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Comment by alluro2 | Hacker News Reader

I know it's a worn-out stereotype to point out, but from an European, I just hope you realize how jarring it sounds that there is a medication that a doctor determined you need, and TWO companies - entities driven by and existing exclusively for profit - are involved in deciding and communicating with each other on whether you will get it or not.

I do think that this should still actively be regarded as scary and abnormal, even if it's the norm for so many people in the US.

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Crazy right? Here in europe they just tell me that my medication isn't covered and I have to pay the whole price for it - if I don't like it, I can switch the government and move somewhere else.

It’s not like you can just switch insurance companies in the US. Most people have healthcare coverage through their employer.

Does your country cover ozempic for obesity? In Canada we don't for non diabetics.

Americans get more drugs covered on average is my impression.

Americans get no drugs covered--at all--unless you're over 65, have insurance through your employer, or pay thousands for insurance yourself (and often thousands more to meet your out-of-pocket deductible each year).

I would take the default of "some" coverage over "no" coverage any day.

Over 65, outside drugs delivered in a clinic, hospital or doctors office you don’t get drug coverage UNLESS you pay for it through Part D Medicare, have a Medicare Advantage pan (the privatized version of Medicare that now 50% of the Medicare population has stupidly picked), or a retirement medical policy that acts like a Medicare supplemental policy that many government employees and some company’s offered their retirees.

That said it’s still a good deal and you can switch Part D policies year to year in case there are formulary issues. Plus with the IRA changes the max out of pocket is 2K which before you had no cap on—some new drugs are so crazy expensive that without this even the co-pay would wipe people out. That’s only recent fixed.

In our own case, my wife who 3 years ago our out of pocket for some daily cancer pills went from 15k in 2023, to 8K in 2024, to 2K this year as the IRA fully kicked in.

What the fuck do all these terms mean?

Welcome to "health care" in America!

To be clear you also need a health insurance plan for medication in Canada generally. The difference is that drug prices are regulated by the provinces, so they cost less. However, this also affects which drugs are available.

Some provinces such as Quebec have a public drug insurance plan as well which you pay into via income tax if you haven't got a private plan.

Of course the overwhelming majority of American do have one of those forms of coverage. You might as well argue American don't have housing or food either since most people need aren't on welfare programs to pay for them.

Over 90 percent of people on ACA plans get subsidies too. Also emergency treatment is guaranteed.

It's certainly a mess of a system, but every time the government does something to "fit" it, the price goes up faster and it becomes a bigger mess.

I don't take it but did look into it.

If anything getting it for diabetes got harder now.

Canadian employers sunlife insurance.

If you were prescribed it before the influx(not specific date) it was covered for diabetic purposes and still covered.

Now if you want to apply sunlife says NO, but you can get your doctor to send us these forms with additional info about the diabetes diagnosis and need and may be covered.

On the flip side theres a local diabetic that has been getting multiple high dosage units covered, but doesn't actually need them or take them

Flips them for $200 cad each to people looki g for weightloss.... (230-280cad in a pharmacy with prescription no insurance)

Only for diabetes. Wegovy is authorized for weight loss. There are other GLP agonists that are also authorized for diabetes. I'm not sure if there are other formulations for weight loss.

The US does allow for "off-label" prescriptions. The question then is : will your insurance pay for it. In my case, even though I am diabetic, they wouldn't cover Ozempic, or, apparently even Trulicity, which is just absurd (or Rybelsus which is the oral form of Semaglutide which they DID cover for a full year before putting me on Ozempic for like 2 months, and then denying (after the "new formularies" are approved and I get to be forced and switch to a med they still claimed to cover but not, apparently - I'm assuming they want me to appeal and give a whole run around on that.

But yeah... Technically it's for Diabetes only, but if you have good insurance, they'll probably hand out for any reason (see: "Hottest Celebrity Weight Loss Drug" for example; maybe that's changed now that Wegovy is released/authorized for weight loss)

IT IS a worn out stereotype. I'm also European and here the doctors are also limited by the national health insurance company on what medication and treatments they can prescribe you due to cost reduction pressure. Their hands are also tied except not by a private corporation but by the government.

Often you'll encounter the infamous "these tests or procedures aren't covered by the national insurance anymore so you'll have to pay out of pocket", or they're covered, but the nearest appointment on the national insurance is 15 months away, at which point you'll either get better or you'll be dead.

My boss recently moved from Germany to the US and was pleasantly surprised how much better the diagnostic, treatment and medication options are for his child who suffers from some rare mental disorder that's basically ignored in Germany by comparison. US seems to always be on the cutting edge of medical research and treatment which of course comes at a cost since research is very expressive.

Your boss is presumably a high-value employee at a prosperous company. They will have good health insurance, but that’s not the norm for most people.

When I worked for Facebook in the US, it was conspicuous how doctors would run extra tests on me because the health insurance was paying for everything and anything. That’s not balanced either because less fortunate people pay for that in their insurance premiums.

Companies negotiate for all employees without tiers for „high value” employees.

What do you consider the norm? 90%+ of Americans have some form of health insurance. I don’t have a bad one, but it’s not as great as some public sector employees do. Am I in the norm? If so, that’s ok

While companies may negotiate for all employees, the percentage of the cost covered can be tiered, and some employees will pay less for better plans.

>Your boss is presumably a high-value employee at a prosperous company.

The company he worked at in Germany was even more prosperous yet had worse healthcare there. What's the deal?

Ozempic in Europe seems to be cheap, under $100 in many cases. In the US it costs 10x or more that. So as much as I hate to defend insurance companies, it's not just them.

It is just them. The way insurance works in the US is that insurers negotiate with pharmaceutical companies to get steep rebates so that they are paying far less for the drug than its list price, typically much closer to what you might pay in other countries. If they can't come to an agreement, they won't cover the drug. Sounds reasonable. But in practice, what happens is that if a pharmaceutical company simply cuts the list price to what the rebate would be anyway, the insurance company ends up dropping them from coverage. This seems counter-intuitive, but it happens for two reasons.

First, the middle-men who negotiate and develop the formularies for insurance companies, called pharmacy benefit managers, get a cut of the reduced cost. So they make more money from a drug being $1000 and rebated to $100 than they would from the drug just being $100 all along. The pharma company makes the same amount per unit, $100, but they are much more likely to get onto an insurance plan if they go through the sham of marking it up to $1000 and then cutting it down.

Secondly, extremely inflated list prices that get rebated down simply mean that it becomes that much more critical for patients to pay for an insurance plan, because it is increasingly untenable to be without one.

These "negotiations" that PBMs do have been closely guarded "trade-secrets" but pharma companies have in recent congressional hearings have essentially said this is the situation. This seems to be supported by the fact that in their financial reports for products like insulin, the actual profit per unit has largely kept pace with inflation over the last few decades, despite the listed price of insulin skyrocketing during the same timeframe.

This is pretty much entirely the result of there not being a non-profit seeking government provided insurance option available to all in the US. If there is a reasonable alternative to private insurance that isn't engaging in the insurance cartel, no one is forced to use private insurance and the private insurers are actually forced to compete in a market. Completely socialized medicine isn't required, we simply need a Medicare-for-all option available to destroy the anti-competitive behavior that currently exists in the US insurance market.

We agree on the cause, but not the solution described in your last paragraph.

If it was truly a free market, the federal government wouldn't be involved at all and I could buy insurance from any company in any state. It's because of the government's involvement that I can't buy insurance of my choice and preferred pricing from any insurer in any state.

I get this sounds crazy.

But what’s more crazy is the prospect your doctor is motivated by profit.

Does that mean it’s less likely to be true?

I’ve had some interactions with doctors that would chill your soul.

“Here’s some long acting opiates. Take three a day for a month.”

I’ve had doctors offer me antibiotics for the flu.

I’ve been offered surgeries for conditions that don’t require them.

I’ve seen doctors offer a week in the psych hospital over mild distress.

I mean yes but there is no solution to that problem, but there are many tried and true solutions to the other problem, so this just reads as deflection

I’ve lived abroad and I’ve seen the solution: massive wait times for rationed care.

I never had the problem of doctors pushing treatments I didn’t need in UK, Canada, Italy, or any of the other places I’ve lived.

Seems to be an American thing, but maybe I’m missing something.

You think that is jarring? How about a drug company giving kickbacks to doctors to tell patients they need a drug?

Four companies. The doctor's office which may be controlled by profit-optimizing administration, the big profit pharma corporation, the for-profit medical insurance company, and the company the insured works for who picks the available insurance plan(s).

Doctor's office won't make money from prescriptions for a drug, and the pharmaceutical company will sell their drug to whoever will buy it. Both those entities also exist in non-US medication transactions as well, so I'm not sure it's relevant. The point is that the insurer and the employer are two extra middlemen.

Don't forget getting an e-mail about it from HR??

You do realize that Euroean countris also decide what drugs and procedures they will cover on their national health plans too? Because you have a more limited set of options, your doctors will know what is covered and only recomend tose options, but it doesn't mean there aren't things that aren't covered.

At least the set of approved drugs is known. In the US you don’t know until you try to fill the orecription, then it becomes a 4-way game of telephone (patient, MD, pharmacist, and insurance) with each trying to outlast the other.

I concur, it is a pain. The US absolutely needs to improve! The point I was making is that the idea of free, unrestrained, unlimited healthcare in Europe is a myth.

My health insurance plan publishes a formulary.

As does mine, but many drugs require either a prior authorization that insurance companies can fight or an exemption which can also be fought. It's not a guarantee that you'll get coverage for a specific drug just because you have an insurance plan.

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