California aims to slash insulin prices
latimes.com
latimes.com
That should make the solution clear: Undo the laws that prevent retailers from driving over the border themselves. If US drug stores could import insulin from Europe, Canada, and Mexico, then it would be impossible to maintain such a large price difference, and the US price would come down.
Now that I've written this I realize that this person has a name, it's not coyote, it's drug trafficker. I'm leaving it because:
How shameful we are. A person whom would drive hundreds of miles to a foreign land to help people get basic medicine they need to survive is called a drug trafficker that is a felony. WTF America.
It's cheaper elsewhere because those countries have set maximum prices. For instance, in Canada, the Patented Medicines Review Board sets maximum prices for pharmaceuticals.
I don't have any kind of philosophical opposition to importing medicines from Canada, but Canada has a practical objection: if we allowed these imports, it's very likely to cause drug import disruptions in Canada. Thus, Canada has asked the US not to do this. [1]
I think this is very likely a legitimate concern. The US is a much larger market, and a _much_ more lucrative market than Canada, since the US does not fix prices. If the US allowed imports from Canada, it's likely the pharmaceutical industry would stop selling to Canada at the rates set by the PMPRB. The industry would sooner miss-out on 100% of sales to Canada than have their pricing power in the US eroded.
Other than the anomaly of Covid vaccines, Pfizer actually has larger sales in the US than the entire rest of the world put together, which tells you something about how much the US is overpaying.
If the US wants to set maximum prices for drugs, and we have the votes to do that via importation, why in the world can't we just have our own Patented Medicines Review Board, rather than relying on Canada to set policy for the US?
[1] https://www.reuters.com/article/us-canada-pharmaceuticals-ex...
Care to share a link if you have a source handy?
Wait, it sounds like you are saying that buy paying higher prices, the USA is subsidizing the rest of the worlds healthcare costs. Is that true?
As others pointed out, it would affect decisions for future research. Because you can't just rake in the money in the US you must be more wise with spending your research money.
> If they could raise the prices they would have already.
Good point
The government literally tells you "you sell it for this much".
And guess what, "that much" already covers their costs plus profit, so they keep selling.
It's just profitable for them to price gouge you, and you don't fight back, at all.
As a general rule, defending the "big guy" on their behalf is generally a losing strategy. They can defend themselves already, no need to stand up for them.
2. I have family working in the medical and pharma fields.
3. I doesn't even matter what and who I know, this tells you everything you need to know:
https://www.macrotrends.net/stocks/charts/PFE/pfizer/gross-p...
The profit graphs for most of the Big Pharmas look similar.
They're hugely profitable. For sure they could lose a chunk of that and do fine.
It's just greed. A bit of greed shows ambition. A lot of greed corrodes everything. It's just pathological at some point (money is not points on a mobile game leaderboard!).
If both countries are limited to a gross margin of $1 and you expect the lifetime gross income to be 0.2B this is now going to be a massive net loss. So you will not invest in it.
If the whale suddenly stops paying, you can continue to profit from regular customers you just don’t make the obscene profit from before.
Can corporations continue to survive with less profit? I think some individuals have to learn to live with less income, so I’m sure a big pharmaceutical company can figure it out, I’ve had to cut out most meat from my diet in lean times, I’m sure pharmaceutical executives can do something similar.
Given you already have the drug, sure, it makes sense to keep selling it. But if you try to research more drugs and make more games with no whales, you will quickly go out of business. The video game analogy is apt. These kinds of video games are only possible because of whales. If whales could not exist due to regulations similar to drugs, they would not be developed / researched
The medical industry in the US has such a huge overhead, it's scandalous. You're feeding millions of administrative leeches.
Companies contract when they have losses... (or when their revenue goes down, but only if they predict it will keep going down, while in this case this would be a 1-time shock).
I see a bunch of people defending these corporations, I have to ask: why? Why are you defending corporations with tens if not hundreds of thousands of employees and decades of years of profits in the mid-to-high tens of billions of dollars? Their abuses are well documented, is it Stockholm syndrome?
A lot of that healthcare spend is wasted on administrative overhead of the US system.
"U.S. insurers and providers spent $812 billion on administration, amounting to $2497 per capita (34.2% of national health expenditures) versus $551 per capita (17.0%) in Canada: $844 versus $146 on insurers' overhead; $933 versus $196 for hospital administration; $255 versus $123 for nursing home, home care, and hospice administration; and $465 versus $87 for physicians' insurance-related costs. Of the 3.2-percentage point increase in administration's share of U.S. health expenditures since 1999, 2.4 percentage points was due to growth in private insurers' overhead, mostly because of high overhead in their Medicare and Medicaid managed-care plans." https://pubmed.ncbi.nlm.nih.gov/31905376/
I have seen revenue projections for go/no go development decisions. US and EU revenue are primary considerations, and heavily weighted to the US.
Some products are never expected to turn a profit in small countries even if the product has already been developed. Passing the regulatory barriers in these cases is done for humanitarian reasons.
* Clearly, this would hugely disrupt the current pharma business model.
* One obvious initial response would be to limit investment into research. However, this isn't a viable long-term solution, given research is the lifeblood of continuing success in the industry. It would therefore increase pressure for regulatory reform - essentially to reverse the trend of recent years, and make medicines easier/quicker (and therefore cheaper) to develop.
* Other typical business-leader responses: cost-cutting, job losses, mergers, etc.
* Pressure on developed countries outside the US to pay higher prices
* Longer-term, it might disrupt the current model of drug research funding altogether. The industry is already at a point where development of many drugs is close to unprofitable, and that trend is worsening as regulators become ever-more conservative, and of course with each new successful drug, the next one becomes progressively more difficult to find. The change we're discussing might well mean that drug discovery and development is simply no longer an area where profit can be reliably made - and as such shareholders remove their investments, and pharma companies would merge/struggle/fold. Faced with this, governments and regulators would presumably need to work together to find ways to continue the funding of drug development - and make up a overall shortfall in research and development funding similar to the GDP of a decent-sized country.
(To be clear, I'm not disagreeing at all that the US is effectively supporting the industry - just the term subsidy in the way it was used.)
And development would continue there.
I'm guessing that'd be the best for everyone except for the profit maximizing pharma companies in the US
Didn't know about NHI.
citation needed
> as regulators become ever-more conservative
... cough
the simple problem is that the drugs that work very well are hard (eg. personalized gene therapy) and there whole healthy-industrial complex is not set up to solve hard problems, it's set up to sell treatments to the market, keep the machine churning, buy promising new formulas from small research labs, do the larger trials, manage the FDA, market the shit out of those that make the cut, rework formulas to keep generics at bay, and so on.
the other trivial problem is that no one wants to confront basic problems affecting health. (obesity comes to mind. nutritional studies are so underpowered it's laughable. also let's say mental health. tinkering with the brain always has the nasty side effect of oh what if the drug accidentally makes you feel funny/good instead of just not-miserable - see the weak results of the esketamine, also see how psychiatrists are afraid to use desoxyn [meth], because oh the paperwork & peer pressure.)
note, I'm not saying that the current setup does not deliver results, and that your predictions are without merit. (they are realistic.) what I'm trying to make explicit is that the industry is already ripe for structural reform. (the easiest no-brainer would be to simply fast track drugs already approved by the EU EMA; tax waste spending [spending that is not R&D or manufacturing - eg. marketing/sales]; make the FDA approval process a lot more standardized and faster; start running publicly funded trials on drugs that are already prescribed by doctors but are not authorized to be marketed)
Look into eroom's law of drug development. There are a lot of papers on the subject. It describes R&D cost, which covers more than just discovery, but gets the point across.
https://www.google.com/search?q=eroom%27s+law&tbm=isch&ved=2...
For Q1 2022, pharmaceutical sales only...
AbbVie: 10.345 Bn US vs. 3.19 Bn ex-US [0]
Roche: 5.292 Bn US vs. 5.308 Bn ex-US [1]
BMS: 7.694 Bn US vs. 3.954 Bn ex-US [2]
So US provides at least >= 50% of total revenue, and in some cases considerably more. Also, given the higher prices, it's likely that the US represents a considerably higher proportion of profit than this - and therefore a major change in drug pricing in the US would be hugely disruptive for the industry.
--
[0] https://investors.abbvie.com/static-files/b37af441-45e9-4e16...
[1] https://www.roche.com/cec228fd-2a55-41e7-a718-19e658c7048d
[2] https://news.bms.com/news/details/2022/Bristol-Myers-Squibb-...
That's the wrong way to look at it.
Your companies are just skinning you alive, because you're letting them.
So MANY of these discussions are pointless when we've had huge changes in the past and 5 years later people can barely remember the past discussions.
Fear of change is huge, the impact of the average change is in general quite small, in the medium to long term.
Unfortunately, this requires the intellectual honesty for people to admit that profits do in fact Drive Innovation which seems to be a sticking point for most.
The rate of innovation would slip for global drug development without the promise of high prices and blockbuster profits in the US market.
I have worked for a couple different Pharma companies, including those HQ'ed in Europe, and this is basically the situation. EU based Pharma companies make most of their profit in the US (almost every pharma company does).
There are other ways to incentivize drug development and/or defray the financial risk of development, of course... but this is situation today... has been for a long time.
Govt then auctions rights to productize drugs. Industry pays govt a royalty. Modulate the royalty to incentivize desired outcomes. eg zero (or negative) royalty for malaria, 3000% for esteem remedies like viagra.
Further, when there is no market demand for obvious public health priorities, govt contracts with industry, paying for mfg, distribution, marketing, training, whatever.
You get what you measure. Americans decided they want to measure profit and so they think their pharmaceutical companies must be working well because of how profitable they are. Sure, the people are miserable, many can't afford medication they need, but there's so much profit that means it's success right?
Nope.
The owner's hilltop mansion and two yachts don't actually make sick children well, or prevent heart failure or anything like that, spending on R&D is not in fact linked to company profits, instead it's necessary for these companies to survive because innovation is their lifeblood. The profits are an excess.
What we actually wanted wasn't richer executives, or more approval paperwork, it was healthier people, and the US scores very badly on that.
And there's no need for making medicines which merely "used to be new" any more profitable than say, felt tip pens or flour. I take Levothyroxine every morning (for the rest of my life) and they figured out how to synthesize that about a hundred years ago. Nobody who worked on that project is even alive still, let alone relying on some hypothetical profits from their work. But guess what, in the US it'll cost more than it does here because the US values profit for pharmaceutical executives over healthcare for its citizens.
The whole point is that the US being profitable allows research for new drugs, not that profits aren’t high in the US. Heck, Pfizer sells stuff at cost to about pretty large portion of the world now.
https://www.statista.com/statistics/267810/expenditure-on-re...
You didn’t really make a claim so I don’t know how to refute anything
The metric is not useful to the point you’re making.
No, because the US is not the center of the universe.
At one place I worked, our general manager literally said, in a meeting, that if too much Canadian product crossed over into the US market, the company would stop selling to Canada. US prices for our drugs were higher than every other country in world, often times by 3x or more. Almost every other country in the world, besides the US, negotiates price as part of the drug approval process.
It is insane that the US continues with the status quo.
But our markets still function, because when it is not so the political elites lose. So let's use a market approach and open the borders to retailers so long as the medicine is labeled as sold in the other country, and guaranteed to their standards. Perhaps the retailers buy some additional insurance policies.
No, human insulin (or its analogues / biosimilars) is a medicine which should be cheap to produce and therefore inexpensive to purchase.[0] It's cheaper elsewhere because the there's something approximating a free market in operation.
The real issue isn't price controls, it's about $bigPharma and their lobbyists getting the FDA to help protect their profitability.
Does the policy have wide democratic support, yes, like many sensible policies, it does.
Does the policy seem likely to survive the lobbying system, where conpanies can just kickback some of the money they extort to the people with the votes, no, like many sensible policies, it doesn't.
This is goofy, though. If it's the same product, there's a real reason it's more expensive here. It could be anything from excessive regulatory hurdles to a cash grab, but there's something wrong. Address the underlying issue.
It's not a new concept and it works with almost all commodities. If you need to buy iphones, you are likely to get a better price for them if you call Apple directly and ask to buy a batch of 10M than if you show up to an apple store to get 5 units.
India does that a lot, and supplies the entire developing world with medicines.
Canada doesn’t have that much leverage. It often receives brand medications much later, and some cases medications aren’t marketed in Canada.
Try to buy Nuvigil in Canada, let us know how that leverage worked out for this drug.
If the cost/benefit ratio is sufficient, a recommendation is made to the government, which then decides whether it will subsidize the drug. If it does, then the drug is provided to patients at a capped price (currently ~AUD40 for non-welfare recipients, ~AUD7 for welfare recipients), with the remainder of the cost paid by the government.
This provides a direct incentive to the pharma company to get their drug listed under the PBS, because it ensures that they have a large market available.
Drugs that are not available under the PBS are still available, but at full price to the patient. However, because of the expectations of pricing in our market, the pharma companies have to keep their prices lower overall.
We’d pay less. They’d probably need to pay more. It’s utterly insane how we’re essentially subsidizing drug development for the entire world.
I think you'll find the only thing you're subsidizing is the profits of American pharmaceutical companies and health insurance providers.
Just get rid of health insurance, and spend that money on actual health care instead. It works mighty well in other countries.
Cut revenue, you cut R&D.
And the US is about half of all global revenue, so half of all R&D expenses. The other 95% of the global population pays the other half.
Since a lot of Pharma research is done at universities and is funded by the public, this holds true especially for insulin, maybe by cutting the costs of meds the companies optimise their system more.
Less marketing, no Pharma people bribing doctors to use their meds etc. I bet if you cut those unnecessary jobs and expenses before touching R&D or Profit a lot can be done.
And no, most pharma research is not funded by the public (the NIH budget is 1/4 what pharma spends).
There are a million things they could cut back on.
But the poor shareholders, would someone thing of the millionaires?!?
34% of money spent on healthcare is administrative overhead. Cut that, and you'll still have plenty of money for R&D https://pubmed.ncbi.nlm.nih.gov/31905376/
Very few countries have a single-payer system without health insurance providers, in case you're unaware. It's far from the norm in Europe and the developed world, or anywhere else for that matter. This map seems like a relatively decent source based on my spot-checking:
https://worldpopulationreview.com/country-rankings/countries...
This isn't necessarily an argument against it, to be clear. I think single-payer systems have certain practical benefits compared to which I quite disliked the system in the last European country in which I lived.
I lived in Australia for 23 years, and Canada for 15. Australia has single payer and universal, Canada (apparently according to your map has single payer)
To be honest you're splitting hairs, and in practice it doesn't make any difference.
You live in the country, you get healthcare without paying a cent out of pocket.
Both of those countries spend less on healthcare per capita than the US, and both have measurably better health outcomes.
So it costs less, and it's better. Why would any person not want something that is measurably better and costs less?
This seems like a (probably unintentional, and partly due to my lack of specificity) straw man. The spectrum doesn't range from Australia to Canada, considering both offer a single payer system that covers a good amount of care, but rather from something like Switzerland to the UK/Nordics.
> You live in the country, you get healthcare without paying a cent out of pocket.
This is far from true in several/many of these systems, which was the point I was trying to make, but again I do believe I could have been clearer about this. My point was just that plenty of countries have healthcare systems that work well while spending money on health insurers rather than just on healthcare.
Single Payer: eg the NHS in UK. Single payer pays all costs and wages, care is free at the point of contact (GP/Specialist/Hospital), prescription prices capped for pharma approved by NICE.
Scheduled Reimbursement: eg Australia. All services have a set scheduled fee, if "bulk billed" then free at point of contact. If not, then gap is payable for GP/Specialist services, or in private hospitals or as "private patient" in public hospitals. Gap can be covered for hospital care by private insurance, which is subsidized. Prescription prices capped for pharma approved by PBS. Private insurance regulated in terms of what is covered and limits due to pre-existing conditions etc.
Regulated Insurance: eg Germany/other EU. Health insurance is "compulsory" for all residents, with costs split between employee/employer, or picked up by government for unemployed. Insurance companies strictly regulated in terms of margins, "medical loss ratios", coverage etc.
All of these models provide better overall care and better overall outcomes for the country than the current US system. In particular, these aspects of the US system cause a large majority of the issues:
1. Lack of Transparency: Medical providers (hospitals/GPs/Specialists) are not required to publish a fixed price for services delivered, with opaque contractual relationships with payers.
2. Pharma: No regulation on prices, windfall taxes on excessive profit, universal availability, or even the negotiation on prices when government purchases.
3. Insurance Company Profit: The overall limit of 20% margins is excessive. There is no reason that insurance companies should be guaranteed this gross margin, when the actual cost of the service they provide is 10% of that, based on the costs incurred by government equivalents such as Tricare and Medicare.
So the solution is not "Let US pharmacies buy drugs from Canada where its cheaper". The solution is: "Let government programs negotiate with pharma companies to use their purchases to reduce prices" and "Require all medical service providers to publish their actual prices transparently and comparably without being able to negotiate secret reductions based on bulk purchases by insurance companies".
I'd say US should get over their lurking savior syndrome.
Once they have the drug developed it makes sense to sell it wherever they can, at whatever price they can get (above COGS and overhead, of course), as profit is profit—so long as it doesn't cannibalize their much more profitable sales in the USA.
If the USA were to suddenly allow retailers to import drugs at scale from other countries to reduce costs then those countries would find their supply of cheaper drugs drying up. They could either accept prices on par with those in the USA, thus eliminating the arbitrage, or simply go without.
Would be interesting to know why these discussions fizzled.
[1] It's unclear how strict is this mandate. The 2020 legislation only requires investigating the feasibility of directly manufacturing drugs in-state. See the summary at https://leginfo.legislature.ca.gov/faces/billNavClient.xhtml... as well as section 127694 specifically. I'm guessing Newsom is trying to find a way to justify building an in-state manufacturing facility. It fits into the state's broader policy to develop the biotechnology sector, which is already significant--depending on metric, first in the nation or second to Massachusetts. Not sure it's worth delaying these deals over, but perhaps Civica and others are demanding long-term contracts in an attempt to preempt California building a competitor. (It's understandable why they wouldn't appreciate more competition. Even for a charitable venture, more capacity would impact their financial viability, especially considering that preexisting, for-profit suppliers will aggressively use their pricing and market powers to try to suffocate these new ventures. OTOH, that's exactly why one might want a state-backed facility, so they're not beholden to investors--even beneficent investors--and the ruthless economics of the market. And theoretically a state-owned facility might be more resilient, either legally or politically, to Federal government suppression, which is one of the primary tools the pharmaceutical industry has used to rig the market in the U.S.)
The extremely expensive insulin that articles are talking about is usually a brand name like Humalog which is an altered form of insulin that is far more convenient to use. It is possible (but rather convoluted) to bring these eye-popping prices down to $99/month without insurance (https://www.admelog.com/savings), or $43-73/vial (https://www.goodrx.com/insulin-lispro or Walmart Novolog). Of course, this is all basically a way for pharma companies to price discriminate to extract as much $$$ from insurance.
https://bnf.nice.org.uk/drugs/insulin-lispro/medicinal-forms...
But also note that in the UK:
> If you use insulin or medicine to manage your diabetes, you're entitled to free prescriptions
I think (though not 100% sure) that covers all prescriptions too, not just those to manage diabetes.
Humalog 100units/ml solution for injection 10ml vials - £16/each
The price you see is the cost to the NHS, not the patient.
So I find it best to ignore that and show them that the whole system is still only paying a tiny fraction of what they're paying.
On the other hand, it may take away some choice people have in selecting health care provider. For example, some people are not happy that they don't get semaglutide (which really helps diabetics to lose weight) because they don't qualify according to the NHS criteria (not obese enough). Of course, they always have a chance to go to private health care providers and pay full price (or private insurance) but not many can afford that. Although I suspect that even in the US many insurers will have similar criteria whether they reimburse the drug or not.
Assuming you cannot afford it, can you just get 'normal' insulin instead?
Sorry to pepper you with Questions :)
https://maori.geek.nz/the-unreasonable-math-of-type-1-diabet...
The tl;dr: is that there are longer+shorter acting insulins, and you want to mix and match them to roughly match your blood glucose levels (so taking short acting insulin shortly before meals when your blood glucose levels spike)
To be honest, the same is true of many countries with socialized medicine, but the snag is not with cost but with availability and speed of care. And some medically solvable problems cannot be solved because changing anything is almost impossible.
It's just like it sounds, it's the military industrial complex but with insurance companies and large corporate hospital systems, etc.
Just look at the story of Wendell Potter [1], an ex US health exec who basically came out and detailed all the lies he spread about Canadian healthcare. So many people in the US believe those lies still to this day.
[1] https://www.npr.org/2020/06/27/884307565/after-pushing-lies-...
When a politician receives benefits for passing certain laws (often hard cash to their campaign!) they are a corrupt politician.
The term “lobbying” is the same kind of linguistic exceptionalism involved in the word “expat” vs “immigrant”.
Shire pulled this trick with Adderall XR: they signed a deal (can't recall who it was, Teva maybe?) to provide the actual drug that the generic maker stamped with their name. When Shire (bought by Takeda) was getting ready to release Vyvanse they suddenly cancelled the contract and stopped providing the XR to Teva. There was a US-wide shortage for almost a year, during which many patients scrambled to find alternatives... some of them ended up with Vyvanse prescriptions as designed.
I don't want to discount what you are saying though: the generic process should be streamlined. For Schedule II medications the extra regulatory burden definitely makes these schemes more profitable. You need a special DEA license to make them and the DEA sets quotas so even if you have a facility certified to make Schedule II drugs you need DEA permission to increase the supply. When Shire pulled the rug out from under everyone it took time for competitors like Teva to start production, get DEA approval, then get approval to manufacture in enough quantity to replace what Shire stopped making.
This was well known at the time. To my knowledge no investigation was done whatsoever. The government simply allows companies to manipulate the market as they please. No wonder they have gotten bolder and bolder.
I was not shocked in the least when Hedge Fund parasites like Martin Shkreli started looking for drug companies to buy to snap up the rights to single-source or low-volume generics to jack up the price. If a huge manufacturer can commit open market manipulation to the point that millions of people can't get an RX filled _anywhere_ to push them onto a newer expensive drug and the government doesn't even bother pretending to investigate... well there's lots of rent to be extracted!
I'd posit that it's almost impossible to get to the point where you can fund something like that without being singularly focused on getting the most money possible
https://en.wikipedia.org/wiki/Benefit_corporation
also:
To summarise, it seems that by declaring as Public Benefit Corp they can not be so beholden to the shareholders and the Corporation can declare "some other societal mission". No real details on what limits or benefits though.
I mean, what is stopping a Public Benefit Corporation declaring a mission for "yacht transport assistance" to be delivered to the selected "needy" and delivered by profits on business as usual? Obvious blatant point I am trying to make but I assume there are further laws and bylaws that usefully try to limit a corporation in that sense.
It seems a bit wishyWashy just going from wikipedia but for a HN discussion is well worth pointing out they exist! Thank you!
They have a whole write up about their getting certified:
https://info.teachstone.com/blog/pioneering-developer-of-ear...
There aren't many of them, but they are great.
corporations have shareholders and can't make risky moves like that
You have to both REALLY care, and be willing to wade through immense BS to make a profit comparable to selling smartphone apps.
Consequently all they have to do is remove the barriers for competition to enter said market and patiently watch as the problem solves itself, thanks to the amazing ingenuity and creativity of the entrepreneurial spirit.
Of course, that would make it clear for everyone that the actual culprits are the politicians who erected said barriers and we'd all be better without their interferences in economy, so... there is a perverse incentive there... let's see what they want to do:
> market failures that plague the pharmaceutical industry
> disrupting monopolistic drug prices requires state intervention and that California can pull it off because the state “has market power.”
Yup. So, any ways to bet on the outcome of this action? Favorite prediction markets?
For life saving care you are strictly better off in Canada, Australia or Britain.
For elective surgery you can probably get it done faster in the US if you have money but the standard of care isn't different. There are in-fact places that embrace even more medical capitalism than the US but with less middleman, lobbying and nonsense - take Thailand for instance, or South Korea. Both of which offer elective medical procedures for less than the US, no wait times, equivalent standard of care served with a side of luxury.
So yeah, utter drivel as usual, the US system is inferior by all metrics and insurance lobbyists have duped conservative Americans into voting for something that is strictly against their interests.
Conservative politicians the world over have perfected the art of getting turkeys to vote for Christmas.
https://www.bostonmagazine.com/health/2015/11/24/boston-hosp...
Furthermore it's probably much more expensive than you realize. Premium contributions and deductibles totaled 11.6% of median income in 2020, compared to 2% Medicare levy in Australia across the income spectrum.
The US system isn't defendable. You can say things like "Well I'm rich so it works for me" but you can't make assertions that it's good as a whole.
But such reform has not occurred despite decades of trying, and that’s because the system is not without the pros, and the pros make it infeasible to reform it at this time.
Pretending that the system is completely useless and broken is ignoring basic facts - such as overwhelming majorities of Americans that like their primary care doctor and their current insurance.
So it’s difficult to make such clear statements when the facts disagree with the progressive shrieking.
Furthermore - https://www.spectator.co.uk/article/why-is-canada-euthanisin...
> When the family of a 35-year-old disabled man who resorted to euthanasia arrived at the care home where he lived, they encountered ‘urine on the floor… spots where there was feces on the floor… spots where your feet were just sticking. Like, if you stood at his bedside and when you went to walk away, your foot was literally stuck.’ According to the Canadian government, the assisted suicide law is about ‘prioritis[ing] the individual autonomy of Canadians’; one may wonder how much autonomy a disabled man lying in his own filth had in weighing death over life.
The world is very complex and nothing is black and white
The system is without pros but that doesn't matter because of the existence of lobbyists. The American political system assigns representation proportionally by wealth of interests, that is just how it is.
You can see it play out over and over again from tobacco, oil, healthcare etc. Preservation of outsized corporate profits at the expense of normal people is simply the norm in America and is ingrained in its political system.
It has nothing to do with the pros and cons of actual healthcare provided to people (or the cost at which that care is provided), simply that those that stand to lose from making the system more efficient are willing to spend anything and everything to prevent that from happening.
Unfortunately too much of the American population are happy to be duped into thinking the current system is good in some way AND that they should tie their political identity to it's preservation regardless of the facts.
It's a tragedy tbh but maybe one day logic and economics will win out. Spending this much of GDP on healthcare is just stupidly inefficient, especially when you still have so many simply not seeking care because of the financial ramifications of doing so - cheating the economy out of their productivity.
This seems like a faulty assertion. It’s possible that this system offers benefits to some subset of people. But you can’t really draw much of a conclusion simply from its continued existence.
If one of your “pro”s is “makes so much profit for insurance companies that they are willing to spend huge amounts of money to fight reform”… well, I can’t imagine that’s really what you mean by “pro”.
It is also a game of super-sub-specialization. The entire field. There essentially numerous subspecialties within each specialty.
Some surgeons do nothing but the same apnea surgery 5 times a day. Some oncologists do nothing but specific neuroendocrine cancers all day. Some diagnosticians are good for a specific area of their field - and utterly useless elsewhere, because they just couldn’t care less and want to work on what they find interesting. Just like anyone else.
If you want to see someone who actually knows what they are doing, sees the same exact issue you are having 10 times per day instead of once per decade, you WILL travel. Of course, you can always settle for the clueless doctor nearby who will do the bare minimum, or maybe even nothing.
Remember: patient outcomes are not part of the standard of care. There are no real incentives to do better than bare minimum, as a physician.
Sometimes the talent is in Switzerland. Sometimes Germany. Korea has some leading talents in niche areas.
It just so happens that the US pays the best, and just like engineers who can write their ticket that move to Bay Area, so do the physicians that move to the US.
Real life example: many neonatal surgeons only begin practising on their own, independently, in literally their late 30s, if not 40s. In training until then, whew. Slightly different than picking up a new JavaScript framework.
Would you seek to maximise your income if you had to study for 20 years after high school?
Neonatal surgery is often $1-2 million per surgery. There are only a handful of such centres. Only some of them operated on a specific condition more than 10 times.
The same really goes for anything else from diagnostic to operators. Even in the US, you’d often have to travel out of state if you want to get a proper opinion. Easier with imaging or biopsies because these can be mailed. Tons of people travel for surgeries. 250k Canadians every year travel to the US to get care they cannot get on time (or at all) at home. I’ve seen it all, even Saudis flying over for dental work.
Next time you see your doctor ask them who would they pick for their surgery: someone who does the procedure 100x per year, or someone who maybe does 1-2 cases per year. Then guess where the most super-specialized talent can maximise their income. Probably not the remote Australia with a population of ~10% of the US.
US simply has the best talent. If you can afford it.
As for Canada/NHS/Australia being better - that’s just laughable. Canada is actually dead last among top 10 richest countries, and happens to have the second highest drug prices after Switzerland. Also has as many beds per capita as Mexico. You’d be better off going literally anywhere else.
Mayo at Rochester has a larger diagnostic antibody library than anything in those three countries combined, and can arrive at your diagnosis within two days instead of two decades. Guess where your tertiary centre in Canada/Aus/Uk often mails your blood work and biopsies once they are at the end of the rope?
That’s right. USA.
It's a utility that exists to protect the investment in it's citizens such that their full productivity can be achieved.
It's in a country's best interest to achieve the highest possible standard of care for all citizens, not just those that can "afford it".
Treating medicine as a business only works for the very top of the totem pole and over time leads to increasing degradation of the labor force. i.e what you are seeing in America right now.
Nobody in Australia ever wonders if they should call an ambulance if they are injured or worried they could be very ill, they just pick up the phone and dial 000. They are guaranteed as citizens of Australia to have access to life saving care whenever and wherever in our borders. They do so with no fear that they will financially ruin themselves.
In Australia we would go as far to call this a basic human right.
What I wrote is harsh reality informed by two decades of being elbow deep in bodily fluids.
You may not like it, but you aren’t getting the best physician just because you developed some far out ideas how the best talent in the world must fix your problems.
Guess what, physicians are free people too, even free to refuse any patient for any reason.
They just want top dollar, and move where the pay is best, that’s all.
You wouldn’t move for a 10x higher salary? You would deny everything that would bring to your family?
Also as a side note: US doesn't have a physician surplus: It has a physician shortage. By your logic, we should see no issue in finding physicians, doctors etc because they should all want to relocate to the US where the salary is the highest.
Because of deep sub-specialization you only have an agglomeration of outliers that are really good at what they do, and then the plankton, just like in every profession.
You can either have someone that knows exactly what he’s doing, or someone who rarely does it. A large part of medicine is guesswork, and you want someone who’s seen enough to be doing the guessing.
There is no shortage of physicians if you have the money. You can see the absolute best physician of your choice literally tomorrow if you have enough money to name a hospital wing. They’ll just see you while they eat their lunch, or come in an hour earlier.
The shortage you are talking about, is a shortage of competent, qualified saints willing to forego compensation after spending a decade in training to treat the poor.
If your expectation is that the top talent should for peanuts - do you really think there can be no shortages? You are literally asking for saints and miracles.
P.S. >there's more to life than just strictly salary. Things like retirement benefits, socialized healthcare, safety nets etc all contribute to reasons why this occurs.
$2-3 million/year solve all of the above. There is more to life, but 90% of every graduating class are there for money, nothing less.
The fact that someone can see a physician tomorrow with enough money is irrelevant because with enough money they are no limited to the US. Experts are not located entirely within the US, hence why many millionaire/billionaires will travel for medical aid because other countries might have people with more expertise in XYZ.
The rest of your comment is completely irrelevant to the argument I'm making.
you do not understand how the industry works. salaries are high because the supply is constrained.
supply is capped. by residency availability.
doctors, like many others, don't want to live in some areas, and supply ends up being unevenly distributed.
In any major US metro, you can see a cardiologist TOMORROW. Don't even have to be a millionaire.
https://www.merritthawkins.com/uploadedFiles/MerrittHawkins/...
Let me guess, next will be "but muh AVERAGES"?
You can remain average. Best of luck.
feel free to edit/nuke it, nbd.
It’s just a US-lite system compared to Canada (which like Cuba outlaws private healthcare, but has a grey healthcare market because the public system is broke), and NHS(which is broke like Canada, but at least you can pay private).
1) Patients avoiding appointments due to costs, just like the US:
“Almost impossible to get bulk billed’: patients avoid seeing doctors due to out-of-pocket costs”
https://amp.theguardian.com/australia-news/2022/may/12/almos... Private healthcare is better in Australia:
2) Private healthcare where cash suddenly trumps virtue-signalling on the internet.
Paying cash money? Jump the queue! The poor can languish and die while on waitlists.
“Public patients requiring elective surgery for cancer, heart conditions and other serious health issues face longer waiting times than their privately insured counterparts in public hospitals, according to a new report. ”
https://thenewdaily.com.au/life/wellbeing/2017/12/06/private...
3) Refusal of public patients.
In some cases, physicians don’t even take any Medicare patients -at all-.
Let’s take a rather relevant specialty for this thread, psychiatry:
“Psychiatry costs in particular are prohibitive. One reader reported paying $300 for 20 minutes with a psychiatrist, while another said they paid $900 for the first session and $500 for subsequent sessions. Another reader said her one-hour psychiatry session cost $435, and the Medicare rebate “didn’t even cover half”. Another reader, Jamie, said she had paid $220 and received $76 back from Medicare, but that her initial appointment was $600.”
Congrats! You are paying American rates! Good job Australia!
https://amp.theguardian.com/australia-news/2021/apr/19/like-...
My goodness, isn’t this a huge surprise! Highly trained people want to get paid even in Australia, news at 11. Who could’ve guessed.
Money talks. It’s that simple. Why is that so hard to accept?
Engineers used to move to Bay Area to get the best possible salaries, but we should suppress doctors who even as much attempt to move overseas for bigger pay checks, lol?
Even in formerly communist countries bribes got you better access.
As soon as you can figure out how to prevent people trying to leverage every resource they have and try to outcompete others to avoid death, let us know. you might get a Nobel.
LMAO, what? It's literally, and defined as the end product of an acceptable standard of care, and used to judge whether a standard of care was given to a patient.
> Probably not the remote Australia with a population of ~10% of the US.
Victor Chang (https://en.wikipedia.org/wiki/Victor_Chang) would have liked a word with you. Trained in the US. But still set up shop in Australia. Considered the world's leading heart transplant surgeon, with survival rates well into the 90%s.
> Guess where your tertiary centre in Canada/Aus/Uk often mails your blood work and biopsies once they are at the end of the rope? That’s right. USA.
Because of course you mention tertiary centres as if any of those three don't actually have primary research facilities. A tertiary hospital in Australia isn't mailing shit to the US for diagnostics. In the event that they can't figure it out, there's many many state of the art facilities available.
All of this reads like some weird xeophobic libertarian fever dream, and the notion of Canadian, Australian healthcare systems as some primitive backwater barely discovering modern medicine is laughably ignorant.
What do you mean? Standards of care vary wildly based on tons of factors. Try getting to a cath lab in under 60 minutes in Nunavut.
Same goes for the middle of the Outback, or the Scottish Highlands.
I don't remember a single OECD measure that the US falls behind the UK in, perhaps child mortality at birth, so I'd be interested to know which life saving care you're referring to.
Moreover, as the nurse was teaching my class (in London) how to give CPR said "if you're going to have a heart attack, have it in America (because your chances of survival will be higher".
The invoice causes another heart attack. The another heart attack will cause another invoice. It's a vicious, if short, cycle.
Life expectancy at birth is affected greatly by, among other things, gun violence in young men (I already shared in another comment an overview[2] of a paper[1] showing how this works). There is a quote[3] in the Guardian by the paper's lead author:
> “I was surprised by the sheer magnitude of the impact of firearm deaths, that they’re only 1%-2% of deaths in the US but responsible for 20% of the gap in life expectancy between the US and other countries in men,” said Andrew Fenelon, the lead author of the letter.
It's not enough to compare simple, bare statistics and come to a judgement that US healthcare is failing compared to other countries based on just that. I'm not an advocate for the US system but I do get the feeling that it can be unjustly maligned at times.
[1] https://jamanetwork.com/journals/jama/fullarticle/2488300
[2] https://academyhealth.org/node/1891
[3] https://www.theguardian.com/us-news/2016/feb/09/guns-car-cra...
Are you suggesting that the US is a special case among the 38 member countries of the OECD, and is the only one that has this phenomenon?
> Life expectancy at birth is affected greatly by, among other things, gun violence in young men
Which is just another way of saying the US needs better healthcare to deal with this major issue that it alone faces.
https://ourworldindata.org/grapher/child-mortality-igme?tab=...
But maternal death (The number of person who die from pregnancy-related causes) is also more than 10 times higher than comparable countries and was raising for 20 years while other comparable countries were lowering it.
It seems an even worse picture of the situation. Adult women dying at 10 times the rate of OECD countries because of pregnancy. It will probably raise again given the new limitations/bans on abortion (accessible abortion is correlated with lower maternal death)
https://ourworldindata.org/grapher/number-of-maternal-deaths...
Life expectancy in the US is quite lower than comparable countries and stopped growing (but it might be related to the 8 to 10 times higher homicide rate than other OECD countries)
https://ourworldindata.org/grapher/life-expectancy?tab=chart...
Death rate from HIV/AIDS is nearly 6 times higher than the UK and it’s not lowering anymore (it has plateaued at a much higher level than comparable countries)
https://ourworldindata.org/grapher/hiv-death-rates?tab=chart...
Is there a health measure that you can find where the US is better or at least at the same level than say UK or at least France? (which is sadly for us French not the best in class…)
Not a trick question, I’m curious to see if the US have some outlier health measure that it aces, sometimes it happens!
I appreciate that, no worries.
Without looking I would go for any cancer statistic, as the UK is often terrible in those[1]. So, I did a search of the OECD Health Care Quality Indicators[2] (as they're the ones used to compare countries) to see if I was right. (As an aside, I look at these every few years and the last time I looked I found some surprising stats, like the ones about child mortality in the States, but occasionally there's a more complex reason behind a poor statistic[3]). Anyway, it seems I was (sadly) right:
## Breast cancer 5 year net survival
France 86.8 87.2 86.7
United Kingdom 79.8 83.8 85.6
United States 88.9 89.8 90.2
## Colon cancer 5 year net survival
France 60.7 63.6 63.7
United Kingdom 52.0 56.5 60.0
United States 64.7 65.5 64.9
Anyway, those are the first two I looked at. I've done this before and honestly, the US system holds up very well. I'm sure it does even better if it's adjusted for economic class - which obviously opens up a barrel of probably quite fair criticism. I know that some on here complain about how the US can bankrupt you if you get sick, but I'd take that over the UK's system in a heart beat. Not sure about France, though it does seem to have a more sane system than the UK.
[1] https://web.archive.org/web/20201111165643/https://www.nhs.u...
[2] https://stats.oecd.org/Index.aspx?QueryId=51882
[3] https://academyhealth.org/node/1891
Edit: missed off a markdown link ref
If you take every man over the age of 55 and provide rigorous diagnosis for prostate cancer, but you then provide zero treatment to anyone, your 5 year survival rates suddenly look really good. This is because you've diagnosed a lot of slow growing cancer that doesn't kill people. But obviously you've done nothing to improve all cause mortality or quality of life.
https://academic.oup.com/jnci/article/98/24/1761/2521971
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5454760/
> Our findings suggest that there are no reliable relationships between changes in 5-year survival and cancer incidence or mortality. Increases in 5-year survival might therefore represent poor indicators of progress in cancer control at the population level. In the absence of over-diagnosis, 5-year survival might only indicate improved diagnosis and treatment in clinical practice.
But why? Diabetics don't want generic insulin, it's not as good as the newer insulins.
And if they want cheap generic insulin, Walmart already sells generic insulin for cheap. Why not just buy it from Walmart and subsidize it? Why would you actually try and make it yourself and sell it for below market prices? That seems like a hard way to accomplish the same thing.
What problem are they trying to solve?
I mean, the LA Times reported on Walmart's cheap insulin not a year ago.
https://www.latimes.com/business/story/2021-06-30/column-wal...
Generic fast-acting insulin is now legal because patents have expired. But generic insulin is still quite expensive in the US.
But regardless, how does that change my argument?
Why is CA getting into generic insulin manufacturing when they could just have someone who knows what they are doing make it?
Why not just find an existing seller and negotiate some pricing deal and then subsidize it for people in CA?
I sure do. I use Humalog now and it's out of patent. There just isn't a generic available for it because it's just not all that cost effective to do. Creating and producing a generic for biologics (like insulins) is not simple like it is for simple chemicals. As I understand it, they need to undergo trials and the like, which drastically raises the price of creating them.
There's also admelog, which is not a generic but is a "biosimilar" that is much cheaper.
I don't get this, but I'm not in the US. Over here the prescriptions are for the active ingredient unless something specific is required and then you get both the name and the "no substitutions" box is ticked. The pharmacy will just ask "are you ok with a generic" otherwise.
Is it much different? Why wouldn't people be prescribed "insulin" in this case?
Even then the question seems weird - people will know about this happening, they will ask for it. How would it not be prescribed?
Somehow this 'fat is bad' lie came into the world. We have been eating fat for thousands of years. Fat is full of all kinds of stuff the body needs. The brain can tell us when we ate enough fat so we feel full. The body can handle fat very well so it doesn't get stored and we won't grow fat.
But no, fat became wrong and was removed from our food making it tasteless. So sugars are added. This is good news for the food industry because the brain doesn't register when we have enough sugars. So we keep eating.
And this item on HN continues the trend. There is no solution but it's about companies making huge profits over insulin.
The appeal to naturalism is kind of iffy, though. The kinds and amount of fat we eat might be substantially different than many of our ancestors. I'm not making an argument either way, just that I doubt modern food resembles ancient diets.
They won’t pay the $400. They often just won’t get any insulin at all and drastically shorten their lives.
Edit: Sometimes people that can’t afford $400 also can’t afford $72. How does your point matter for those real life humans?
edit: say their insurance covers 80% of the cost, the patient still has to pay $80 (at $400). if the cost of a vial was $20, they only pay $4 which is more reasonable.
Lobbying, start-up costs and more can all be contributing factors. Something can be exceedingly cheap to manufacture, but then you gate others from manufacturing through other fashions. Or they just outright buy out your manufacturing capabilities for pennies, then turn around to sell the insulin at massive profits again.