4 in 5 Americans who need insulin have taken on credit card debt to cover cost | Hacker News Reader

4 in 5 Americans who need insulin have taken on credit card debt to cover cost

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194 pointslaurex187 comments

On a per capita basis we already spend enough money in the US to have the best socialized medicine system on the planet: https://data.oecd.org/healthres/health-spending.htm (if you remove voluntary spending we still spend more than anyone else)

They have the funds, our government just isn't competent enough to deliver it.

Cruelty is the point.

Don't you think it's rather corruption than incompetence?

ah yes, corruption and incompetence are exclusive to American systems in a way which no other country can deal with.

Whataboutism achieves nothing

Why give them something for free when you can just have then work to death instead?

Most of it is likely going to lawyers and health and malpractice insurance companies.

No it's not. Do some research malpractice is a tiny percentage of costs overall. That's a red herring thrown out there by doctors and insurance companies.

Yes it is. A single large judgement anywhere in the country and the malpractice insurance for all doctors everywhere in the US is bumped up just for premiums. Some disciplines like OB are forced to pay a quarter of a million in malpractice insurance every year just to practice. For others, it went up from 30 to 50K per year just this year alone. When that happens every practitioner starts requiring expensive tests that have a tiny % of catching something, but may catch that stroke that triggers the $100 million lawsuit. 60% of doctors in the US are sued every single year, with each case worth 100k for the doctor to defend, and almost all are without merit. If you want to cut down healthcare costs, insurance and tort reform would be the #1 place to do it. Create a pool of money to cover bad cases and push out bad doctors, but the current system is untenable and benefits nobody in healthcare.

> Some disciplines like OB are forced to pay a quarter of a million in malpractice insurance every year just to practice

That's one and a half premature babies[0], or ten c-section babies. That number could be low or high depending on the average number of babies that OB is working with.

[0] "a premature baby spends an average of 25.4 days in a speciality care nursery at an average cost of $144,692" - https://www.oviahealth.com/blog/the-real-cost-of-preterm-bir...

[1] "A cesarean section (C-section) is much more expensive, costing an average of $22,646 including standard predelivery and postdelivery expenses." - https://www.valuepenguin.com/cost-childbirth-health-insuranc...

1/10 or less of that money is going to the OB. The facility collects a far bigger chunk. If you break down the hours worked by the amount doctors get actually paid, they are a tiny tiny share of health expenses and often make very low $ per hour worked. The biggest expenses go towards insurance, defensive tests, hospital management, and expensive specialized materials.

Yes, but worth remembering this is more than just cutting out capitalist's profit. This would need to involve running the medical sector better + pushing wages for doctors and other medical professionals down, but yeah the fact that US federal government spends more than the UK on healthcare per capita while not actually delivering healthcare to everyone is crazy

Yep, doctors in the US make anywhere from 2-5x that of doctors in the UK. Take a look at these salaries posted by the NHS [1]. Nurses make more too. It's very common for RNs in California to make upwards of $50/h even starting out, which works out to more than the specialized doctor pay in the NHS link.

Student loan debt isn't even a big factor in this because of the sheer size of the salary gap. $500k loan gets paid off fast when you make $300k+, and you get that salary for life whereas the loan only weighs you down for the first 5-10 years.

[1] https://www.healthcareers.nhs.uk/explore-roles/doctors/pay-d...

OTOH, doctors in the US often pay $50-$200k/year in malpractice insurance[1]. In the UK, indemnity comes from the NHS automatically.

https://www.nerdwallet.com/article/small-business/how-much-i...

Yes, for a surgeon. Scroll down to internal medicine, which is closer to who will be prescribing insulin, and note it's 8k to 50k. (No median or mean is given?)

I'm not at all shocked someone who cuts people open and removes or adds objects has a high liability insurance.

I have no source for this, but blaming medical system costs on liability insurance feels like a way of blaming the patients instead of the system. "If only greedy people were not trying to get rich quick off lawsuits."

Yes, doctors in the US can make good money, but imo, many deserve it - its is hard to become a doctor, and it should be - 4 years of undergrad, 4 years of medical school and then 2-3 years as a lowly paid resident making a pittance (compared to a doctor) - so that is 6-7 years of opportunity cost lost over someone that only had 4 years of school - i.e. years when you could have been working and making salary doing something else.

Compare that to a programmer, assume 4 years of undergrad, and then you get out making $100K easily - especially if you were a very smart student, probably much more (i.e. someone that was smart enough to be a doctor or a programmer), not even accounting for raises and inflation, 6-7 years at $100K and also assume 400K for med school loans and the programmer is already almost $1Million ahead of the doctor at year 7.

Over the long haul the doctor will likely do better, but it will take years to catch up once you factor in the huge costs a doctor has vs a programmer - I for one am glad only really smart people can become MDs.

Sure, the point isn't do they deserve the money, the point is to achieve European like prices for healthcare you need to do more than stick it to the venture capitalists or something

Can UK doctors own their practice or are they all employees of NHS?

Competency? The system is working as intended, it prioritizes the needs of capital flowing to the elites. You must come from somewhere else, one that places citizens on a slightly higher strata than the US does.

To believe this shows total ignorance of the history of the healthcare system in America. The whole thing is a crazy pile of hacks and accidents with 0 design or intent. It’s tape and string all the way down. We just stumble from unintended consequence to unintended consequence. Shit, the only reason it’s tied to employment is because of post war wage and price controls.

This is true. But fatal flaws such as the fact that Medicare cannot negotiate prices with drug companies are not accidents but rather artifacts of corporate lobbying. There are many examples of rent seeking like this across the system

Medicare didn't cover drugs at all until 2003 when Bush put together Medicare Part D to bolster flagging support. Medicaid doesn't negotiate prices either, but it's mandate that it will pay the lowest negotiated price in the market. When Part D was passed it almost had a similar structure. In 2016 there was a move to add negotiation but it fizzled. In both cases the CBO estimated that negotiating prices would save precisely no money. The way Medicare plans actually work is that plan provider bid to be part of the program and they are selected on a cost basis, and they then negotiate drug prices. Could Medicare administrators do a better job? Well the CBO has twice said no. Medicare Part D was a huge hack to cover a made up problem, which is to say seniors too wealthy for Medicaid not being able to afford their heart medicine. It was essentially GWB trying to buy voted before the 2004 election. So I think you're wrong on the history here.

Who do you think cane up with and wrote his domestic policies? That’s literally what lobbyist are for. They have these things drafted up ready to go years in advance (just like the Heritage foundation and SC picks). The only thing that might be last minute is the decision to go with it.

They know exactly what the downstream effects of these programs will be. Regulatory capture is a well attested phenomenon, so I’m skeptical of any claims that all the Byzantine policies that just so happen to favor big business came about haphazardly

Bill Frist wrote most of the legislation that became Medicare Part D, he was old buddies with Rove. Frist was a hospital guy and a bit of a scammer before going to congress, I won’t deny that he was in the tank for hospitals, but the pharma lobby didn’t write his law. The original version was pretty modest, people criticized it at the time for not spending enough money, though it may now bankrupt Medicare. I remember it pretty well because I was just then getting interested in politics, but a ton has been written about it.

I guessed and was basically directionally correct. That guy seems like he fits the Bush mold - Cheney and Rumsfield privatizing huge parts of the military comes to mind. Don’t get me wrong what you are saying makes sense. I’d be more surprised if it were a coherent system.

But I do believe many government regulations and laws that may seem like sphaghetti against the wall at first are actually very intentional and lucrative to someone.

We’ll this thing in particular was Frist’s pet project for years, Bush and Rumsfeld just needed seniors on board for the election so it finally got done.

A lot of things happen that way, just horse trading and trying to get re-elected.

> To believe this shows total ignorance of the history of the healthcare system in America. The whole thing is a crazy pile of hacks and accidents with 0 design or intent.

No. The health insurance companies spend a lot of effort and influence on lobbying to make sure they are there in the loop to cash in on every health care transaction. It's all very intentional.

What percentage of healthcare spending would you guess is health insurance company profits?

The number is around 3% of healthcare becomes health insurer profits.

https://content.naic.org/sites/default/files/inline-files/20...

The more frightening thing is how many middlemen's costs are baked in. Of course insurers aren't sitting around twirling their moustaches, figuring out how to be incrementally more evil; but they are spending astronomical amounts on compliance and other side-things that aren't actually healthcare.

As someone else pointed out the insurance industry’s profits account for a grand total of 3% of expenditures. The majority of healthcare spending is through Medicare, Medicaid, and the VA. You can also see in the thread below how I explain the non insurance industry history of Medicare Part D.

There are so many times in the history of American healthcare history that someone had an idea for a fix, sold it to their voters, wrote the law, got it passed, and then it flopped.

> As someone else pointed out the insurance industry’s profits account for a grand total of 3% of expenditures.

The insurance industry profit is not a meaningful number in this context.

Profits are only what is left over after all expenses are deducted. These expenses include all the operating costs of the medical insurance industry (salaries of all employees, massive CEO bonuses, real estate costs and on and on and on).

Every penny of those costs are unnecessary overhead. All those (hundreds of) thousands of administrators and CEOs getting bonuses are not providing any health care to anyone, only adding overhead to the system. They feed off the work of doctors, nurses and medical staff but don't provide any value.

So the number to look at is the total gross revenue of all medical insurance companies. All that money could be saved by simply eliminating the insurance industry middleman and paying medical staff (those who actually directly contribute to providing health care) directly.

The reason for the initial bad design is that it was all hacked together.

The reason it hasn't been fixed is that there are powerful people that don't want it to be fixed.

I wouldn’t attribute to malice what could be more easily explained by incompetence. There are a ton of broadly agreed upon tweaks that could in aggregate fix a lot but none of them are big enough to campaign on, and they don’t fit neatly into either party’s platform. For example funding more residency positions could drive down the cost of delivering a lot of services over the course of 10 years, but that’s at the edge of CBO accounting and doctors are maybe mildly against it. It’s too free market oriented for dems and a little to spendy for Republicans.

I could go on, but the point is a lot of fixes just aren’t sexy, we elect dummies, and well intentioned people make mistakes.

https://stanmed.stanford.edu/2017spring/how-health-insurance...

You should read this before claiming I show "total ignorance of the history of the healthcare system in America". Stop making excuses for shitty politicians.

I'll quote some for you to start:

>By the 1990s, the Blues, which offered insurance in all 50 states, were hemorrhaging money, having been left to cover the sickest patients. In 1994, after state directors rebelled, the Blues’ board relented and allowed member plans to become for-profit insurers. Their primary motivation was not to charge patients more, but to gain access to the stock market to raise some quick cash to erase deficits. This was the final nail in the coffin of old-fashioned noble-minded health insurance.

>WellPoint’s first priority appears no longer to be its patient/ members or even the companies and unions that choose it as an insurer, but instead its shareholders and investors. As in any for-profit enterprise, executives are compensated for how well they perform that financial function and are compensated well. In 2010 WellPoint had intended to hike premiums in California by 39 percent, before an attorney general effectively nixed the plan. CEO Angela Braly received total annual compensation of more than $20 million in 2012, despite the fact that she resigned under pressure that year because the company revenues were down. Joe Swedish, the new CEO appointed in 2013, is a longtime health care executive who served at the for-profit Hospital Corporation of America. His starting salary and bonus totaled about $5 million, not including stock options.

>To express their collective frustration, members gathered signatures for a MoveOn.org petition: “Anthem Blue Cross: Stop Playing Politics with Our Premiums.” They urged their insurer “to stop spending corporate funds on political campaigns, disclose everything it has spent directly or indirectly on political campaigns, and use the money to lower rates for Anthem policy-holders and California taxpayers.”

>To increase profits, all insurers, regardless of their tax status, have been spending less on care in recent years and more on activities like marketing, lobbying, administration and the paying out of dividends.

Yep

- artificial limit on number of doctors

- unlimited lobbying by pharma companies

- unlimited advertising for said companies

- single payer system gutted every time

- insurance company lobbying prevents insurance across state lines

- on and on

Whenever talking about America, you need to do a massive cost-of-living adjustment for the entire system. For instance, a general practitioner in Germany can expect to earn around 3,000 Euros after taxes per month, and a surgeon barely grosses six figures. Ask a doctor in America if they'd be willing to work for that salary. And the same adjustment needs to be made for nurses, administrative staff, pharma employees, device manufacturers, medical suppliers, etc.

Edit: since I've being downvoted, I just wanted to clarify I'm neither agreeing with or disagreeing with the assertion that the U.S. spends enough to have the best medical system. I'm just highlighting the fact that, in general, highly skilled labor in the U.S. often earns 3-5x (or more) than highly skilled labor in other countries.

I wonder if the German surgeon would work in the US for some smaller amount of salary increase (though I suspect everything in the US is designed to prevent this).

Globalization is apparently good in all contexts except medicine and law, the two most common fields of employment for a congressperson or senator. The AMA would scream bloody murder if someone seriously proposed hiring foreign doctors to stem the shortage they caused by limiting residency slots for decades.

The AMA limitations of residencies and restrictions on foreign doctors should be challenged though anti-trust litigation.[1]

1. https://journalofethics.ama-assn.org/article/challenging-med...

That's misinterpreting data. We subsidize global pharmas (and medical device companies) based out the of US with the excessive cost we pay as patients. That is probably because of their lobbying. Since private health insurance mostly acts as a pass through, they are happy to let the cost curve rise as long as individuals and employers pay the bills.

The only place in the US government that controls its formulary is the VA/Tricare and they have remarkable success in managing costs there. Otherwise, you mistakenly believe the government controls these costs. We have incompetent or corrupt private industry, and a major party that is eager to deregulate things further.

> Since private health insurance mostly acts as a pass through

Citation Needed.

Prior Authorizations and other "misfeatures" ensure this private health insurance blocks necessary treatment and captures the "savings" at patient's health and sometimes, their lives, expense.

https://www.medpagetoday.com/opinion/second-opinions/99422

> We subsidize global pharmas (and medical device companies) based out the of US with the excessive cost we pay as patients.

Pretty sure this has been forever debunked. Not sure why you’re wanting to be a end-stage capitalism apologist

Insulin is not a subsidized item. It is very old tech and they make a profit in other countries. Its about <=$5/vial to make

We - the US consumer, not the US government - subsidize global pharma with the ridiculously high prices we are forced to pay for drugs. That is exactly my point.

With CHIP[0], Medicare[1] and Medicaid[2] that isn't really true. The US taxpayer foots the bill for the majority of medical costs in the US. If you are a child, elderly or disabled (ie. most of the people with high medical costs) it's very likely that you fall under one of those programs.

[0]https://en.wikipedia.org/wiki/Children%27s_Health_Insurance_...

[1]https://en.wikipedia.org/wiki/Medicare_(United_States)

[2]https://en.wikipedia.org/wiki/Medicaid

Certain companies making crazy markups is not the same as subsidising the world. Get off your high horse

Let unpack both of your points separate. Last point, first: I don't mind subsidizing the world to a degree. A lot of these are US companies or international pharma with substantial US presence. The US is a phenomenally wealthy country, and a healthy and stable world is in everyone's interest along with being a moral imperative. The balance of whom that is falling on is inequitable for various reasons within the US, though.

Back to your first point: this is exactly about companies charging crazy markups. Look at https://costplusdrugs.com/ for some examples of how bad it is.

Now, we all understand that R&D and studies for safety are necessary and expensive, and not every drug succeeds. Every successful drug pays those as amortized costs, it's not simply a matter of manufacturing and raw materials.

However, https://en.wikipedia.org/wiki/Martin_Shkreli was a famous and egregious example vis a vis Daraprim of a common practice. Further, you have increases for non-elastic needs (insulin, epi-pens) that far exceeds increases to increases in manufacturing costs. Then you ones like Solvaldi that are just priced on the max the market will bear: https://www.fiercepharma.com/financials/gilead-prices-hep-c-... ... this is not all about recovering development and testing costs, obviously.

This is simply not true- you can purchase this cheap generic insulin from Walmart for not much more than that. However, most people group all sorts of new versions of insulin into a category of drug, and those new versions are definitely not "old tech".

I have no idea on what the costs to develop, produce, and distribute these insulins is, or even what is being charged for them. Maybe it is too high, but it is not so simple as a generic 5$ per vial drug.

Modern insulin is over 20 years old. There have been some small incremental improvements that help some but they are not what most want to use. Novolog/Novorapid were release in 1999

The old versions of insulin are still very cheap. its the much more modern versions that are much better at controlling diabetes, with much less side effects, etc.

Modern insulin being over 20 years old

You don't need to subsidize anything. I mean sure, you pay for those ridiculous salaries of all people involved in pharma, insurance, all lobbyists and snake salesmen who push/bribe doctors for over-prescriptions and obviously shareholders. Out of those, doctors are the only ones deserving high salaries, mostly. But they shouldn't come from such a bad incentive.

World would be just fine if US healthcare wouldn't be such a bad joke on democracy, freedom and all other things that seem to win US elections but actually matter little where they should.

Drug and device marketing and sales really ought to be illegal. Kickbacks to physicians and administrators should be limited in the same way they would be for bribes to government officials, both on the medical and industry sides.

I think this comment author's use of the word "competent" means "in delivering medical treatment to Americans."

But I also think "the government" shouldn't "deliver medical treatment" - I suppose they could mean "in deciding how to spend tax dollars to get medical treatment delivered."

In which case, I agree that is not their competency.

it doesn't have consensus

and that comes from the people and their representatives

I disagree. It is an efficient system, which pays dividends to its investors every month:

https://www.statista.com/statistics/257364/top-lobbying-indu...

If the US government was really efficient, US citizens would be paying big pharma and the military industrial complex every day in order to go to work.

You don't need more efficiency, you need less corruption. And that starts by severely curtailing lobbying.

It’s not competency. It’s the predatory insurance companies in the middle. Socialized medicine takes away that inefficiency but the GOP will block any attempt at improving life for the common person. It’s blunt but true. They desperately want to maintain the hierarchy of men over women and white races over others. It’s really that simple but with a prime directive like that most of us in the US are going to be unhappy.

One of America's greatest paradoxes. By far largest per capita health expenditure in the World but not the best healthcare.

by 'not the best healthcare' do you just mean that it's not the most efficient and affordable, or are you claiming that another country has better expensive healthcare?

I think it was my choice of words. By healthcare I mean the populations's effective health care which is what matters and not just the quality of the services offered.

US ranks 46th on the life expectancy. Not saying that's a perfect metric but's a strong signal.

https://www.worldometers.info/demographics/life-expectancy/

- Cost-plus contracts disincentive cost-benefit value delivery. - Costly healthcare disincentive use of health services.

It's a system that combines the worse of public and private healthcare systems.

doesn't seem like much of a paradox for the best and most expensive healthcare in the world to also not be very efficient otherwise

> 4 In 5 Americans Who Need Insulin Have Taken On Credit Card Debt To Cover The Drug's Cost

This smelled fishy to me so I looked a little further into the numbers. The page linking to the study says that it involved 1,000 insured participants and 1,000 uninsured. So right off the bat, unless exactly 50% of the population is insured/uninsured, you can't really extrapolate exact numbers from this survey, unless they gave you results broken down by insurance status.

According to https://www.cdc.gov/diabetes/data/statistics-report/diagnose..., about 46% of diagnosed diabetes cases are in people >65, meaning covered by medicare. I'd assume that at least a good chunk of people <65 have insurance, meaning this survey is completely unrepresentative from the start.

Don't take any of this to mean that I don't think the price of insulin is too high. It certainly is. But this survey is misleading at best.

So if 100% of uninsured people have taken out credit card debt for insulin, merely 60% of insured people have! That doesn’t sound much better.

Yea the op is bringing up a bunch of details to obscure the findings. Its still really bad no matter how you slice it, and trying to slice it a bunch of different ways to make it look less bad is just disingenuous

I don't believe this is true. I'm merely calling out the lack of detail on methodology of this "study". They are already pretty explicit that this isn't a true random sample, but I'd like more info on how. For all I know, this study was done on CharityRx's own website, which presumably caters to people who are less likely to be able to afford insulin in the first place.

I'm not in any way saying insulin prices aren't an issue, but at the same time, I don't think misleading headlines are helpful either.

Sure, but I'm skeptical of all the claims made here given the lack of clarity in the example I point out above. This is not a peer-reviewed study, it's a "survey" performed by a company with very little information given about methods.

About 10% of US residents are uninsured.

https://www.aha.org/news/headline/2021-11-17-cdc-reports-uni...

Regular Medicare doesn't cover insulin. Beneficiaries would have to enroll in a drug plan.

https://www.medicare.gov/coverage/insulin

Just looking at statistics of who has any kind of diabetes isn't valid either. T2 diabetics are vastly less likely to use injectable insulin, where as 100% of type 1 diabetics must use insulin. Type 1 diabetics are commonly young, hence it being known as juvenile diabetes.

T2 diabetes gets more common in the overweight and those unable to exercise because of mobility issues increasing their levels of insulin resistance, hence the rise you see in the elderly.

One of my brothers is a diabetic and was involved in a project to give insulin to US Americans. I thought it was a joke at first. They were sending some kind of Red Cross style Medical Aid Packages in the ordinary mail. I think the point was that it was technically illegal, breaking import restrictions, and the point was to shame the US authorities.

At this point literally every other country in the world chimes in about how broken the American healthcare system is.

Yup.

The world should hope we don’t fix it. Most of the R&D is done here because the market opportunity is huge. But if that dries up, then costs will go up for everyone else.

how much R&D are these companies doing for insulin?

Whatever amount it is, US politicians are not willing or able to pay for it with US taxpayer’s money.

Yeah, if anything, the explosive profit opportunity is all the more reason to effectively subsidize insulin for the general public. Since pharma folks are already so greedy, go ahead and get a government contract for it, those are always hugely overinflated anyway!

Most of the markup is not done by big pharma. It’s done by PBMs. The fictional ‘list’ prices exist as a marketing scheme to get private insurance to pay high prices ‘at a discount’. Cash buyers are a casualty caught in the middle of this scheme.

Sounds like anonuser needs to read about the insulin's history: https://en.wikipedia.org/wiki/Insulin#Patent

Snarky comments only work when you are factually correct.

Modern insulin analogs were not invented 100 years ago.

That is very true...Insulin now of days is very different then when it was first introduced. For example, there are now "long-lasting" and "fast-acting" insulin that has been molecularly modified for different outcomes.

Diabetes is a very old disease that ironically is pushing the limits of sensor fusion, but it is very poorly understood by people outside of the Type 1 community.

I personally wish these two diseases were completely renamed as it does a disservice to both Type 1 and 2 patients.

sigh, sure let's give a more than 1-line answer to your original (pretty worthless, let's be honest) 1 line comment.

"Unlike many pharmaceutical markets, which see the entry of generic competitors, no generic or biosimilar insulins have been approved in the United States.68 This is not due to patent protection of the existing products.69 The patents for the majority of human and analog insulin products have expired or are about to expire.70 At the end of 2015, 11 insulin products had no associated patents or exclusivities.71 This number has since risen to approximately 17 by July 2019 (including those products where only the insulin pen device is protected), shown in Table 2."

Knox, Ryan. “Insulin Insulated: Barriers to Competition and Affordability in the United States Insulin Market.” Journal of Law and the Biosciences 7, no. 1 (July 25, 2020): lsaa061. https://doi.org/10.1093/jlb/lsaa061.

This is corroborated by Health Access International's deep dive from several years ago:

"There are no patents on any formulations of human insulins. Based on the filing date and a 20 year patent period, patents on analogue insulins already on the market in the US and Canada have expired or will soon expire in these countries and elsewhere (Figure 1)."

https://haiweb.org/wp-content/uploads/2015/05/HAI_ACCISS_fac...

https://haiweb.org/wp-content/uploads/2016/04/ACCISS-PatentR...

And yet, despite this, the US remains alone in having prices not only multiple times the cost of any other country, but increasing at an alarming rate (tripling over the past deacde) while prices stay the same or fall elsewhere. There's zero shortage of analysis and ink spilled in both the popular press or in academic analysis/ peer-reviewed press on why markets are so fucked in the US pharmaceuticals, so I just assume any talk about how R&D cost recovery happens to only be a thing in the US (and somehow accelerating despite new products not being released) to be either extreme low effort or just plain bad-faith (which are you anon?), but for those reading along that might be interested, a few places to start to do their own research if they really care about the topic:

Mulcahy, Andrew W., Daniel Schwam, and Nathaniel Edenfield. “Comparing Insulin Prices in the United States to Other Countries: Results from a Price Index Analysis.” RAND Corporation, October 6, 2020. https://www.rand.org/pubs/research_reports/RRA788-1.html.

Hirsch, Irl B. “Insulin in America: A Right or a Privilege?” Diabetes Spectrum : A Publication of the American Diabetes Association 29, no. 3 (August 2016): 130–32. https://doi.org/10.2337/diaspect.29.3.130.

Schneider, Tyler, Tara Gomes, Kaleen N. Hayes, Katie J. Suda, and Mina Tadrous. “Comparisons of Insulin Spending and Price Between Canada and the United States.” Mayo Clinic Proceedings 97, no. 3 (March 1, 2022): 573–78. https://doi.org/10.1016/j.mayocp.2021.11.028.

Herman, William H., and Shihchen Kuo. “100 Years of Insulin: Why Is Insulin So Expensive and What Can Be Done to Control Its Cost?” Endocrinology and Metabolism Clinics of North America 50, no. 3S (September 2021): e21–34. https://doi.org/10.1016/j.ecl.2021.09.001.

Luo, Jing, and Aaron S Kesselheim. “Evolution of Insulin Patents and Market Exclusivities in the USA.” The Lancet Diabetes & Endocrinology 3, no. 11 (November 2015): 835–37. https://doi.org/10.1016/S2213-8587(15)00364-2.

A lot. Insulin is a category of human insulin analogs. Each analog has unique properties.

You can have the ‘old insulin’ for something like 25$ / 1k units. But it’s very hard to use relative to modern analogs, so people prefer modern analogs.

Edit: Minus points for facts that disrupt the narrative. I love it.

My family member uses Humalog and it's patent expired in 2014 yet it's hundreds of dollars:

https://medcitynews.com/2019/03/lilly-to-introduce-lower-pri...

The problem is that there isn't competition on the market for this product. The Open Insulin people were trying to make it available to the public but they are stuck trying to get through the regulation.

It's entirely possible that if we got rid of the regulation then the whole problem takes care of itself and it becomes a non issue.

IMO it's not the regulation that is the problem...it's the entire healthcare system we have in the US.

Humalog and other types of the same exact insulin are pennies on the dollar in other countries with very different healthcare compensation programs between the vendors and purchases. It's bizarre to say the least.

This is precisely because the US market pays for all of the risk. Once the risk is paid for by the US market, it’s very cheap to sell extra capacity to other countries. All the fixed costs are already paid for and the risks are low.

You can buy generic novolog at Walmart for 75$ for 1000 units vs. 550$ list for the same of branded humalog.

But basically you are correct that regulation is the largest barrier to price reductions. Patients pay the price of FDA regulation (for better or worse). That’s not really the drug companies fault.

>But it’s very hard to use relative to modern analogs, so people prefer modern analogs

Are you actually suggesting people are going into debt [1] and killing themselves[2] just because they prefer modern analogs?

[1] this post

[2] https://www.independent.co.uk/news/world/americas/us-politic...

If you are very rigorous with diet and exercise, you can live with the old stuff.

The new stuff lets you eat a wider range of foods without having to time everything precisely or worry as much. about hypoglycemic events.

I don’t know if that’s a preference or if it reflects the way Drs treat T1 patients.

>so people prefer modern analogs

>I don’t know if that’s a preference

so which one is it?

Doesn’t like.

Cuba, of all places, have pretty great medical R&D?

Don’t think your statement means too much.

I wonder how many lives all that R&D costs in the US. Seems like a strange trade to let US citizens die due to lack of healthcare to fund the world's R&D. I doubt anyone here would vote to ratify such a deal, formally.

The drugs have to be developed, and no other mechanism seems to produce them. Clinical trials are extremely expensive and very risky.

In the long run, these drugs go off patent and become low cost and highly available.

Yes, people today will struggle, maybe even die today. But in a generation more people will thrive.

Ah yes, which is why the US was the only place to quickly develop effective COVID vaccines.

  BioNTech SE
  An der Goldgrube 12
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I'm all for giving the US credit for healthcare R&D, there's a lot of credit due. But don't just take it for granted, or you'll miss the signs that point in other directions.

Specifically with COVID-19, there was a lot of global collaboration.

I think parent is being sarcastic.

But that said, the key point remains; the US is where the money is. The US underwrote the mRNA platforms with a guarantee of 10 billion in revenue while the EU haggled with AZ for like 1 billion.

In the process, the US developed an entire scalable delivery pipeline for mRNA that didn’t exist prior.

Don't worry, the invisible hand of the market will step in and correct this any time now!

I'm pretty sure this comment won't be appreciated, but the amount of government intervention in the market with respect to healthcare in the United States makes it one of our most highly regulated industries, if not the most highly regulated. Some would say that crying "market failure" isn't a legitimate criticism.

It won't be appreciated, because people making the comment that you did don't understand that an unregulated market will naturally lead to a regulated market that protects entrenched interests organically, by itself.

There wasn't anyone in government that decided hospitals and insurance companies need to have record profits and price gouge their customers. It happened, because entrenched interests lobbied government officials to enact such legislature.

Business is the one that perverse incentives through pressure on government. It doesn't originate in government spontaneously.

> Some would say that crying "market failure" isn't a legitimate criticism.

Saying market failure isn't a criticism in and of itself, it's a statement of fact. It arises whenever the market is unable (for a multitude of reasons) to distribute the services to the end consumers (e.g. health care recipients) in an effective manner.

For example, saying that "tying health care to employment creates perverse incentives, because policymakers automatically assume that more people are covered than actually are, since policymakers themselves are employed" is a criticism (without judging how valid/accurate it is).

Broadly saying "market failure" is not.

I understand what laissez-faire is.

Oh, the invisible hand is definitely there. Though, it's just slipping into your back pocket and lifting your wallet.

The USA doesn't even have ingredients listed out per 100g. Comparing packaged goods is very difficult. The solution is not to tax and spend more money on socialized medicine, its to cut sugar out of packaged food products to reduce diabesity in the first place.

Sugar tax of 1c per 1g added sugar is another easy solution. Use the proceeds to reduce sales taxes on food and drink generally.

There are two types of Diabetes...type 1 and 2. I don't agree with your comment on reducing obesity as Type 1 is a much different disease than Type 2.

Type 1s actually benefit from the widespread obesity, since it sends a lot of money into drugs and monitors that both type 1 and type 2 use. :)

I argue many Type 2 patients do a VERY POOR job on average on monitoring their diabetes. Many Type 2 still have moderately functioning cells that manufacture insulin...Type 1 have no choice.

I argue the opposite in that Nightscout and other initiatives that predominately serve the Type 1 community help push the advancement of monitoring, etc. that benefit the rest.

Nightscout is a great initiative. Monitoring of type 2 is rapidly improving, especially as CGMs aren’t restricted to type 1s on insurance as much as they sued to be. Increasing the market size of CGMs has led to significant competition.

Thought on treating type 2 is also evolving in ways that don’t benefit type 1 as much. For example, the trend is for pre-diabetes to be taken seriously and detected earlier.

Anecdotally, a colleague needed back surgery in the US and was able to get scheduled within 2 weeks. Our Canadian colleagues marveled at that speed.

But it is far from universal. My daughter needs to see a pediatric gastroenterologist in Oregon, she isn't scheduled for an appointment until December (we were told this in May). So she has to wait ~7 months?

You can find a case of someone getting into a specialist or a surgery within 2 weeks in the US, but you can also find the opposite.

Also anecdotal, I had a situation in which I needed to get an MRI in 2020. While I was in Canada, the doctor quoted me about 6 months. I had to go to NYC for a week. While in NYC, I went to a walk-in clinic and they got an MRI scheduled for me the same day. With my US health insurance, I was out of pocket about $75 for the whole thing.

As much as Canadians like to crap on US healthcare, it does have its perks in certain situations.

There's a capital utilization story here, even aside from everything else; if the MRI machine was waiting and available, it would have gone unused otherwise; I suspect the Canadian one is running at airline percentages of use.

Anecdotally, I've got a 6 month wait to see a specialist in the US, and I have very good insurance.

A phrase I've heard said: The rest of the world thinks of the USA in the same way that the USA thinks of Florida.

*rest of the world on twitter

Scoreboard says people still want to move to the US

I've always wondered why that is. I would guess it's a legend that persisted from previous centuries when north America was the newfound land, the country to start a new life, where you can dig for gold, with a modern legal system (even if that was only by virtue of being recently founded back then), the whole narrative around the USA is still like that.

Meanwhile the actual social mobility in the USA is lower than in Europe[1], so you'd be better to stay put or go to Europe. People here don't know what they got.

You say twitter, but it might just be people that have access to the internet and better information?

I'd be curious if anyone looked into why the USA is seen as so ideal when various metrics are only on par with developing countries. (Of course, it's clearly beyond a developing country, it just doesn't like to admit it -- healthcare, welfare, incarceration rates, income equality, minimum wage, minimum paid time off, university costs, etc. Sources here are OWID and Wikipedia, mainly from memory but feel free to ask for a specific source)

Another theory is that the USA generally sees itself as the best country, with e.g. starting every morning of primary school with this "pledge of allegiance" indoctrination (sorry, I have no other word for it and I still have a hard time believing this is real). With English being the lingua franca online, much of what you read online is likely to be written by someone who thinks this way.

[1] See figure 1 on the 43rd page which has page number 40 https://docs.iza.org/dp1993.pdf

Internal mobility doesn't matter as much as the one-time mobility you can get from moving to the US.

If you get stuck at a moderate FAANG salary for life, it may still be better than where you started from, for example.

I wouldn't expect an economic immigrant, evidently coming from a poorer place because (1) the USA simply has some of the most inflated incomes in the world but also (2) they wouldn't come for a better life if they were already rich, is going to fare better than someone natively born in the USA.

I would expect the opposite, as they already have the ability to leave their home country, which puts them at middle-class or so at least, and they apparently do quite well in the US.

So, study from the 1990s by a European confirms self-biased conclusion that Europe has more social mobility than America, despite evidence to the contrary.

Notably, all but 2 of the European countries in that study have smaller populations than Los Angeles. It's a lot easier to have social mobility for a small group than it is for a much larger group, especially when they can offload a lot of social ills (homelessness, immigration) entirely to other countries. Which is presumably why the study excluded the Mediterranean and Eastern European countries.

Why couldn't LA offload homelessness and immigration to another state, if you say that's such an effective strategy for these European states?

Also I didn't hand-pick the source, it's just a piece of info I came across while reading https://news.ycombinator.com/item?id=31705542 which had a link to clearerthinking.org which had a quiz called "Political Bias Test" (wouldn't recommend it btw, at least not for the advertised purpose; it's more of a "do you know random stats about the world" quiz) which had a question about social mobility with the aforementioned source. The website seems to be made by an organisation founded in New York, but it's not clear to me whether a European made this particular quiz question.

Most of LA's homeless are the offloaded homeless from other states; we ship as many of them back as we can but we can't legally force them to go back to their homes.

At any rate, it seems the European HNers took issue with learning that their tiny homogenous countries do better than a country with a larger population than their entire continent. Which is made possible because the U.S. pays for their defense.

You say you've always wondered why that is, but it doesn't seem like you're prepared to consider the possibility that America, in its current state, actually is a desirable place to live for a majority of the world's population.

If stats tell you one story but reality tells you a different one, then you should ask why that is, and not say the numbers are right and reality is wrong, or vice versa. There are more possibilities than just the world is getting bamboozled by brainwashed Americans online.

It's super simple: America is rich, and people want the opportunity to participate in our wealthy economy.

Yes, to be fair, "the rest of the world" should be "the rest of the industrialized first world".

Still, though...

Scoreboard also says many people from the rest of the industrialized world want to move to the US

>>Scoreboard says people still want to move to the US

Scoreboard also says many, many people are choosing to move to Florida at the expense of other states - one of the top 10 states IIRC.

Poor uneducated desperate people mostly. Even those would be most probably better off in most of western Europe rather than barely surviving in US. US honors well top 1%, very well top 0.1%, rest not so much. But simpler folks often can't see beyond the illusion of American dream, to their detriment.

Ie I can move with my skillset and languages to most of the world. I did move twice. Didn't consider US, ever, even if I loved common US folks I met when I spent few months there. Society is just not that good - lack of true freedoms, high criminality, class system based on income, messed up medical and school system, too much workoholism. Not a place to raise your child in, if you can stay ie in Switzerland.

so all those 'desperate, uneducated and poor' people should move to your Switzerland instead? with its 96% white population and 27% higher cost of living? Would Switzerland even accept poor minorities in large numbers?

You sound like quite the elitist...that would be like me telling those 'poor uneducated and desperate people living in Detroit, they should just move to Naples FL or Beverly Hills to escape the poverty and crime - if only they were smart enough.

To be fair, scoreboard says Americans still want to move to Florida

https://en.wikipedia.org/wiki/List_of_U.S._states_and_territ...

And yet Florida is richer than almost every country on Earth. Depending on how you measure it, Florida might actually be wealthier than every single European country and the typical European would be much better off in Florida.

Possibly true. Not sure it is relevant though.

Especially given then title of the article, and that insulin in generally free in Europe AFAIK.

It's certainly relevant to anybody who thinks Florida is some kind of weird backwater that's clearly inferior to Europe, when the exact opposite is objectively true. (I can't speak to "quality of life" measures, which people are free to argue about until the sun burns out, but objectively Florida is the richer geography and objectively the typical European would be far richer if they moved to Florida.)

> The rest of the world thinks of the USA in the same way that the USA thinks of Florida

So the rest of the world wants to move to the USA because of the great weather, low income taxes, and the fact that the government doesn’t demand that you stay at home during a health scare?

Great as in hurricanes or great as in sunburn and heatstrokes?

> the government doesn’t demand that you stay at home

You mean "politely suggest" without any coercion.

Good luck "staying at home" when your home falls into the ocean the day after your last 3 insurance companies decided to close their doors forever.

ahh yes everybody who doesn’t live in Florida assumes death and destruction are always a minute away.

They should see the waiting times in Europe.

What are the waiting times in Europe? I live in the Netherlands and have never had a waiting time.

Seems the idea that wait times are longer in Europe is a misconception:

https://worldpopulationreview.com/country-rankings/health-ca...

https://www.oecd-ilibrary.org/sites/242e3c8c-en/1/3/2/index....

It must be a misconception that it takes me 2 weeks to see a GP here in Europe, yes.

I am not sure how to extrapolate your personal experience into global trends, although I am sorry that you have to go through that. I don’t personally have that experience at all (I am always able to visit a GP the same day) and am also in Europe. My experience lines up with the data in the links, both now here and in the US when I lived there.

>I am not sure how to extrapolate your personal experience into global trends, although I am sorry that you have to go through that. I don’t personally have that experience at all (I am always able to visit a GP the same day) and am also in Europe. My experience lines up with the data in the links, both now here and in the US when I lived there.

As an American with expensive (~$800/month, rising to over $1000/month next year) insurance, I often have to wait to see a specialist and only go see my GP for regular check-ups.

If I have an issue that needs to be addressed immediately, I have two choices: an "urgent care" facility or an emergency room.

Urgent care, at least in my experience, is a misnomer as I've (with a small sample size) alternately been refused treatment and been told to go to the emergency room ("we can't handle that sort of thing") while still being charged for something, or given substandard treatment.

Which, I guess, is why urgent care is 1/3 the cost (out of pocket) of an emergency room visit.

Should I wish to see my GP, I likely would need to wait at least a few weeks, possibly longer. With even longer waits for specialists.

In Europe no one is dying of bankruptcy.

Certainly not half a million people a year most of whom are insured.

That explains why the world's wealthy come to America for their health treatments.

Yep. Because it's broken...

America pays more because our health care system is capitalist, and that naturally leads to increased prices because demand is inelastic (meaning, that demand does not decrease based on price).

Her short-acting insulin, Lispro, costs $70.22 for 1 vial, which lasts her about 30 days.

That's not far off from what I pay in Canada, assuming we're talking a standard 1000 U vial. I thought insulin was typically around 5x that price in the USA.

I saw this in the news recently:

https://www.deseret.com/utah/2022/3/8/22968089/utah-company-...

I'm not sure how $30 for 100 units of insulin compares to the status quo, but they make it sound like it'll be significantly cheaper. It's supposedly slated for 2024, assuming FDA approval.

iirc it's not the insulin but the injectors that are expensive, similar to epi-pens.

> I thought insulin was typically around 5x that price in the USA

Insulin comes in several different forms. It's the patented, long-acting forms that are currently expensive in the United States.

Regular generic insulin is $25/vial at Walmart. You actually don't even need a prescription to get it in most places. The low price of regular insulin is actually unknown to huge numbers of Americans, who are only familiar with insulin analog prices talked about in headlines. There's even a Snopes page confirming that Walmart sells $25/vial insulin because so many people think it must be untrue ( https://www.snopes.com/fact-check/insulin-walmart-vial/ )

WalMart also sells a long-acting insulin analog (NovoLog) for about $75/vial (1000 U total): https://www.walmart.com/cp/relion-diabetic-care/3769564

There is a major problem with insulin education among healthcare providers, IMO. A lot of them will write prescriptions for expensive long-acting forms because they don't ask the patient's financial/insurance status. A lot of patients aren't even aware that they are on a specific patented insulin analog. They just know they take "insulin", that it's expensive when they fill the prescription, and that all of the headlines say insulin is expensive and therefore their experience is normal. It's a dumb situation.

Even dumber: Many Insulin analog manufacturers will actually reimburse low-income patients for their out-of-pocket costs of buying insulin. If you do some research, even the expensive insulins can become very affordable or even free by filling out the right forms. Again, dumb situation, but it's out there.

Also consider this, different manufacturers of "short-acting" and "long-acting" respond differently within people's bodies. My daughter responded very differently between Humalog and Novolog even though they are both considered "short-acting".

Another problem to factor in with costs is if you have a HSA (and some other insurance plans). Many of the insurance companies are forcing ppl to purchase their supplies through a handful of "authorized" medical suppliers. If you fail to purchase through them, they will not apply the costs against your deductible, which I think is completely BS. To add insult to injury, these "authorized" medical suppliers mark up the supplies substantially (compared to Costco and other pharmacies).

Something is really broken in this model...

> That's not far off from what I pay in Canada

It's not free?

Prescription drugs are not included in Canada's healthcare system. Dental and optical aren't either. Each province has a drug program where people can pay a monthly fee (depending on income) and get drugs inexpensively (cost depends on income). For example, I pay $30/month for my provincial drug plan and never pay more than $15 for however many prescriptions I am picking up from the drug store. Some people pay for their own health insurance and others get it through their employer. Also, those on social assistance or over 65 are also on a similar provincial drug program.

Nope. Hospitals and doctors are free, but prescriptions aren't.

This survey seems flawed. It’s a survey of 1,000 insured and 1,000 uninsured, but the rate of insured in the US is closer to 90-95%. The uninsured use cheap generics and manufacturer’s discount cards. There doesn’t seem to be a control for the type of insurance. Typical copay for insulin are in the range of $10-50/mo.

80% credit card use sounds like American consumer finance behavior across the board, whether to defer payment or earn points. Accumulating an average debt of $9,000 solely from insulin would be difficult to accomplish given the high insurance rate, and difficult to separate from other debt and report (plus there appears not to be a control for personal finance ability and circumstance.)

There are serious initiatives and legislation to provide cheap, high quality generic insulin and monitoring tools, that don’t need help from counterproductive, bad statistics.

Really is insane. Started dating a girl with Type 1 and started researching it.

There's a group in Oakland called the Open Insulin Foundation doing some good work: https://openinsulin.org/

Somewhat mystifies me why a much-much cheaper alternative to the Big Three hasn't sprung up, but I'd bet a lot on the FDA.

The only reasonable explanation for the price of meds in the US is some form of collusion between insurance and pharma companies.

I can't see any other reasonable explanation for list prices for the same medications that cost 3X, even 10X! Times more than in France, Sweden, or even Mexico or Brazil.

There is probably a symbiotic relationship where insurance providers benefit from very high public listing prices while paying heavily discounted prices behind the scenes and providing market protection for monopolist pharma companies.

The places you listed have compulsory license laws. The US does not.

Why would a pharma company collude with insurers in one country and no others?

Take the 4/5 with a grain of salt. They surveyed 1,000 insured & 1,000 uninsured people. That over represents the uninsured which likely over represents those that took on CC debt.

I feel like even if 100% of the uninsured took on debt, that would mean 60% of the insured aren't getting it covered enough to avoid taking on debt, which is pretty wild.

I would think it is fairly common knowledge that insulin is rather expensive in the US, and while the sample size is small, anecdotal evidence from my experience in health IT and working with social determinants of health seems to indicate that debt with diabetes is fairly common.

I don't think it is a stretch to assume that these high medical costs, specifically insulin are forcing patients into debt.

At thousands of dollars a month out of pocket, it makes sense that most people would struggle affording it.

But 79% still seems really high, given 90% are covered by health insurance.

I fear the price controls for insulin will only lead to shortages. I think allowing imports would be a better strategy.

Lower prices elsewhere in the world seem not to have lead to shortages.

Maybe a sudden surge of consumption due to greater availability will be a regression for the rich people that could previously buy as much as they wanted, but it will be a life-saver for countless others. Supply ought to pick up so long as the price is above production cost, and that's if there is a shock in the first place. Producers can anticipate if this is announced ahead of time.

This is a better article with actual data of how much the different brands cost versus a somewhat sensationalist headline: https://www.goodrx.com/healthcare-access/research/how-much-d...

I wonder whether the continuing deterioration of the US' ability to provide medical care for normal people will lead to a rise in bio-hacking.

At some point, the technology needed to produce simple but effective medication for widespread illnesses must be feasible enough for many people.

And when you're detached from an affordable access to the medical system, you may not care about the potential shunning that results from DIY medication.

Any DIY approach will be regulated out of existence by the same status quo lobbying.

I thought this was one of the medications Mark Cuban started https://costplusdrugs.com/medications/categories/diabetes/ to address but I don't see if listed there unfortunately.

He did, but it’s a lot harder to source and manufacture than their starting drugs. He has said in interviews that it’s coming.

While Insulin is not on the list some other medications for diabetes are available for cheap here: https://costplusdrugs.com/medications/categories/diabetes/

Considering that 90% of the people with diabetes have type 2, which is 100% preventable, perhaps we should focus on diet and lifestyle instead of asinine political debates about the cost of insulin. I do however, feel very badly for the poor people with 10% with type 1 though, they are getting shafted.

Many type-2 diabetics can even put the condition into remission by following a strict diet.

https://www.virtahealth.com/research

How many percentage paid down those credit back those back within 0-30-day?

Otherwise, the headline is meaningless.

The US needs dramatic, progressive change, but instead we're failing and regressing in so many ways and places. I expect cascading failures to continually compound.

at what point does the healthcare system become a national security issue? Failure to properly support the citizenry for routine healthcare surely leads to a debilitated population, one which may increasingly be unable meet the demands of war

The national security issue is more with chronic lifestyle conditions such as obesity.

https://www.militarytimes.com/opinion/commentary/2018/07/18/...

sooner terminators arrive the better in this case

Is it possible (feasible, legal) to buy insulin from countries where it's cheaper?

Possible, yes, legal....

My endocrinologist recommended I take a trip to Nogales to get supplies back when I lived in Tucson. AFAIK that's perfectly legal to do.

I am aware of situations where ppl have crossed over legally into Mexico from the US to purchase insulin at a substantially reduced cost.

If you're near the Canadian border, I've heard some anecdotes about folks crossing to get cheaper insulin. I've not done it, though was on the fence about doing it.

Also, I know that some makers ( Eli Lilly in particular ) also offer need-based aid programs to provide insulin. If you reach out to them and they're manufacturing, I believe you can get the insulin at near free if not free. ( This is also true for many medications that fall into the commonly-used category, you can explore manufacturer sites to see if they provide aid for a particular drug that is in your list )

Corollary to this: if you have insurance, it's also worth asking your insurance provider if they know of any aid programs that can assist. I was shocked to discover Humana has a team that will help you discover aid programs to cover the rest of the cost that Humana might not cover.

Obvs it would be great if they covered 100%, but if you're trying to cover your ass right now, it's worth asking your provider about.

And as another note, if you qualify for aid programs, and they are not oversubscribed, then you should sign up even if you can afford not to - if you feel bad, donate the difference to an appropriate charity or cause.

Because the number of people using aid programs is a major factor in getting them identified and improved.

I'm a Michigander and while I've never brought insulin, I've brought unapproved painkillers across the border regularly. My uncle (T1 diabetic) has brought insulin.

So some more ancedotes to confirm.

Not really anecdotal, Bernie Sanders did "lead" a "caravan" of US citizens into Canada for cheaper insulin.

https://web.archive.org/web/20220521183320/https://www.nytim...

Why is it cheaper elsewhere and what purpose do these barriers serve? High drug costs seem to be fixable in part by making US drug makers compete with foreign competition that can pass some standards of manufacturing.

That's a big part of the problem. Price gouging combined with a legislative monopoly, paid for by "contributions" to legislators.

Legislators with health industry contacts are the only healthcare users in the US whose effective copays are negative.

Yes, there are sites that will sell US citizens insulin from Canada. It's not legal, but it's doubtful that it's enforced very often.

When the cure for type 2 diabetes is free, this becomes especially stupid.

Come live in the EU?

This should be flagged, it's flagrantly misleading.

Messed up

Reminder that Biden could have solved this on day 1 but chose not to.

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