sicker faster if I weren't taking Pepsi Insulin (tm) or is it just a placebo and I'm just going through the disease normally (or tricking my self into feeling better because I'm taking something). Ok, this drug does make me feel better but it turns out it makes mutant babies if I happen to get pregnant while taking it (see Thalidomide or the warnings on basically any acne medication).
I make "no perfect market" or "perfect information" assumption.
I am pretty confident that people will take stupid risks, as I am confident that people who want to be safe - buying from reputable sources - will be able to.
How do people without a scientific background and without the access to clinical testing data (since we're deregulating here companies won't even have to do them before going to market legally) have a hope of evaluating what new drugs are safe and which companies are reliable?
If you want an example of how an unregulated medicine market works, check out the American medical "supplement" market. Plenty of producers, dubious and often purposely wrong claims, often don't even contain the compound as advertised, and still hilariously expensive.
If unregulation begets competition and that begets lower prices, why do these turmeric supplements cost $30[0] while you can go to the spice aisle and get 10x as much for $5?
It would be hard to notice if it were adulterated with something else with long term harmful effects though. Say something that increases the potency or allows the effect to last longer (so I'm not strawmanning a The Jungle style willfully negligent corp) but is ultimately harmful over long term or combination with other medicines?
Yes, this type of libertarian thinking presumes good information. Medicine and chemical production rarely have good information. It is too expensive. So the people as a collective must investigate these costs. This is why the government regulation exists. Even then it took a long time to fight against the greed of the tobacco companies as they fight tooth and nail to continue poisoning the populace and keep people ignorant about it.
Mass murder for profit is normal operating procedure. Otherwise we wouldn’t have cigarette companies, mining companies fighting safety regulations or companies fighting tooth and nail to keep leaded gas.
> Mass murder for profit is normal operating procedure.
That's just not true. Of course a profit-maximizing entity (which is an idealized abstraction that doesn't perfectly match anything in the real world) would 'love' an addictive product, or to minimize their costs, including an externalities for which they're liable, but, again, ideally, those same entities would absolutely prefer that their product does NOT in fact kill their customers or potential customers as that would just reduce their maximum potential profit.
Per your hyperbole, mass media is also engaging in 'mass murder for profit' as they cause people stress and stress likely shortens their lives. A tradeoff involving the potential loss of life or some period of life is not literally murder.
If you sold all of your possessions and lived a life of poverty you could donate the proceeds, and any income you earn that you don't strictly use to prolong your own life, to a charity that could save lives or lengthen others. That you do not, nor almost anyone else, is NOT literally the same as murder.
There’s a difference between making money and short term exploitation. If I own woodland, I can earn a living harvesting trees for decades, or cut the whole thing down. Clear cutting gets you a big check now, but less over time. Responsible harvest gets you more money in the long run, but spread over time.
None of this is sustainable, and many of these companies even outsource their manufacturing. By maximizing short term results above all else, they will kill the golden goose, and ultimately will either be nationalized, or replaced by foreign competitors.
" those same entities would absolutely prefer that their product does NOT in fact kill their customers or potential customers as that would just reduce their maximum potential profit."
But since their products or their production methods kill people they prefer more profits over less profits. I can't find any possible excuse for lobbying against safety regulations in coal mines other than them being greedy bastards.
The entire military industrial complex is predicated on murder for profit. Remember this every time someone tries to sell you the lie that we need to airstrike Iran because they shot down a drone.
Guess who's really winning there? Lockheed Martin, Raytheon, General Dynamics and their shareholders. Certainly not the Iranian or American people at large.
Thanks for sharing this by the way. I actually checked out a published book of his (and associated) essay from my local library and read it just yesterday.
His perspective against for-profit wars, yet lean towards defensive military spending (not to be conflated with modern offensive military spending) was nuanced and very insightful.
There certainly is a legitimate self defense need for weapons technology. Realistically you cant do without. But things get murky when we start selling weapons to questionable allies.
I'd prefer that our society classifies it as illegal rather than evil or immoral. We need to have laws which also take away the acquired wealth from those who benefit from such practices.
Illegal is a classification a state makes about things considered immoral or evil. Or sometimes neither and someone is out to make a quick buck by corrupting the law. I cannot classify something as illegal, but I can point out that it is downright evil. If enough people do this then eventually the law might catch up, that is if the law hasn't been bought out already by the evil bastards out to make a buck. Which it has, unfortunately.
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.