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Comment by mgarfias | Hacker News Reader

There’s different kinds. IIRC the cheap stuff and Walmart is just that, cheap. It’s fast acting, and varies in how it reacts in the body.

Our real issue here is that there is absolutely no incentives to control costs.

You’d think our ins companies would do it, but I’m practice, they end up negotiating sweet deals with the drug manufacturers. say med X @ $1000/mo msrp, but the ins companies negotiate it down to $400/mo. The drug company makes out like a bandit, and the ins people get kick backs for buying from the drug co, and passes on the costs to the insurance buyers.

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> It’s fast acting, and varies in how it reacts in the body.

I believe they offer R (short acting / 2-5h), N (medium), and L (long acting / 24h). The problem with the older insulins isn't so much that they're faster, it's that they're less "specific" (from my experience). A newer short acting insulin (Apidpra, etc) has a spike in the 15-30 minute range and the spike is steep and the tail (while up to 5 hours) is low. Whereas R peaks in the 30m-1h range and the peak is low and the tail is much higher. As such, you need to plan ahead much better for your eating. It's frustrating, but not horrible. The N and L have similar problems (L is the reverse, where you want a tail equal to the spike, but it isn't).

The newer insulins a just much more convenient and require a lot less planning of what you eat and when... and not as close an eye on your blood.

If that's actually the case that puts all the "You're literally killing us with expensive insulin prices" people in a very negative light. At best they're ill-informed, at worst they're being intentionally deceptive to achieve political aims.

I have to ask, are you suffering from a Type 1 diabetes? If not, at least for me, this answer kind of misses the point completely. Type 1 is a hell to manage. It is REALLY hard.

Like I actually use an open source pancreas to control my glucose levels so now I can sleep every night without having to worry about dying. This is in Europe where the insurance covers everything and prices are cheaper than in US.

Using the Walmart insulin makes everything much much more complex, and even for the smartest of us, even with the best possible insulins, managing T1 is a HUGE pain and can kill you quite fast.

I hope I misread your comment...

I do have type 1 diabetes, and I lived on R/L for over a decade. The point being made here is

> The high price of tier 1 insulins is killing people

Is (more or less) a lie. While

> The high price of tier 1 insulins is making people's lives considerably worse and their diabetes harder to manage.

Is (more or less) true.

When you try to push for change and use, as part of your argument, a lie, you sabotage yourself. People can point at what you're saying and, ignoring the validity of what you're trying to achieve, say "you're lying". That's bad.

The truth is that there are good reasons why tier 1 insulins should not cost as much as they do, not by a long shot. And destroying your own progress towards changing things is counter productive. Just don't do it.

It is not a lie if you think about real human behavior, rather than a theoretical rational automaton. There are real, documented cases of people who were prescribed insulin they could not afford, tried to ration it, and died as a direct result. Maybe their doctor told them not to use it, or they didn't live near a Walmart, or they didn't know it existed. Maybe they tried the Walmart stuff and almost died because it's so difficult to manage, so their doctor told them to switch back to the best treatment available. I promise they did not die to make a political point.

One in four patients in the US have rationed insulin because of the cost: https://news.yale.edu/2018/12/03/one-four-patients-say-theyv...

It is simply untrue to say the high cost only forces people to use the cheaper Walmart generic. That isn't what happens. They ration it, and sometimes they die.

Finally, it doesn't make sense to say that the high price is making diabetes harder to manage, but isn't killing people. That's like saying speeding doesn't kill, it just makes the car harder to manage.

Correction

> One in four patients say they’ve skimped on insulin because of high cost

> say they've

^ is the key component. I expect the vast majority of those people had a choice, and they chose not to take it. A poor choice, and a choice they shouldn't have to make, but a choice nonetheless.

The point is, if you're going to fight for positive change, use an argument that can't be trivially dismissed because it isn't true. Fight effectively.

Yes, why did they choose not to take it? Try to empathize with these people. Why did they do something so dangerous? Then follow it one step further. In the case of those that died, why did they die? What factors contributed to their death? If the price of insulin had been lower, and everything else was the same, would they have died?

I would argue these two statements are equivalent:

- My patient was killed by the high price of insulin.

- If the price of insulin had been lower, my patient would still be alive.

I suspect that you accept the second statement, but not the first. What's the difference?

They are two different, but related, things. There are people who die early because they eat extremely poorly; lots of fats and sugars.

1. If the fatty and sugary foods were too expensive for them to buy, they would not have died from those things.

2. They did not die because fatty/sugary foods weren't expensive. They died because they chose to eat fatty/sugary foods. [1]

Just because X (good insulin being cheaper) would have helped prevent Y (deaths) doesn't mean that <not X> caused Y.

[1] I'm ignoring the fact that truly healthy foods tend to outside the price range of the poorer segment. The analogy only really goes so far here.

Ok, I guess that's the core of our disagreement. I do believe that "X prevents Y" means "<not X> causes Y". Thanks for the discussion.

To me, it's the difference between "is a requirement for" and "is the cause of".

- People drive cars.

- Cars are car jacked.

- If people did not drive cars, carjackings could not happen.

- People driving cars is a requirement for carjackings.

- People driving cars is not a cause of carjackings.

I understand that it is possible and truthful to argue that people driving cars is a cause of carjackings; it's just not my view of the meaning of those words.

You're letting pedantry get in the way of the far more important point that making the medication more affordable would save lives.

By claiming that the companies are colluding and have raised the price, the charge is leveled that the companies are behaving immorally.

When people learn that the "old insulin" and "new insulin" are completely different products and that "old insulin" is still available at a low cost, the narrative and goodwill is shattered.

People hate being lied to and they hate being manipulated.

If you want to have a discussion that we should make the "new insulin" available for at low cost of for free, that is great! We can talk about the cost to manufacture and to develop drugs.

There are many smart people here and around the world, when we put our minds to a problem, we can find a solutions.

But by not acknowledging and downplaying the time and effort that companies and people have put into the "new insulin", then you are cheapening the work they have done and are signaling to everyone that you would do the same to their time and effort as well.

Saying that cheap insulin kills people seems like a hyperbolic, but essentially true statement.

It's well known that you need to keep all sorts of things under control with type 1 to avoid long-term health complications. Blood sugar is the most obvious.

I watched my father manage his for decades, starting in the 1980s. The technology improvements were interesting - his first insulin pump (about the size of a VHS tape), the custom software to data-dump his glucose meter, "supply-hacking" to keep the infusion sets affordable...

He still had management challenges despite being a dedicated, disciplined, marathon-running Mormon on the leading-edge of treatment. He was fortunate enough to be involved in the DCCT/EDIC trials at the University of Washington, and took the early lessons about future complications very seriously.

You make Diabetes harder to manage by removing modern improvements to the standard of care, and you are certainly going to see increases in deaths and severe negative outcomes.

What you've said is true. Refusing to use the older insulins is what is killing people. Having to use the older insulins is shitty, and it shouldn't be happening, but it's not the thing that's killing people.

However, actually _saying_ that tends to get people up in arms, harassing you about how it how it shouldn't be necessary for people to use the older insulins, and how the newer insulins shouldn't cost what they do. Even though everyone actually agrees with them and they're arguing against a point that nobody it actually trying to make. It is... frustrating trying to get people to understand that you agree with them, but you're talking about something different.

I had this exact discussion with one such person yesterday, and I was trying to explain that they are sabotaging their own goals by misrepresenting the issues. And that I WANT them to succeed in changing things, but they're making it harder to do so.

Edit: You're already being downvoted for stating something that is obviously and undeniably true, because people are not bothering to understand what you're saying. I'm sorry for that.

Having to use the older insulins is shitty, and it shouldn't be happening, but it's not the thing that's killing people.

In a way it is killing people, blood sugar control is much easier with a mix of the newer insulins, and patience compliance is much higher. This directly translates into better quality of life and lower disease burden from diabetes complications.

No one can argue that pharmcos shouldn't be paid for R & D that increases quality of life, in civilized countries the taxpayer should and will pay for your medication if it's an improvement over what's already at market.

But here people seem to be arguing that if you can't afford anything else there's still Walmart short-acting Humalog, and you get to bear all the risk, and that's just fine.

How cheap is the cheap option?

I found some references for "old" versions that claim price increase from $17 in 1997 to $138 today, another from $21 to $255.

Going by inflation only those would be around $30-40.

I don't know how much a typical diabetic needs per month (I imagine it varies) but I could see that being a problem for a lot of people if that is, say a monthly supply.

> How cheap is the cheap option

About $25, that last I checked. The ones you're talking about, I believe, are the "newer" ones (which are not very new). The prices of those have shot up over the years (in the US) for no good reason. It's shameful.

I guess my mistake was thinking 20 plus years was old enough, that would be out of patent.

My understanding it that they are out of patent, but regulations make it hard for new players to enter the market. Since the number of companies making them are so limited, even the generics cost a lot.

For example, Basaglar is a "generic" of Lantus, but it's still expensive.

Here’s How to Save on Basaglar, the Expensive Lantus “Generic” https://www.goodrx.com/blog/basaglar-expensive-lantus-generi...

> Basaglar contains the same kind of insulin as Lantus (insulin glargine), and while it is cheaper—Basaglar costs about 15% less than Lantus—it is still expensive, with a cash price of around $450 for a 30-day supply.

Unlike normal generics, the bio-similars need to go through their own clinical trials and prove they work the same as the original. They can't just "use the same ingredients" and release it. Mind you, that doesn't explain the extreme price markup, but it does explain why these "generics" don't follow the same "85% cost reduction" of normal generics. They still have, effectively, a costly R&D phase.

At least, that's my understanding.

I understand that argument.I hadn't thought of the issue of insulin being a biologic, so true generics aren't likely, hence biosimilars. None of this justifies a 10x+ price increase on the same product over 20 years of course.

By the way that same site had an interesting article breaking down costs normalized by insulin unit

https://www.goodrx.com/blog/how-much-does-insulin-cost-compa...

By that table and some assumptions about approx 40 IU/day it looks like the cheapest you could get away with at full retail would be about $120/mo, assuming optimal usage etc. The most expensive version would be at least 5x that.

It's extremely hard to manage your health with old insulins because they're so much less precise. Imagine if you were programming but your keyboard works such that any key you type might be +3/-3 key presses actually. Except in the case of diabetes, this results in the loss of body parts and blindness.

The people who can least afford healthcare also have the most external constraints on their work and life, making it the most difficult to make good, non-harmful use of older insulin in the long term.

There are plenty of cases of people literally dying because of difficulty managing insulin due to cost. It’s nice to say other low cost forms are available while handwaving away actual deaths as well as accumulative long term damage from difficult insulin management.

https://khn.org/news/insulins-high-cost-leads-to-deadly-rati...

Many of the “newer” forms are 20+ years old, and are also extremely low cost to produce.

It's the same with basically every other campaign that wants to grab headlines. It literally makes no sense that insulin prices are killing people and it's unavailable, and a basic amount of research shows that yeah indeed, it's clickbait intended to hook you into a more complex discussion.

I pay zero attention to people and news sources that repeat that behavior more than once. Lead with the truth.

You are a prime example of WHY that lie is bad. The discussion they are trying to drag you into is an important one, and well worth having. However, by starting out with a lie, they are driving you away before they can even start the conversation with you about it. A conversation where you might agree with them.

That's context I've never gotten before. Obviously there's a nice convenience benefit built into this product that a company has created, they should get to charge some markup for that.

I wonder how different the production costs are though, my understanding is the costs to consumer are greater than 10x

The difference with the old insulin vs. the analogs is that with the old ones it's really easy to lose a toe, leg, kidney or get blind. With the new analogs it's possible to control your glucose levels so that you can stay healthy and get old.

Source: a T1 diabetic, used all possible insulins in my life. Very happy in Europe.

They also tend to have a more reliable absorption curve. I take both Novolog (short acting) and Lantus (long acting), which are the newer insulins. Lantus has a more predictable long acting curve than the older L did, even though I take it in a 12 hour cycle. It rises not so much like a bell, but more like a plateau, I guess it a better analogy. At least for me. The L really was a pain for planning, especially when physical activity was involved, as it would shorten the bell curve.

On a related note... if you can afford a CGM (continuous glucode monitor), especially one with alerts (like the Dexcom G6), I wholeheartedly recommend one. They are life altering for a type 1 diabetic. Being able to check your blood sugar by just looking at your phone (or separate receiver) is very convenient. I check my blood sugar 100 times a day, instead of poking a hole in myself 10 times a day. And I can (mostly) rely on it alerting me if my blood sugar gets low (or is going to get low soon). I cannot stress enough how much it changed my control of my diabetes.

Admittedly, they're not cheap w/o insurance, which sucks. But if you can get one, so do. You won't be disappointed.

I keep on trying to get one, but being well controlled, the ins cos won't approve it. And its pretty spendy out of pocket. My biggest use case would be an alert that my glucose levels are tanking while exercising so I can do something about it before I drop out. I find myself not doing things like long bike rides that I'd really like to do because of it.

You should be able to get the Libre 14 day sensors for about $120/per month (2 sensors) without insurance. I've been using it for about a year and it has been a huge game changer for me. I've been on insulin for about 23 years. The Libre doesn't have alerts but being able to tap your phone to your arm to test your glucose makes a big difference in how you test/monitor even without alerts.

The alerts (of the G6) are certainly desirable (amazing). But, as mike notes, even just being able to check your glucose with 0 effort... just changes everything. You wind up checking it so often that it's more than just checking it, you get more of a feel for how your body is reacting to your food/activity/etc. I can't say enough positive things about it.

I guess the question is, do countries with socialized healthcare provide the cheap version or the expensive one?

Not actually the question since countries with modern healthcare systems provide all types of insulin at an average cost per unit that is roughly 1/10th to 1/20th the cost in the United States (cheap vs. expensive is an over simplification).

No, it is the question because countries with public health systems often don’t pay for the latest generation of drugs, since they don’t feel the extra cost is worth the benefit.

My comment answered that "countries with public health systems" actually do "pay" for the "latest generation insulin" (i.e. the price for the "latest generation insulin" is still a tiny fraction the cost in the United States).

Just repeating the question, when I gave you the answer, isn't very productive.

It's still the wrong question to ask.

We should ask what are the outcomes that these systems produce, not how new the drugs are.

A cutting-edge healthcare system plagued by inequality and extreme costs can produce worse results than a more efficient healthcare system which is not as high-tech.

Well all the diabetics in this discussion are claiming they can’t do without the latest generation insulin.

But yes, I agree. Sometimes the juice isn’t worth the squeeze.

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