"Rome said the companies seem to be maximizing prices while negotiating discounts behind the scenes with health and drug insurers and then setting yet another price for direct-to-consumer cash-pay sales."
This describes the biggest problem in US healthcare. No clear and consistent pricing. If we had a real market, you would get a prescription and then go to the seller with the lowest price. And everybody would get the same price. This whole business with PBMs that are owned by the insurance companies, discount cards and other shenanigans just invites corruption.
I just had some bloodwork done, myself. My provider accidentally billed insurance, which had lapsed due to being laid off. I got my "Explanation of benefits" and it was $1000 billed to them, but I was given a $500 "discount." So I only owed $500... Cash cost was $50. Makes no goddamn sense.
Also I went in for a colonoscopy and an endoscopy. Insurance was billed for $14000. I got statements from 4 different doctors, and the facility where it was performed. None of the statements matched the explanation of benefits from the insurance company. And when I called each doctor, to pay them, they all told me that I didn't actually have to pay them what it said I owed. So I just ended up paying $2500 to the insurance company. It again, makes zero sense.
It makes perfect sense. The prices are inflated with a few extra zeroes to try to force people to get any job with insurance. The big numbers are just to scare people. You can also turn negotiating with the hospital into a full time job and get the real numbers. If you're too unhealthy to do either of these then you can just die I guess.
Well, there is that. But there is also the fact that they charge you or your insurance company to smooth out other costs like $2,000,000.00 cancer treatment or for people who show up to the hospital, don’t have insurance, and the hospital has to treat them.
I’m reaching the point where I don’t really care if it’s private or public, but what we are doing today is the worst of both worlds. It either needs to be fully private, maybe with mandatory insurance purchase, or it needs to be fully public, though that has its own baggage.
“ But there is also the fact that they charge you or your insurance company to smooth out other costs like $2,000,000.00 cancer treatment or for people who show up to the hospital, don’t have insurance, and the hospital has to treat them”
I bet whatever cost these patients cause, the hospital will inflate this by an order of magnitude. It’s the same with charity care. Hey, my sticker price for an aspirin is $1000. I’ll give away 10 aspirin and I can get credit for $10000 charity.
A lot of that is tied into billing in general, even without the people who can't afford to pay for their care. When they send out an invoice for $50,000 for services rendered, even if the insurance company only ends up paying them a fraction of that, when it comes to accounting and taxes you can be sure they are using that $50,000 number for deductions and such when it benefits them.
This uncertainty of what things cost would kill me. It must be terrible!
We had a baby 2 weeks ago, which included 4 nights in the hospital before and after the birth, a surprise c-section, various specialists, follow ups, consultants and blood tests.
Our total outlay so far is about €30 for the parking at the hospital every day.
We have insurance, but we did not use it for the baby. I need to see a dermatologist next week. Cost will be €300, which I can claim back from my insurance afterwards. I just punch the doctor's name into my insurance portal, and they list the procedures and the amounts I'm covered for each.
If I asked my GP to refer me to a public dermatologist, I would have waited longer for an appt, but I would have only had to worry about parking at the hospital, everything else would be free.
>> I don't think the hospital expects to actually ever get paid what they bill out
OH YES THEY ABSOLUTELY DO!
When I was in-between jobs I had a medical emergency and I was on the ACA around the first year it was offered. I was billed above medicare rates so I was on the hook for ~40k after out of pocket max. They told me this limit is what insurance has to cover but hospitals can still bill above it. First they told me they could work on the prices and asked for my last 5 years tax returns. When they saw that I had dividend payments they said they couldn't help me and I owed them the $40k. I think that was the problem because even though I wasn't working in their mind if I had investments then technically I was not in need so they set up four-year payment plan and paid every penny with no cost reduction.
I probably did something wrong but to this day I didn't know what I would have done differently. The only people I could talk to were the hospital and they only cared about the hospital.
This happened in 2013, 9 years before the Act. Hopefully the Act prevents this kind of stuff. The medicare limit is what really confused me. If there is a limit insurance will cover up to, then how is it possible to exceed that limit?
I really don't believe you, but according to HN, I am supposed to trust in good faith you aren't lying.
Maybe you just don't have any assets or make very little money. I have equity and cannot just toss it to a collection agency and hope they forget. I also play by the rules, silly, I know, but I don't want to risk getting fucked some other way later in life.
In practice, the whole system is set up in a way that discourages asking questions. Waste of time. It's truly the opposite of the transparent ideal market.
That’s what is insane. I called my insurance to ask if some tests were covered since preventative care is 100% covered.
They couldn’t answer if cholesterol test would count. How is that not automatically classified as preventative? It’s one of the most basic metrics.
So they want me to get the doctor to give me the ICD code and the diagnosis code. Or something. Two different codes. They’ve added so much bureaucracy and crap into the system because they can. Nobody’s stopping them and there’s too many fingers in the pie.
I think you might be confused by the terminology. Under the ACA (Obamacare) there are a limited set of preventive health services that are covered at no cost to the patient. These are a subset of all preventive care services that meet strict criteria for effectiveness. Cholesterol screening may or may not be included based on your age and diagnosed conditions.
> How is that not automatically classified as preventative? It’s one of the most basic metrics.
They're incentivized to classify whatever they can as not being their problem, so it makes sense for them to double-check everything - there is always a possibility that some edge case was found that lets them off the hook for some specific test or treatment. Moreover, obscuring information and spreading support staff as thinly as possible means that extra barriers heavily discourage people from fully knowing what they'll be on the hook for, which makes them more likely to just nod their heads and do/pay what is asked. These decisions aren't driven by medical concerns. It's a universal problem of nearly all kinds of privatized insurance - their core incentive is to ask for as much money as possible and provide as little in return as it's legally feasible. All the things mentioned in this comment thread are used to thwart any possibility of competition, which would otherwise act against this strong pull towards pure profit-seeking.
The place where I live is often used by Americans as the first line of defense to justify their healthcare system. Among certain political circles, there is almost a reflex to point at us and say "see how terrible it is?!" by exaggerating all the drawbacks and minimizing all the upsides. Yet even in such a flawed, underfunded, mismanaged system, my government insurance plan covers all "medically necessary" lab testing, with a couple rare exceptions that are only covered if you're diagnosed with certain conditions. The process of getting a test consists of a doctor filling out a standardized sheet, then going to a lab and handing them that sheet and my regional insurance card. No money exchanged.
"And everybody would get the same price. This whole business with PBMs that are owned by the insurance companies, discount cards and other shenanigans just invites corruption."
It's hard to say that it isn't racketeering at this point.
"Specifically, a racket was defined by this coinage as being a service that calls forth its own demand, and would not have been needed otherwise."
There's demand for the meds, but the demand for discount cards, forcing people to use specific services/companies, and related programs is all invented by the companies themselves.
Most of the non "cut everything" GOP plans still involve trying to get the consumer to shop around, but shopping around is impossible. The consumer can't be a consumer and impact the market if they don't know what is going on.
The system is fundamentally broken.
I go to the doctor and I have zero clue what will come back on the bills.
Health insurance in general is the problem; PBMs/discount cards are just a cherry on top. Insurance is fundamentally incompatible with clear and consistent pricing.
Insurance companies do not force the sellers to use complex billing practices, they would benefit from more transparent pricing (since they are seeking to pay less).
The root cause is healthcare is inherently complicated and complex, it has a problem of supply being nowhere near demand, and since prices for things are so high (including liability), there is a lot of cover your ass and fraud prevention going on.
Insurance companies absolutely benefit from the higher and opaque prices, because they negotiate rebates with providers. This allows them to maximize patient copays and ensures they hit their deductible, i.e. paying as much as possible under their respective insurance plans. Contrast this with a no-rebate world with cheaper/more transparent pricing. Fewer patients would hit their out of pocket maximum.
They can use the rebates they get from the providers to subsidize the insured, allowing them to offer lower premiums and gain market share. This is what people mean when they say "In America, the sick people pay to subsidize the health care of the healthy people".
Of course, that above only applies if there is competitive pressure. If there is no competitive pressure (e.g. in states with only one or two insurers), they can keep premiums high and book as profit the difference between what the patient paid out and what the patient would have paid out in a lower-cost no-rebate world.
> Contrast this with a no-rebate world with cheaper/more transparent pricing. Fewer patients would hit their out of pocket maximum.
And premiums would go up. Every insurer has to get their premium approved by every state’s insurance regulator, and every state’s insurance regulator is not going to allow them to have more than a few percent of profit.
> They can use the rebates they get from the providers to subsidize the insured, allowing them to offer lower premiums and gain market share. This is what people mean when they say "In America, the sick people pay to subsidize the health care of the healthy people".
I’ve never heard of this, and it’s legally not allowed. The ACA mandates insurers price plans so that old people only pay at most 3x what young people pay. And the ACA does not allow insurers to charge more to people likelier to need healthcare. Mathematically, that means younger and healthier people pay higher premiums so that older and sicker people can have lower premiums.
NY state goes even further and says all ages pay the same premium, so young subsidizes old even more. MA has a 2x cap, I believe. And then of course, FICA taxes mean the young and working are paying for the healthcare for the old and non working, the vast majority of all healthcare spend in the US (Medicare).
Yes. As I wrote above, insurers compete on premiums, and they do do so by using rebates to subsidize those premiums by spreading patients' deductibles across the insured population. As far as profits go, I can't speak to regulatory issues since they will vary by state, but in any case the same critique would apply if insurers are pocketing a fixed percentage of a larger amount.
Re your second point, it completely twists my point and is largely irrelevant. Yes, older people paying the same premiums as younger people is a counter-argument in that older people are more likely to need healthcare, but the central point is that people who have to USE their insurance (i.e. sick people) subsidize the premiums of people who don't (healthy people), and this critique applies regardless of age. Now, one could argue that the structural factors that control costs across age cohorts counterbalances this phenomenon. And I'd agree with you! But that doesn't negate the original point that insurance companies benefit from, and advocate for, high sticker prices.
> but the central point is that people who have to USE their insurance (i.e. sick people) subsidize the premiums of people who don't (healthy people), and this critique applies regardless of age.
You’re losing me here. This claim is categorically false. You cannot consider only the deductible when calculating who subsidizes who.
The only way to calculate it is premiums + deductible + out of pocket maximum = total healthcare costs. And the subsidy via premium is so large that it negates effects of a deductible and out of pocket maximum.
Note that all plans have to be actuarially equivalent, regardless of what deductible you choose. The actuaries have to account for rebates and other pricing strategies when ensuring actuarial equivalence, so that the ratio of what the plan pays versus what you pay meets the required ratio for that metal level.
Since your health is not a factor in pricing your insurance, it has to be that people less likely to need healthcare pay for the people likely to need healthcare.
It is the same as if the government forbade auto insurers from using moving violations history, or life insurers from using health measures, or home insurers from using flood maps.
The claim about who subsidizes who was always hyperbole, I'll grant you that. I included the statement to make the point that this is the phenomenon people are referring to when they make that statement.
I happen to think there is validity to the statement if you control for other actuarial factors. But if you don't think that makes sense as a lens through which to look at the problem, I won't quibble, even though I disagree. We're also only talking about drug prices here, which is a small portion of overall healthcare spending.
In any case, the central point, that insurers benefit from higher prices, still stands.
> In any case, the central point, that insurers benefit from higher prices, still stands.
All sellers benefit from higher prices. No one limits the price they ask for out of the goodness of their hearts. Lower prices are because a competitor offers a lower price, and because buyers can’t pay a higher price.
Don’t do pro bono PR for those companies. Healthcare isn’t so complicated that every other country in the world hasn’t been able to solve it for significantly less money and far less stress for users, not to mention better health outcomes in most cases.
Providing a chain of reasoning to support a logical conclusion is not “pro bono PR for those companies”. Claiming that someone doing that seems like an emotional kneejerk reaction to an idea that does not jive with the model of the world you would like to have.
I even provided an example of a healthcare provider choosing to be more transparent. It is always Eli Lilly’s choice to sell their medicine at a flat price to everyone. But it is also in Eli Lilly’s benefit to engage in price discrimination, so that they get paid more by people who can pay more:
Another example of this was when I was in college, US textbooks cost multiple times more than the international
version of the textbook I could buy on Abe books or whatever website. Or, coupons for grocery stores. The insurance company has no hand in this.
To be clear, insurance companies also cause waste, because the government does not audit them, and the insurance companies are not staffed appropriately to resolve disputes in a timely manner.
What you gave us wasn’t a chain of reasoning: you just regurgitated the industry’s preferred excuses (“it’s complicated”, “people will use too much healthcare if it’s cheaper”, “liability!”) while begging the questions of whether those are true or why they affect the United States far more than any other advanced country. If you wanted to construct a logical chain of reasoning, that would be far more interesting than repeating another round of simply asserting that the status quo is inevitable.
If you need proof that delivering cutting edge services requiring split second decisions and multiple highly qualified people who are liable to the tune of millions of dollars for each decision is not complicated, then we are living on different planets.
> If you wanted to construct a logical chain of reasoning, that would be far more interesting than repeating another round of simply asserting that the status quo is inevitable.
You are welcome to explain why an insurance company would want to make things so complicated. They don’t make it so complicated for claims on a vehicle or a house. They are earning meager profit margins with the situation as is. There is literally nowhere they could go except up…why are they choosing not to?
And if you can come up with a more efficient system to administer insurance, I’m sure a few rich people like Dimon and Buffett and Bezos would be interested in your services. These two “titans” of industry couldn’t figure out how to make it better.
> it has a problem of supply being nowhere near demand,
Get rid of the patents and this will solve itself in no time.
> The insurance company has no hand in this.
False. Insurance companies in the US own stock in big pharma firms like Pfizer, Johnson & Johnson, Eli Lilly, etc. They maintain substantial investment portfolios and generate returns on premiums and reserves. They also have voting rights as institutional investors.
Yes, no one is stopping US (or other countries’) taxpayers from paying for all the drug trials so that the resulting medicines are in the public domain.
> False. Insurance companies in the US own stock in big pharma firms like Pfizer, Johnson & Johnson, Eli Lilly, etc. They maintain substantial investment portfolios and generate returns on premiums and reserves. They also have voting rights as institutional investors.
This is a wild assertion. The sum total of all 7 publicly listed insurance companies’ market caps is less than Eli Lilly, just one pharmaceutical company. I would need some evidence before believing that health insurance company leaders have any influence on pharmaceutical companies.
I would also be surprised to learn insurance companies hold specific stocks, seems like a risk insurance companies would not take, especially ones that have lots of routine cash expenses. They spend ~85% of their premiums on medical expenses, and probably at least 5% to 10% on their own staff, so they shouldn’t even have much extra cash left to invest for the long term.
Edit: hit posting limit, so to respond to comment below about net income, that Yale link does not seem relevant as it is for all healthcare companies. All 7 publicly listed insurers’ combined annual net income is $35B or less for the previous 20 years, at a profit margin of 3% or less, which is peanuts. The pharmaceutical companies earn much more money than them, which is why the pharmaceutical companies have higher market caps.
> Why are we using market cap as a metric ? Look at investment value.
Because a company that owns influential portions of another company would have that reflected in their market cap. Like Berkshire Hathaway does. with the exception of UNH (due to its healthcare provider business), the other insurance companies are relatively tiny businesses compared to pharmaceutical companies and so cannot be holding any influential amount of stock.
The U.S taxpayer already pays for this. ~40% of FDA-approved drugs have direct NIH funding behind them. Nearly all modern drugs rely on NIH-funded foundational science. Taxpayer money additionally also floats through BARDA, DOD and DARPA.
COVID mRNA vaccines (Pfizer-BioNTech, Moderna) got billions in public funding. Yet, patents usually belong to the private company and prices are not capped as a condition of public funding. It is gross corruption begging for heads to be put on pikes.
Correct, people should be asking their federal politician why the US federal government is not spending the few billion dollars on drug trials to avoid having to pay extra to pharmaceutical companies.
But instead, people rail at health insurance companies and pharmaceutical companies and others who can’t or won’t make a difference.
> But instead, people rail at health insurance companies and pharmaceutical companies and others who can’t or won’t make a difference.
Because this is the Corrupt Evil Nexus that continues to ensure that taxpayer funds and exclusive patents keep flowing to them, while keeping prices high. They buy political power via campaign financing by the bucketload and the congressman/woman changes their vote to kill/oppose bills that would make a difference. You can find dozens of examples. Do your own research. As an example, take a look at the voting for the bill to permit Medicare to negotiate drug prices. Look at who received bribes and from whom to vote "No".
I am talking about the "Medicare Prescription Drug Price Negotiation Act of 2021", then "Medicare Drug Price Negotiation Act", then "Elijah Cummings Lower Drug Costs Now Act". They all had MUCH stronger drug-pricing proposals, all got stalled shamefully, with a watered-down version in BBB, which was further diluted in IRA that big pharma laughed at and accepted.
More specifically, the stronger acts which were killed by Big Pharma bribes would have
- Tied U.S. prices to international reference pricing (e.g., prices paid in Europe)
- Broad Medicare negotiation for many high-cost drugs - including dozens of new drugs.
- Applied negotiated prices beyond Medicare in the commercial market. (Private Insurance too!)
- Imposed strong penalties on drug companies that refused to comply
- Generated large federal savings. Also would have had faster rollout. Remember IRA pricing is YET to come into effect.
PS: Look at the Senators who diluted drug-pricing in BBB even further to a bad JOKE. (lol at price reduction for 10 drugs in 2026). Look at whom they received bribes oops..donations from.
> This is a wild assertion. The sum total of all 7 publicly listed insurance companies’ market caps is less than Eli Lilly, just one pharmaceutical company
Why are we using market cap as a metric ? Look at investment value.
"Over the past 20 years, health care companies spent 95% of their net income on shareholder payouts, totaling up to $2.6 trillion, according to the research findings. Shareholder payouts also tripled over this period - a trend largely shaped by a few powerful pharmaceutical companies, the research team noted."
> US textbooks cost multiple times more than the international version of the textbook
I mean, I think a lot of the incentives behind textbook pricing in the US are honestly not that dissimilar to the ones in healthcare. I know Pearson is particularly egregious for price gouging students because they have exclusive deals with schools to provide the textbook for some specific class or subject. They raise prices because f*ck it why not, they won’t get pushback, which is not a valid reason to do so in most other countries.
"they raise prices because f*ck it why not, they won’t get pushback"
This applies to more and more businesses these days. Textbooks, hospitals, colleges, veterinarians and so on. They basically have a captive audience so they do whatever they want.
Pharmaceutical companies, hospitals, and doctors are free to charge like that. But if I'm using insurance, it's irrelevant; that's the price to the insurer. It's the insurance company who determines the price I pay, using whatever arcane rituals they've chosen.
Germany has health insurances and they don’t do that nonsense. They fulfill their task which is to spread the risk over a wide range of people. That’s what insurance is for.
> "Rome said the companies seem to be maximizing prices while negotiating discounts behind the scenes with health and drug insurers and then setting yet another price for direct-to-consumer cash-pay sales."
This sounds like typical negotiating 101. You know you are going to be forced to lower from your starting position, so increase your starting position so when you do negotiate down you are closer to where you wanted to be.
It’s not only a logical negotiating position, it has legal implications.
Way back in the 50-60’s the government put in laws around “usual and customary price” in an attempt to rein in medical costs.
What providers were doing is charging cash customer $10, then when an insured patient came in (back when insurance paid 100%) they charged $100.
So a law was put into place to define what a “usual and customary price” is. The provider could not charge any customer more than this.
Like most well intentioned laws it created perverse incentives to jack up the public price as high as possible - if someone paid it, great, otherwise offer a discount.
As a european living in the US, the idea there is a market at all is laughable. I tried to get price quotes for treatments several time just to get a "well, it's hard to say" or "it's very complicated".
Here in Brazil, we have something called 'Genéricos.' These are essentially the same medications as the brand-name versions, produced with the same chemical ingredients, but they often cost half the price, sometimes even cheaper than that.
Interestingly, while on-patent medications in the US tend to be significantly more expensive than elsewhere, generics in the US tend to be less expensive than generics available elsewhere.
But prices are going up. Look at the statements your insurance company provides about the reimbursed "cost" of covered generics:
Some experts report that PBMs overcharge for generics; The Wall Street Journal estimated that Cigna and CVS Health, both of which own PBM services, are able to charge prices for specialty generic drugs that are 24 times higher than what manufacturers charge.
So this must be worldwide. It seems like the patents held by big pharma are the root of the corruption. What is the guarantee here? That the chemicals are pure, or just that the companies are getting their cut?
Generic is the English word for it. The brand name drugs have a limited time patent and they are supposed to help cover the initial research and development costs of bringing that drug to market.
Huge caveats. The drug manufacturer gets over a decade of market exclusivity which bars the selling of generic versions of the medication, which they can then extend again if they find another distinct use case for the medication (3 more years). This is why the Vyvanse generic took so long.
> This describes the biggest problem in US healthcare. No clear and consistent pricing.
For anyone not in the US wondering if this is an exaggeration, here is my history of buying prescription drugs.
1. For years, when I had insurance through my employer, I'd go the the nearest in-network pharmacy, which was Rite-Aid, for them. Those insurance plans always had a copay which was typically $10-15.
It was this way across several different insurance providers I had over the years at that employer. (For non-Americans wondering why my insurance company changed so often, it is common for employers to frequently switch providers to try to save money. Besides that being annoying because it means frequently changing coverage limits, it also means frequent changes in what doctors and dentists are in-network).
2. I saw something about Walmart's generic drug program. They were selling many generic drugs for a cash price of $4 for a month supply and $10 for a 3 month supply. Most of my drugs were included, so for those I switched my prescriptions to Walmart and didn't use insurance.
3. Later, for my drugs not in Walmart's generic drug program, I found that the GoodRx app or website could usually provide a discount coupon that would bring the cash price with coupon down below my insurance copay.
The GoodRx discount could vary significantly from pharmacy to pharmacy so I had my prescriptions split across two pharmacies.
4. My employer downsized and could no longer afford to provide insurance. I switched to a plan purchased on my state's Affordable Care Act (ACA) marketplace. I made too much money to get a government subsidy on my premiums, but not enough to afford a marketplace plan in the top two of the three tiers of plans (gold and silver). I had to settle for the third tier, bronze. That basically meant bigger copays and/or bigger coinsurance on everything, including drugs, than I had when I was on plans through my employer. Walmart generics + GoodRx coupons continued to be how I bought drugs.
5. I eventually switched to an HMO plan from the ACA marketplace, when rising costs made it so even the bronze non-HMO plans were too expensive. This meant I had to switch doctors to one that worked for the HMO (Kaiser), and the only in-network pharmacy was the one from the HMO.
It remained cheaper for nearly everything to continue with Walmart and GoodRx. The only drug I regularly got through Kaiser's pharmacy was generic Lipitor. That was $0. I refilled one of my other prescripts at Kaiser once, and my out of pocket came to twice what that drug was at Safeway with a GoodRx coupon.
I didn't try any of the others through Kaiser because there was no way that I could find to get the price other than actually getting the prescription filled there. Even though it was a Kaiser pharmacy, which is located in a Kaiser building and only takes Kaiser plans (and maybe people paying cash), they have no way apparently to answer the hypothetical "If I get drug X and I have Kaiser plan Y and my ID number is 12345678, what will my out of pocket cost be?".
I would have expected that one of the benefits of an integrated system like Kaiser where it is one company basically providing all of your health care except for some special services they contract out for would be that they could tell you the damn costs. I would have expected that when I'm in the doctor's office and he gives me a new prescription that on his terminal it would have the cost of getting it filled in the Kaiser pharmacy that is in the same building.
Nope. So I'd have to waste his time and mine getting out my phone, looking up the drug he's about to prescribe in the GoodRx app, and then decide where I want it. A nice thing about the GoodRx app was for Walmart if they did not have a GoodRx coupon because the drug was in Walmart's generic program GoodRx would still include it in the listing, showing the cash price so I didn't have to separately check Walmart's generics list.
6. It does get better when you get older. When I turned 65 and switched from a marketplace plan to Medicare I had to choose an insurance company that offered a Medicare drug plan. You can enter all your prescriptions on Medicare.gov and you can enter 5 pharmacies and the listing of available plans in your area will show you the annual total (premiums plug drugs) for each plan for both getting your drugs at the cheapest pharmacies on your pharmacy list and for getting them via mail order. By default it sorts the list by lowest total.
You still have the hassle of plans possibly changing each year. My plan on my first year went away. It was a $0 premium and $0 for all my drugs. There is still a $0 premium and $0 for all my drugs plan available for 2026, but I'll have to change pharmacies to one less convenient.
The above is if you choose regular Medicare when you enroll in Medicare. You can instead choose Medicare Advantage. The way Medicare Advantage works is instead of providing your medical coverage itself Medicare pays a private insurance company to do it. The plans offered by those private insurance companies broadly look a lot like the marketplace plans that offer on the ACA marketplaces or the plans they offer through employers.
They are usually pretty cheap, often with no premium from the insurance company (although you still have to pay a premium to the government for Medicare). Some even have negative premium plans. They also have most of the annoyances of ACA marketplace and employer plans, but there are usually ones that include drug coverage similar to the part D plan coverage for people on regular Medicare.
And when you get a broken leg you'd go shop around, comparing prices and looking up reviews? You can't have a "real" healthcare market. It is inelastic, people will always pay whatever is asked of them. It requires massive investments, naturally consolidating into a few large actors that are then easily able to join in a cartel, lobby the State for regulatory capture, etc. Price gouging and profiteering are just the end game of a free market functioning normally.
The US' main problem (seen from the outside) is that there seems to be no long term strategy just a sports-like us-versus-them mentality, where each team just thinks about how they can win more by making others lose. Winning the points is the goal, while all people forgot this was supposed to be a friendly game ans some even forgot which sport it is supposed to be.
This may well be the end game of capitalism, no pun intended.
Why is the supreme-court slow-walking the tariff decision which is crystal clear as lower courts clearly demonstrate only Congress can set taxes/tariffs?
It would end inflation within 90 days
Even their silly 15% tariff fallback law abuse would be more sane than the 50-150% currently
Mate, this Supreme Court ruled that the President is immune to prosecution and de facto outside and above the law. I’m honestly not sure what to tell you if you’re still hoping for rule-of-law decisions to come out of it.
The 14th Amendment says all people born or naturalized in the US and subject to its jurisdiction are citizens.
If someone is immune to prosecution and de facto outside and above the law, I wonder if a case could be made that they are not subject to US jurisdiction, and that invalidates prior citizenship by birth or naturalization.
It slowed down Americans because we aren't recently used to it. The rich did adapt relatively quickly by buying up all the housing they could at negative real interest, stocks, gold, and to a lesser extent crypto.
The lesson has been learned by this point though, even a day laborer is holding silver and crypto nowadays because we have in recent memory the COVID shenanigans of mass QE.
People in China and Russia have basically taken for granted so long that their currency is completely manipulated, they all already knew to not be hoodwinked.
Someone once proposed a National Sales Tax. I think it was suggested that we could eliminate personal income taxes if we imposed a federal sales tax on all purchases.
Liberals vehemently opposed the idea, calling it 'regressive', meaning it would be socially backwards, but the idea held appeal as a simple and fair way of "taxing everyone equally". For some reason, a majority of public opinion leaned left on this particular idea, and it never gained a foothold.
When I learned of the blanket tariffs being imposed on everything imported into the US, I think I knew what I was seeing-- this was a National Sales Tax in disguise. This was an attempt to fund the federal government off the backs of people, who will at the very least pay 10% more for everything they buy.
The big lie was told-- that this was an emergency necessary correction for an ongoing American-life-threatening international trade imbalance. But the real lie was bald-faced, right there in front of us-- everybody was going to have to pay more for everything, because this was, and is, a new tax.
I think there's a slim chance the Supreme Court may not even issue a decision addressing the legality of the president's impertnent array of tariffs. Although two full months have passed since oral arguments were made before the court, we may have an even longer wait for a decision, because it sure looks like John Roberts and company can't find/manufacture a reason to uphold/allow the president's seizure of tariff power.
They have demonstrated a preference for empowering the president. The court's character is displayed with quick mute indecipherable decisions from the shadow docket, while unpopular new anti-precedents get leaked ahead of release, delayed until opinion can be spun. So I would not be surprised to see the decision delayed, maybe even all the way to next October.
However it turns out, I'll pay the price and take my medicine, and try to be happy.
> Liberals vehemently opposed the idea, calling it 'regressive', meaning it would be socially backwards,
That's not what "regressive" means in the context of taxation. A "regressive tax" is one that takes a successively higher proportion of your income/wealth the poorer you are, while a progressive tax is one which takes a higher proportion of your income/wealth the richer you are. This is standard vocabulary in economics.
> Liberals vehemently opposed the idea, calling it 'regressive', meaning it would be socially backwards, but the idea held appeal as a simple and fair way of "taxing everyone equally"
I'm not sure what you mean by "socially backwards".
"Regressive" and "progressive" are terms of art in tax law and theory. A tax is regressive if people with less income pay a higher percentage of their income toward that tax than do people with more income. Progressive is the opposite.
Sales taxes are regressive because most people with lower income necessarily spend a higher percent of their income than most people with higher income, and so even if a sales tax is the same percentage of the sale price of items lower income people end up spending a higher percentage of their income on sales tax.
Yes, that was very much my point, and thank you for making it clearer than I did. I confess to having attempted to couch the term (in single quotes) in order to lessen its potential to trigger reactionary righteousness.
By "socially backwards" I meant to allude to a reversal of social evolution. If you start with the premise that we evolve as a society (and as individuals, cells in our grand aggregate organism), then you might see an increased tax burden on the poor as moving backwards, de-evolving, regressing.
I apologise for obscuring my meaning, stepping so lightly through (what I perceive to be) the minefield of HN's perpetual potential political polarization (and for here, now, my abuse of alliteration) that I danced over the point I was trying to make.
A blanket tariff policy is effectively a national sales tax which is regressive (and bad, taxation without representation is bad, bass ackwards orange man bad).
> Drugmakers plan to raise U.S. prices on at least 350 branded medications including vaccines against COVID, RSV and shingles and blockbuster cancer treatment Ibrance, even as the Trump administration pressures them for cuts
Few days ago, Donald Trump pressured Emmanuel Macron to raise the prices of all medicines. The pressure was made with unspoken threats according to several mainstream French media such as this one [1].
It's possible that Americans are all about free markets (I have severe doubts on this point, but let's accept it), but Trump and his MAGAts are far more concerned about fucking with people weaker than them.
If given two options, they will take the one that will hurt more people, every day of the week.
But of a paywall there, can't tell if raw materials and precursors are costing more, or R&D spend is up, or employee wages and salaries have risen. Those are usually the "pressures" on prices. I can't understand what or who might be applying "pressure" to lower prices on oligopolistic pharmaceutical makers.
big Pharma has properties unlike many other business. The R&D is very, very expensive and, income is not directly related to expenses each year. The natural "moat" is such that only a relatively few, giant and wealthy, companies exist over time.
Why does the US consumer of said medications subsidize many other countries who have access to the same medications for a fraction of the US sticker price?
Lots of reasons. One of them is that other countries negotiate deals country wide and can get bulk discounts. The US does this with the VA and Medicare, and people using those services generally pay less than the rest of Americans. In the end, it is largely a policy choice, as having a single payer could get better negotiated deals on drugs.
Thanks for adding this information and yes this is exactly the point I was trying to make. Nationalized systems have better outcomes when they control the supply, demand, and pricing. If that doesn’t work manufacture it ourselves at a discount.
Bah! Begone with your socialist mumbo jumbo! Fox News Entertainent channel tells me about you communist and your “single payer” sham all the time! We have the best healthcare! Merica!
Do you believe that the deals they make are unprofitable given the discount? Do you think the other countries are keeping guns to their heads or what?
The discounts are there because they can be, not because other countries want to pay below the break-even price.
It is in the US where the drug companies can invest in the government just enough to recoup that with massive premiums in the convoluted medical system.
Nobody's forcing US pharama companies to sell to those countries at those prices, they choose to, because it makes them more money.
Foreigners aren't the reason American healthcare sucks. Stop looking for people to blame abroad, all the sources of your problems are in the presidency, congress, and in the boardroom that directs the former.
This is not like IT where the Americans are completely dominant and clearly superior.
The European pharma companies are doing more than fine, despite their main market being heavily regulated and price-controlled.
The less charitable explanation is that US companies want to charge outrageous prices, and the American system let them to, so they do it.
That's what the USA are: a machine to prioritize profits over people. Sometimes it turns out fine, like for the startup scene. Sometimes it's terrible, like when lives at stake.
There are a lot of bad health outcomes built into our society, yes, but by the time people are confronted with the health impacts of cars, agriculture subsidies, for-profit healthcare, etc. it is likely that drugs will be necessary to treat the very real, immediate problems which any given patient has. Reversing the subsidies for things like car-dependency would positively benefit millions of people but it’s a generational change, not something most individuals can do.
I agree about the significance of those large-scale changes; still ...
> Reversing the subsidies for things like car-dependency would positively benefit millions of people but it’s a generational change, not something most individuals can do.
Individuals frequently can chose to not use a car, of course. Still, it's not realistic for everyone or all the time, especially in a society built for automobile use.
> by the time people are confronted with the health impacts of cars, agriculture subsidies, for-profit healthcare, etc. it is likely that drugs will be necessary
My point is that there are other treatments for illness. I doubt it's a coincidence that this patentable technology is so relied on in a hyper-capitalist society; other countries with better health outcomes use far fewer pills, iirc. Who will fund the large-scale study that says a valuable pill is unnecessary?
> Individuals frequently can chose to not use a car, of course
To some extent, yes, but my point was that it’s not realistic for many people because we treat walkable neighborhoods like luxuries. If you wake up in your 40s with a bad back and cardio problems because you live in a suburb and drive everywhere, you can’t roll back the clock and build sidewalks, legalize density, or run decent transit and on average don’t have the money to move somewhere dramatically better.
I think a growing number of people, especially younger ones, realize this is unsustainable but it took generations to get here and it’ll take a while to change trajectories, too. If gas prices had stayed high in the seventies that might have gone differently but a huge percentage of American neighborhoods are designed to minimize physical activity and that’s often enforced by law.
That's what I meant by, it's not realistic for everyone and everywhere.
> I think a growing number of people, especially younger ones, realize this is unsustainable but it took generations to get here and it’ll take a while to change trajectories, too.
Urbanist movements, including walkable communities, are much older than this younger generation. I think within a certain segment - well-educated upper middle class, maybe - it's long had influence.
I think they need to bring those ideas to other segments of society, which they have a hard time doing.
I definitely don’t think that it’s new to the current young generation but I am optimistic that they might have enough political clout to actually make progress. My neighborhood narrowly avoided becoming a highway in the 60s so we have some older folks who have been fighting car culture since before I was born, but there were a lot of people who didn’t really care because it was more affordable in the past, but their kids are a lot more motivated because it’s so financially non-viable now.
In the United States, the other big factor was recognizing how much it wasn’t just car culture but racism driving things. Despite the current moment, I get the impression that a lot of people are more aware of how much avoiding sidewalks and transit was driven by racism and just hurt everyone.
>Maybe drugs, or these drugs, aren't the most efficient solutions. Shouldn't we direct resources toward more efficient ones?
Turns out all the low hanging fruit have already been picked, so the only "more efficient ones" left are stuff like gene therapy, which are absurdly expensive, but still theoretically cheaper than a lifetime of care. Unsurprisingly the high sticker price draws much backlash from the public and politicians.
> all the low hanging fruit have already been picked
What is that based on?
Also, I'm not talking about 'low hanging fruit' necessarily; only solutons that become cost effective for vendors if drug prices aren't so extreme.
There's reason to think there is low-hanging fruit: Research is incentivized for the most profitable solutions for the vendors, not the most cost-effective solutions for patients.
>Also, I'm not talking about 'low hanging fruit' necessarily; only solutons that become cost effective for vendors if drug prices aren't so extreme.
>There's reason to think there is low-hanging fruit: Research is incentivized for the most profitable solutions for the vendors, not the most cost-effective solutions for patients.
High drug prices also mean you can charge more for one-off cures. See, the gene therapy example above.
US voters have no principles. Even republicans started artistically screaming about nationalizing companies when they didn’t want to play ball with the president.
I'm assuming you're European and just want to make an "America bad" post because this is comically ignorant. There wouldn't be mountains of federal code to adhere to if that was the case.
This is a trope among populists: pass legislation around <thing>, observe consequences of doing so, blame the "free market", repeat.
Sure, but that article literally contradicts your original point about Americans wanting a "free market" as it lists the complicated nature of existing laws, Medicare, PBMs etc. and the incentives those create.
You could just say "Americans need to vote better and cleanup their laws around this" and yes, that would be ideal, but I don't see that happening anytime soon. It's part of why some want the government to not involve themselves at all: no matter how good the politicians you elect, others can come into office and fuck it all up while everyone is forced to deal with it because they have the monopoly on violence. Not to mention the glacial pace at which our legislative bodies move.
> US voters prefer the free market as opposed to government regulation and nationalized healthcare.
Because US voters are dumb. (Just for context, I'm a US citizen).
Free markets don't work when there is inelastic demand for a good or service, and an awful lot of health care (unless you consider 'well, guess I'll just die then' as a reasonable outcome) is inelastic demand.
Rueters doesn't show a paywall for me. The source of the pressure described is in the headline though. I'm not sure why OP editorialized it (as it is against hn guidelines): Exclusive: Drugmakers raise US prices on 350 medicines despite pressure from Trump.
The article is about drug pricing, which is the part I found interesting (and by extension thought we’d find interesting). I thought taking it out both saved space and made the comments less likely to veer into flamebait.
Thanks for filling that in. I, too, am interested in this topic, because the oligopolistic market in the US, and the multinational corporations in the oligopoly, cause unusual, counter-intuitive and counter-doctrinal economic results. We're not in a recession or depression, so I was curious about causes of downward pressure on prices.
There's a character limit on the titles you can submit, probably wasn't intentionally editorializing. I assumed from the HN title that the pressure was from the Trump admin just based on the current state of US politics.
I think its obvious: theres a LOT of love for Trump here in VC circles. So anything speaking ill of his laughable policies, EO's, and other garbage is -1'ed or flagged to oblivion.
Ironically the past 6 months now all the political content is just insta dead flagged and removed, the love isn't lost but nobody wants to be the one responsible for defending it.
I'm sure Trump pressure will soon bring those 1000% savings on pharmaceuticals, just hold on.
"Rome said the companies seem to be maximizing prices while negotiating discounts behind the scenes with health and drug insurers and then setting yet another price for direct-to-consumer cash-pay sales."
This describes the biggest problem in US healthcare. No clear and consistent pricing. If we had a real market, you would get a prescription and then go to the seller with the lowest price. And everybody would get the same price. This whole business with PBMs that are owned by the insurance companies, discount cards and other shenanigans just invites corruption.
Last year I needed to get blood work done, some of which may or may not be covered.
It took me two weeks, dozens of phone calls, and multiple "escalations" to learn what would be covered and what the price would be if it wasn't
Totally insane. The kicker is that after all that, the price I was billed wasn't even the price I was given (thankfully it was less though).
I just had some bloodwork done, myself. My provider accidentally billed insurance, which had lapsed due to being laid off. I got my "Explanation of benefits" and it was $1000 billed to them, but I was given a $500 "discount." So I only owed $500... Cash cost was $50. Makes no goddamn sense.
Also I went in for a colonoscopy and an endoscopy. Insurance was billed for $14000. I got statements from 4 different doctors, and the facility where it was performed. None of the statements matched the explanation of benefits from the insurance company. And when I called each doctor, to pay them, they all told me that I didn't actually have to pay them what it said I owed. So I just ended up paying $2500 to the insurance company. It again, makes zero sense.
It makes perfect sense. The prices are inflated with a few extra zeroes to try to force people to get any job with insurance. The big numbers are just to scare people. You can also turn negotiating with the hospital into a full time job and get the real numbers. If you're too unhealthy to do either of these then you can just die I guess.
Well, there is that. But there is also the fact that they charge you or your insurance company to smooth out other costs like $2,000,000.00 cancer treatment or for people who show up to the hospital, don’t have insurance, and the hospital has to treat them.
I’m reaching the point where I don’t really care if it’s private or public, but what we are doing today is the worst of both worlds. It either needs to be fully private, maybe with mandatory insurance purchase, or it needs to be fully public, though that has its own baggage.
“ But there is also the fact that they charge you or your insurance company to smooth out other costs like $2,000,000.00 cancer treatment or for people who show up to the hospital, don’t have insurance, and the hospital has to treat them”
I bet whatever cost these patients cause, the hospital will inflate this by an order of magnitude. It’s the same with charity care. Hey, my sticker price for an aspirin is $1000. I’ll give away 10 aspirin and I can get credit for $10000 charity.
A lot of that is tied into billing in general, even without the people who can't afford to pay for their care. When they send out an invoice for $50,000 for services rendered, even if the insurance company only ends up paying them a fraction of that, when it comes to accounting and taxes you can be sure they are using that $50,000 number for deductions and such when it benefits them.
This uncertainty of what things cost would kill me. It must be terrible!
We had a baby 2 weeks ago, which included 4 nights in the hospital before and after the birth, a surprise c-section, various specialists, follow ups, consultants and blood tests.
Our total outlay so far is about €30 for the parking at the hospital every day.
We have insurance, but we did not use it for the baby. I need to see a dermatologist next week. Cost will be €300, which I can claim back from my insurance afterwards. I just punch the doctor's name into my insurance portal, and they list the procedures and the amounts I'm covered for each.
If I asked my GP to refer me to a public dermatologist, I would have waited longer for an appt, but I would have only had to worry about parking at the hospital, everything else would be free.
I don't think the hospital expects to actually ever get paid what they bill out, or anything at all, if it's not paid onsite or by insurance.
>> I don't think the hospital expects to actually ever get paid what they bill out
OH YES THEY ABSOLUTELY DO!
When I was in-between jobs I had a medical emergency and I was on the ACA around the first year it was offered. I was billed above medicare rates so I was on the hook for ~40k after out of pocket max. They told me this limit is what insurance has to cover but hospitals can still bill above it. First they told me they could work on the prices and asked for my last 5 years tax returns. When they saw that I had dividend payments they said they couldn't help me and I owed them the $40k. I think that was the problem because even though I wasn't working in their mind if I had investments then technically I was not in need so they set up four-year payment plan and paid every penny with no cost reduction.
I probably did something wrong but to this day I didn't know what I would have done differently. The only people I could talk to were the hospital and they only cared about the hospital.
This is called "balance billing" and the No Surprises Act usually prevents it, especially in emergency cases.
https://www.healthinsurance.org/glossary/no-surprises-act/
This happened in 2013, 9 years before the Act. Hopefully the Act prevents this kind of stuff. The medicare limit is what really confused me. If there is a limit insurance will cover up to, then how is it possible to exceed that limit?
Not for ambulances!
[]
I really don't believe you, but according to HN, I am supposed to trust in good faith you aren't lying.
Maybe you just don't have any assets or make very little money. I have equity and cannot just toss it to a collection agency and hope they forget. I also play by the rules, silly, I know, but I don't want to risk getting fucked some other way later in life.
In practice, the whole system is set up in a way that discourages asking questions. Waste of time. It's truly the opposite of the transparent ideal market.
That’s what is insane. I called my insurance to ask if some tests were covered since preventative care is 100% covered.
They couldn’t answer if cholesterol test would count. How is that not automatically classified as preventative? It’s one of the most basic metrics.
So they want me to get the doctor to give me the ICD code and the diagnosis code. Or something. Two different codes. They’ve added so much bureaucracy and crap into the system because they can. Nobody’s stopping them and there’s too many fingers in the pie.
I think you might be confused by the terminology. Under the ACA (Obamacare) there are a limited set of preventive health services that are covered at no cost to the patient. These are a subset of all preventive care services that meet strict criteria for effectiveness. Cholesterol screening may or may not be included based on your age and diagnosed conditions.
https://www.healthcare.gov/preventive-care-adults/
> How is that not automatically classified as preventative? It’s one of the most basic metrics.
They're incentivized to classify whatever they can as not being their problem, so it makes sense for them to double-check everything - there is always a possibility that some edge case was found that lets them off the hook for some specific test or treatment. Moreover, obscuring information and spreading support staff as thinly as possible means that extra barriers heavily discourage people from fully knowing what they'll be on the hook for, which makes them more likely to just nod their heads and do/pay what is asked. These decisions aren't driven by medical concerns. It's a universal problem of nearly all kinds of privatized insurance - their core incentive is to ask for as much money as possible and provide as little in return as it's legally feasible. All the things mentioned in this comment thread are used to thwart any possibility of competition, which would otherwise act against this strong pull towards pure profit-seeking.
The place where I live is often used by Americans as the first line of defense to justify their healthcare system. Among certain political circles, there is almost a reflex to point at us and say "see how terrible it is?!" by exaggerating all the drawbacks and minimizing all the upsides. Yet even in such a flawed, underfunded, mismanaged system, my government insurance plan covers all "medically necessary" lab testing, with a couple rare exceptions that are only covered if you're diagnosed with certain conditions. The process of getting a test consists of a doctor filling out a standardized sheet, then going to a lab and handing them that sheet and my regional insurance card. No money exchanged.
"And everybody would get the same price. This whole business with PBMs that are owned by the insurance companies, discount cards and other shenanigans just invites corruption."
It's hard to say that it isn't racketeering at this point.
"Specifically, a racket was defined by this coinage as being a service that calls forth its own demand, and would not have been needed otherwise."
There's demand for the meds, but the demand for discount cards, forcing people to use specific services/companies, and related programs is all invented by the companies themselves.
Most of the non "cut everything" GOP plans still involve trying to get the consumer to shop around, but shopping around is impossible. The consumer can't be a consumer and impact the market if they don't know what is going on.
The system is fundamentally broken.
I go to the doctor and I have zero clue what will come back on the bills.
> This describes the biggest problem in US healthcare. No clear and consistent pricing.
AIUI, this is one reason Kenneth Arrow argued (in 1963 [1][2]) that healthcare could not really use a market-oriented solution: information asymmetry.
[1] https://assets.aeaweb.org/asset-server/files/9442.pdf
[2] https://pubmed.ncbi.nlm.nih.gov/15042238/
Health insurance in general is the problem; PBMs/discount cards are just a cherry on top. Insurance is fundamentally incompatible with clear and consistent pricing.
Pharmaceutical companies, hospitals, and doctors are free to charge by the medicine, by the night, and by the minute.
For example, this place does it:
https://surgerycenterok.com/surgery-prices/
Insurance companies do not force the sellers to use complex billing practices, they would benefit from more transparent pricing (since they are seeking to pay less).
The root cause is healthcare is inherently complicated and complex, it has a problem of supply being nowhere near demand, and since prices for things are so high (including liability), there is a lot of cover your ass and fraud prevention going on.
Insurance companies absolutely benefit from the higher and opaque prices, because they negotiate rebates with providers. This allows them to maximize patient copays and ensures they hit their deductible, i.e. paying as much as possible under their respective insurance plans. Contrast this with a no-rebate world with cheaper/more transparent pricing. Fewer patients would hit their out of pocket maximum.
They can use the rebates they get from the providers to subsidize the insured, allowing them to offer lower premiums and gain market share. This is what people mean when they say "In America, the sick people pay to subsidize the health care of the healthy people".
Of course, that above only applies if there is competitive pressure. If there is no competitive pressure (e.g. in states with only one or two insurers), they can keep premiums high and book as profit the difference between what the patient paid out and what the patient would have paid out in a lower-cost no-rebate world.
> Contrast this with a no-rebate world with cheaper/more transparent pricing. Fewer patients would hit their out of pocket maximum.
And premiums would go up. Every insurer has to get their premium approved by every state’s insurance regulator, and every state’s insurance regulator is not going to allow them to have more than a few percent of profit.
> They can use the rebates they get from the providers to subsidize the insured, allowing them to offer lower premiums and gain market share. This is what people mean when they say "In America, the sick people pay to subsidize the health care of the healthy people".
I’ve never heard of this, and it’s legally not allowed. The ACA mandates insurers price plans so that old people only pay at most 3x what young people pay. And the ACA does not allow insurers to charge more to people likelier to need healthcare. Mathematically, that means younger and healthier people pay higher premiums so that older and sicker people can have lower premiums.
NY state goes even further and says all ages pay the same premium, so young subsidizes old even more. MA has a 2x cap, I believe. And then of course, FICA taxes mean the young and working are paying for the healthcare for the old and non working, the vast majority of all healthcare spend in the US (Medicare).
> And premiums would go up.
Yes. As I wrote above, insurers compete on premiums, and they do do so by using rebates to subsidize those premiums by spreading patients' deductibles across the insured population. As far as profits go, I can't speak to regulatory issues since they will vary by state, but in any case the same critique would apply if insurers are pocketing a fixed percentage of a larger amount.
Re your second point, it completely twists my point and is largely irrelevant. Yes, older people paying the same premiums as younger people is a counter-argument in that older people are more likely to need healthcare, but the central point is that people who have to USE their insurance (i.e. sick people) subsidize the premiums of people who don't (healthy people), and this critique applies regardless of age. Now, one could argue that the structural factors that control costs across age cohorts counterbalances this phenomenon. And I'd agree with you! But that doesn't negate the original point that insurance companies benefit from, and advocate for, high sticker prices.
> but the central point is that people who have to USE their insurance (i.e. sick people) subsidize the premiums of people who don't (healthy people), and this critique applies regardless of age.
You’re losing me here. This claim is categorically false. You cannot consider only the deductible when calculating who subsidizes who.
The only way to calculate it is premiums + deductible + out of pocket maximum = total healthcare costs. And the subsidy via premium is so large that it negates effects of a deductible and out of pocket maximum.
Note that all plans have to be actuarially equivalent, regardless of what deductible you choose. The actuaries have to account for rebates and other pricing strategies when ensuring actuarial equivalence, so that the ratio of what the plan pays versus what you pay meets the required ratio for that metal level.
https://www.healthcare.gov/choose-a-plan/plans-categories/
Since your health is not a factor in pricing your insurance, it has to be that people less likely to need healthcare pay for the people likely to need healthcare.
It is the same as if the government forbade auto insurers from using moving violations history, or life insurers from using health measures, or home insurers from using flood maps.
The claim about who subsidizes who was always hyperbole, I'll grant you that. I included the statement to make the point that this is the phenomenon people are referring to when they make that statement.
I happen to think there is validity to the statement if you control for other actuarial factors. But if you don't think that makes sense as a lens through which to look at the problem, I won't quibble, even though I disagree. We're also only talking about drug prices here, which is a small portion of overall healthcare spending.
In any case, the central point, that insurers benefit from higher prices, still stands.
> In any case, the central point, that insurers benefit from higher prices, still stands.
All sellers benefit from higher prices. No one limits the price they ask for out of the goodness of their hearts. Lower prices are because a competitor offers a lower price, and because buyers can’t pay a higher price.
Everybody in this system benefits from this insanity, except the patient.
Don’t do pro bono PR for those companies. Healthcare isn’t so complicated that every other country in the world hasn’t been able to solve it for significantly less money and far less stress for users, not to mention better health outcomes in most cases.
Providing a chain of reasoning to support a logical conclusion is not “pro bono PR for those companies”. Claiming that someone doing that seems like an emotional kneejerk reaction to an idea that does not jive with the model of the world you would like to have.
I even provided an example of a healthcare provider choosing to be more transparent. It is always Eli Lilly’s choice to sell their medicine at a flat price to everyone. But it is also in Eli Lilly’s benefit to engage in price discrimination, so that they get paid more by people who can pay more:
https://en.wikipedia.org/wiki/Price_discrimination
Another example of this was when I was in college, US textbooks cost multiple times more than the international version of the textbook I could buy on Abe books or whatever website. Or, coupons for grocery stores. The insurance company has no hand in this.
To be clear, insurance companies also cause waste, because the government does not audit them, and the insurance companies are not staffed appropriately to resolve disputes in a timely manner.
What you gave us wasn’t a chain of reasoning: you just regurgitated the industry’s preferred excuses (“it’s complicated”, “people will use too much healthcare if it’s cheaper”, “liability!”) while begging the questions of whether those are true or why they affect the United States far more than any other advanced country. If you wanted to construct a logical chain of reasoning, that would be far more interesting than repeating another round of simply asserting that the status quo is inevitable.
If you need proof that delivering cutting edge services requiring split second decisions and multiple highly qualified people who are liable to the tune of millions of dollars for each decision is not complicated, then we are living on different planets.
> If you wanted to construct a logical chain of reasoning, that would be far more interesting than repeating another round of simply asserting that the status quo is inevitable.
You are welcome to explain why an insurance company would want to make things so complicated. They don’t make it so complicated for claims on a vehicle or a house. They are earning meager profit margins with the situation as is. There is literally nowhere they could go except up…why are they choosing not to?
And if you can come up with a more efficient system to administer insurance, I’m sure a few rich people like Dimon and Buffett and Bezos would be interested in your services. These two “titans” of industry couldn’t figure out how to make it better.
https://www.forbes.com/sites/brucejapsen/2021/01/04/amazons-...
> it has a problem of supply being nowhere near demand,
Get rid of the patents and this will solve itself in no time.
> The insurance company has no hand in this.
False. Insurance companies in the US own stock in big pharma firms like Pfizer, Johnson & Johnson, Eli Lilly, etc. They maintain substantial investment portfolios and generate returns on premiums and reserves. They also have voting rights as institutional investors.
Yes, no one is stopping US (or other countries’) taxpayers from paying for all the drug trials so that the resulting medicines are in the public domain.
> False. Insurance companies in the US own stock in big pharma firms like Pfizer, Johnson & Johnson, Eli Lilly, etc. They maintain substantial investment portfolios and generate returns on premiums and reserves. They also have voting rights as institutional investors.
This is a wild assertion. The sum total of all 7 publicly listed insurance companies’ market caps is less than Eli Lilly, just one pharmaceutical company. I would need some evidence before believing that health insurance company leaders have any influence on pharmaceutical companies.
I would also be surprised to learn insurance companies hold specific stocks, seems like a risk insurance companies would not take, especially ones that have lots of routine cash expenses. They spend ~85% of their premiums on medical expenses, and probably at least 5% to 10% on their own staff, so they shouldn’t even have much extra cash left to invest for the long term.
https://www.oliverwyman.com/our-expertise/insights/2023/mar/...
Edit: hit posting limit, so to respond to comment below about net income, that Yale link does not seem relevant as it is for all healthcare companies. All 7 publicly listed insurers’ combined annual net income is $35B or less for the previous 20 years, at a profit margin of 3% or less, which is peanuts. The pharmaceutical companies earn much more money than them, which is why the pharmaceutical companies have higher market caps.
> Why are we using market cap as a metric ? Look at investment value.
Because a company that owns influential portions of another company would have that reflected in their market cap. Like Berkshire Hathaway does. with the exception of UNH (due to its healthcare provider business), the other insurance companies are relatively tiny businesses compared to pharmaceutical companies and so cannot be holding any influential amount of stock.
The U.S taxpayer already pays for this. ~40% of FDA-approved drugs have direct NIH funding behind them. Nearly all modern drugs rely on NIH-funded foundational science. Taxpayer money additionally also floats through BARDA, DOD and DARPA.
COVID mRNA vaccines (Pfizer-BioNTech, Moderna) got billions in public funding. Yet, patents usually belong to the private company and prices are not capped as a condition of public funding. It is gross corruption begging for heads to be put on pikes.
Correct, people should be asking their federal politician why the US federal government is not spending the few billion dollars on drug trials to avoid having to pay extra to pharmaceutical companies.
But instead, people rail at health insurance companies and pharmaceutical companies and others who can’t or won’t make a difference.
> But instead, people rail at health insurance companies and pharmaceutical companies and others who can’t or won’t make a difference.
Because this is the Corrupt Evil Nexus that continues to ensure that taxpayer funds and exclusive patents keep flowing to them, while keeping prices high. They buy political power via campaign financing by the bucketload and the congressman/woman changes their vote to kill/oppose bills that would make a difference. You can find dozens of examples. Do your own research. As an example, take a look at the voting for the bill to permit Medicare to negotiate drug prices. Look at who received bribes and from whom to vote "No".
Which bill are you referring to? The 2022 Inflation Reduction Act passed with a provision allowing Medicare to negotiate drug prices.
(Although it is, of course, true that having special drug rates for Medicare trends against rather than towards "clear and consistent pricing".)
I am talking about the "Medicare Prescription Drug Price Negotiation Act of 2021", then "Medicare Drug Price Negotiation Act", then "Elijah Cummings Lower Drug Costs Now Act". They all had MUCH stronger drug-pricing proposals, all got stalled shamefully, with a watered-down version in BBB, which was further diluted in IRA that big pharma laughed at and accepted.
More specifically, the stronger acts which were killed by Big Pharma bribes would have
- Tied U.S. prices to international reference pricing (e.g., prices paid in Europe)
- Broad Medicare negotiation for many high-cost drugs - including dozens of new drugs.
- Applied negotiated prices beyond Medicare in the commercial market. (Private Insurance too!)
- Imposed strong penalties on drug companies that refused to comply
- Generated large federal savings. Also would have had faster rollout. Remember IRA pricing is YET to come into effect.
PS: Look at the Senators who diluted drug-pricing in BBB even further to a bad JOKE. (lol at price reduction for 10 drugs in 2026). Look at whom they received bribes oops..donations from.
> This is a wild assertion. The sum total of all 7 publicly listed insurance companies’ market caps is less than Eli Lilly, just one pharmaceutical company
Why are we using market cap as a metric ? Look at investment value.
From the NAIC report at https://content.naic.org/sites/default/files/capital-markets..., common stock holdings alone of U.S. insurance industry is roughly ~$1.2 trillion.
"Over the past 20 years, health care companies spent 95% of their net income on shareholder payouts, totaling up to $2.6 trillion, according to the research findings. Shareholder payouts also tripled over this period - a trend largely shaped by a few powerful pharmaceutical companies, the research team noted."
https://medicine.yale.edu/news-article/health-care-company-p...
> US textbooks cost multiple times more than the international version of the textbook
I mean, I think a lot of the incentives behind textbook pricing in the US are honestly not that dissimilar to the ones in healthcare. I know Pearson is particularly egregious for price gouging students because they have exclusive deals with schools to provide the textbook for some specific class or subject. They raise prices because f*ck it why not, they won’t get pushback, which is not a valid reason to do so in most other countries.
"they raise prices because f*ck it why not, they won’t get pushback"
This applies to more and more businesses these days. Textbooks, hospitals, colleges, veterinarians and so on. They basically have a captive audience so they do whatever they want.
Pharmaceutical companies, hospitals, and doctors are free to charge like that. But if I'm using insurance, it's irrelevant; that's the price to the insurer. It's the insurance company who determines the price I pay, using whatever arcane rituals they've chosen.
Unless the anesthesiologist is mysteriously out of network, or you failed to get some silly pre-approval, or…
Germany has health insurances and they don’t do that nonsense. They fulfill their task which is to spread the risk over a wide range of people. That’s what insurance is for.
> "Rome said the companies seem to be maximizing prices while negotiating discounts behind the scenes with health and drug insurers and then setting yet another price for direct-to-consumer cash-pay sales."
This sounds like typical negotiating 101. You know you are going to be forced to lower from your starting position, so increase your starting position so when you do negotiate down you are closer to where you wanted to be.
It’s not only a logical negotiating position, it has legal implications.
Way back in the 50-60’s the government put in laws around “usual and customary price” in an attempt to rein in medical costs.
What providers were doing is charging cash customer $10, then when an insured patient came in (back when insurance paid 100%) they charged $100.
So a law was put into place to define what a “usual and customary price” is. The provider could not charge any customer more than this.
Like most well intentioned laws it created perverse incentives to jack up the public price as high as possible - if someone paid it, great, otherwise offer a discount.
As a european living in the US, the idea there is a market at all is laughable. I tried to get price quotes for treatments several time just to get a "well, it's hard to say" or "it's very complicated".
There is a market but you aren't part of it :-)
Prices should be transparent, yes. But supply and demand isnt going to take down an oligopoly.
Here in Brazil, we have something called 'Genéricos.' These are essentially the same medications as the brand-name versions, produced with the same chemical ingredients, but they often cost half the price, sometimes even cheaper than that.
Insanely comical.
Interestingly, while on-patent medications in the US tend to be significantly more expensive than elsewhere, generics in the US tend to be less expensive than generics available elsewhere.
in the US, we call these 'generics'
Now look into the places that manufacture these generic versions. Not all factories are equal, and some are not of the best of reputations.
Additionally generics can differ in terms of the inactive ingredients or coating or other stuff. See e.g. https://news.osu.edu/all-generic-drugs-are-not-equal-study-f...
Those are available in America too
But prices are going up. Look at the statements your insurance company provides about the reimbursed "cost" of covered generics:
Some experts report that PBMs overcharge for generics; The Wall Street Journal estimated that Cigna and CVS Health, both of which own PBM services, are able to charge prices for specialty generic drugs that are 24 times higher than what manufacturers charge.
https://www.americanprogress.org/article/5-things-to-know-ab...
So this must be worldwide. It seems like the patents held by big pharma are the root of the corruption. What is the guarantee here? That the chemicals are pure, or just that the companies are getting their cut?
Generic is the English word for it. The brand name drugs have a limited time patent and they are supposed to help cover the initial research and development costs of bringing that drug to market.
Generics can only be made after the patent expires. And due to pressure from western countries, these are enforced worldwide.
Which takes over a decade and can be extended multiple times if they find more uses for the drug.
Huge caveats. The drug manufacturer gets over a decade of market exclusivity which bars the selling of generic versions of the medication, which they can then extend again if they find another distinct use case for the medication (3 more years). This is why the Vyvanse generic took so long.
That's what he said. Brazil is in (South) America.
> This describes the biggest problem in US healthcare. No clear and consistent pricing.
For anyone not in the US wondering if this is an exaggeration, here is my history of buying prescription drugs.
1. For years, when I had insurance through my employer, I'd go the the nearest in-network pharmacy, which was Rite-Aid, for them. Those insurance plans always had a copay which was typically $10-15.
It was this way across several different insurance providers I had over the years at that employer. (For non-Americans wondering why my insurance company changed so often, it is common for employers to frequently switch providers to try to save money. Besides that being annoying because it means frequently changing coverage limits, it also means frequent changes in what doctors and dentists are in-network).
2. I saw something about Walmart's generic drug program. They were selling many generic drugs for a cash price of $4 for a month supply and $10 for a 3 month supply. Most of my drugs were included, so for those I switched my prescriptions to Walmart and didn't use insurance.
3. Later, for my drugs not in Walmart's generic drug program, I found that the GoodRx app or website could usually provide a discount coupon that would bring the cash price with coupon down below my insurance copay.
The GoodRx discount could vary significantly from pharmacy to pharmacy so I had my prescriptions split across two pharmacies.
4. My employer downsized and could no longer afford to provide insurance. I switched to a plan purchased on my state's Affordable Care Act (ACA) marketplace. I made too much money to get a government subsidy on my premiums, but not enough to afford a marketplace plan in the top two of the three tiers of plans (gold and silver). I had to settle for the third tier, bronze. That basically meant bigger copays and/or bigger coinsurance on everything, including drugs, than I had when I was on plans through my employer. Walmart generics + GoodRx coupons continued to be how I bought drugs.
5. I eventually switched to an HMO plan from the ACA marketplace, when rising costs made it so even the bronze non-HMO plans were too expensive. This meant I had to switch doctors to one that worked for the HMO (Kaiser), and the only in-network pharmacy was the one from the HMO.
It remained cheaper for nearly everything to continue with Walmart and GoodRx. The only drug I regularly got through Kaiser's pharmacy was generic Lipitor. That was $0. I refilled one of my other prescripts at Kaiser once, and my out of pocket came to twice what that drug was at Safeway with a GoodRx coupon.
I didn't try any of the others through Kaiser because there was no way that I could find to get the price other than actually getting the prescription filled there. Even though it was a Kaiser pharmacy, which is located in a Kaiser building and only takes Kaiser plans (and maybe people paying cash), they have no way apparently to answer the hypothetical "If I get drug X and I have Kaiser plan Y and my ID number is 12345678, what will my out of pocket cost be?".
I would have expected that one of the benefits of an integrated system like Kaiser where it is one company basically providing all of your health care except for some special services they contract out for would be that they could tell you the damn costs. I would have expected that when I'm in the doctor's office and he gives me a new prescription that on his terminal it would have the cost of getting it filled in the Kaiser pharmacy that is in the same building.
Nope. So I'd have to waste his time and mine getting out my phone, looking up the drug he's about to prescribe in the GoodRx app, and then decide where I want it. A nice thing about the GoodRx app was for Walmart if they did not have a GoodRx coupon because the drug was in Walmart's generic program GoodRx would still include it in the listing, showing the cash price so I didn't have to separately check Walmart's generics list.
6. It does get better when you get older. When I turned 65 and switched from a marketplace plan to Medicare I had to choose an insurance company that offered a Medicare drug plan. You can enter all your prescriptions on Medicare.gov and you can enter 5 pharmacies and the listing of available plans in your area will show you the annual total (premiums plug drugs) for each plan for both getting your drugs at the cheapest pharmacies on your pharmacy list and for getting them via mail order. By default it sorts the list by lowest total.
You still have the hassle of plans possibly changing each year. My plan on my first year went away. It was a $0 premium and $0 for all my drugs. There is still a $0 premium and $0 for all my drugs plan available for 2026, but I'll have to change pharmacies to one less convenient.
The above is if you choose regular Medicare when you enroll in Medicare. You can instead choose Medicare Advantage. The way Medicare Advantage works is instead of providing your medical coverage itself Medicare pays a private insurance company to do it. The plans offered by those private insurance companies broadly look a lot like the marketplace plans that offer on the ACA marketplaces or the plans they offer through employers.
They are usually pretty cheap, often with no premium from the insurance company (although you still have to pay a premium to the government for Medicare). Some even have negative premium plans. They also have most of the annoyances of ACA marketplace and employer plans, but there are usually ones that include drug coverage similar to the part D plan coverage for people on regular Medicare.
And when you get a broken leg you'd go shop around, comparing prices and looking up reviews? You can't have a "real" healthcare market. It is inelastic, people will always pay whatever is asked of them. It requires massive investments, naturally consolidating into a few large actors that are then easily able to join in a cartel, lobby the State for regulatory capture, etc. Price gouging and profiteering are just the end game of a free market functioning normally.
The US' main problem (seen from the outside) is that there seems to be no long term strategy just a sports-like us-versus-them mentality, where each team just thinks about how they can win more by making others lose. Winning the points is the goal, while all people forgot this was supposed to be a friendly game ans some even forgot which sport it is supposed to be.
This may well be the end game of capitalism, no pun intended.
http://archive.today/Gxx7p
Why is the supreme-court slow-walking the tariff decision which is crystal clear as lower courts clearly demonstrate only Congress can set taxes/tariffs?
It would end inflation within 90 days
Even their silly 15% tariff fallback law abuse would be more sane than the 50-150% currently
Next few years is going to be insanity
Mate, this Supreme Court ruled that the President is immune to prosecution and de facto outside and above the law. I’m honestly not sure what to tell you if you’re still hoping for rule-of-law decisions to come out of it.
The 14th Amendment says all people born or naturalized in the US and subject to its jurisdiction are citizens.
If someone is immune to prosecution and de facto outside and above the law, I wonder if a case could be made that they are not subject to US jurisdiction, and that invalidates prior citizenship by birth or naturalization.
I sure hope not. We don't need any help weakening citizens' protections from the government.
There was a lot of inflation before tariffs, and it didn't even have the effect of slowing China down economically or Russia militarily.
It slowed down Americans because we aren't recently used to it. The rich did adapt relatively quickly by buying up all the housing they could at negative real interest, stocks, gold, and to a lesser extent crypto.
The lesson has been learned by this point though, even a day laborer is holding silver and crypto nowadays because we have in recent memory the COVID shenanigans of mass QE.
People in China and Russia have basically taken for granted so long that their currency is completely manipulated, they all already knew to not be hoodwinked.
Inflation is low (relative to the last few years) and so far tariff related inflation hasn't manifested.
Someone once proposed a National Sales Tax. I think it was suggested that we could eliminate personal income taxes if we imposed a federal sales tax on all purchases.
Liberals vehemently opposed the idea, calling it 'regressive', meaning it would be socially backwards, but the idea held appeal as a simple and fair way of "taxing everyone equally". For some reason, a majority of public opinion leaned left on this particular idea, and it never gained a foothold.
When I learned of the blanket tariffs being imposed on everything imported into the US, I think I knew what I was seeing-- this was a National Sales Tax in disguise. This was an attempt to fund the federal government off the backs of people, who will at the very least pay 10% more for everything they buy.
The big lie was told-- that this was an emergency necessary correction for an ongoing American-life-threatening international trade imbalance. But the real lie was bald-faced, right there in front of us-- everybody was going to have to pay more for everything, because this was, and is, a new tax.
I think there's a slim chance the Supreme Court may not even issue a decision addressing the legality of the president's impertnent array of tariffs. Although two full months have passed since oral arguments were made before the court, we may have an even longer wait for a decision, because it sure looks like John Roberts and company can't find/manufacture a reason to uphold/allow the president's seizure of tariff power.
They have demonstrated a preference for empowering the president. The court's character is displayed with quick mute indecipherable decisions from the shadow docket, while unpopular new anti-precedents get leaked ahead of release, delayed until opinion can be spun. So I would not be surprised to see the decision delayed, maybe even all the way to next October.
However it turns out, I'll pay the price and take my medicine, and try to be happy.
> Liberals vehemently opposed the idea, calling it 'regressive', meaning it would be socially backwards,
That's not what "regressive" means in the context of taxation. A "regressive tax" is one that takes a successively higher proportion of your income/wealth the poorer you are, while a progressive tax is one which takes a higher proportion of your income/wealth the richer you are. This is standard vocabulary in economics.
> Liberals vehemently opposed the idea, calling it 'regressive', meaning it would be socially backwards, but the idea held appeal as a simple and fair way of "taxing everyone equally"
I'm not sure what you mean by "socially backwards".
"Regressive" and "progressive" are terms of art in tax law and theory. A tax is regressive if people with less income pay a higher percentage of their income toward that tax than do people with more income. Progressive is the opposite.
Sales taxes are regressive because most people with lower income necessarily spend a higher percent of their income than most people with higher income, and so even if a sales tax is the same percentage of the sale price of items lower income people end up spending a higher percentage of their income on sales tax.
Yes, that was very much my point, and thank you for making it clearer than I did. I confess to having attempted to couch the term (in single quotes) in order to lessen its potential to trigger reactionary righteousness.
By "socially backwards" I meant to allude to a reversal of social evolution. If you start with the premise that we evolve as a society (and as individuals, cells in our grand aggregate organism), then you might see an increased tax burden on the poor as moving backwards, de-evolving, regressing.
I apologise for obscuring my meaning, stepping so lightly through (what I perceive to be) the minefield of HN's perpetual potential political polarization (and for here, now, my abuse of alliteration) that I danced over the point I was trying to make.
A blanket tariff policy is effectively a national sales tax which is regressive (and bad, taxation without representation is bad, bass ackwards orange man bad).
> Drugmakers plan to raise U.S. prices on at least 350 branded medications including vaccines against COVID, RSV and shingles and blockbuster cancer treatment Ibrance, even as the Trump administration pressures them for cuts
Few days ago, Donald Trump pressured Emmanuel Macron to raise the prices of all medicines. The pressure was made with unspoken threats according to several mainstream French media such as this one [1].
[1]: https://www.tf1info.fr/international/trump-se-vante-d-avoir-...
That's like pressuring a politician to commit seppuku. French would be rioting in the streets if he would even try that.
Furthermore how Macron can increase prices of drugs? I was thinking that Americans are all about free market.
It's possible that Americans are all about free markets (I have severe doubts on this point, but let's accept it), but Trump and his MAGAts are far more concerned about fucking with people weaker than them.
If given two options, they will take the one that will hurt more people, every day of the week.
Hmm, I heard they’re down 1500%.
But of a paywall there, can't tell if raw materials and precursors are costing more, or R&D spend is up, or employee wages and salaries have risen. Those are usually the "pressures" on prices. I can't understand what or who might be applying "pressure" to lower prices on oligopolistic pharmaceutical makers.
big Pharma has properties unlike many other business. The R&D is very, very expensive and, income is not directly related to expenses each year. The natural "moat" is such that only a relatively few, giant and wealthy, companies exist over time.
ref- The Billion Dollar Molecule
> big Pharma has properties unlike many other business. The R&D is very, very expensive and, income is not directly related to expenses each year
Isn’t this any capital-intensive business with variable demand?
Why does the US consumer of said medications subsidize many other countries who have access to the same medications for a fraction of the US sticker price?
Lots of reasons. One of them is that other countries negotiate deals country wide and can get bulk discounts. The US does this with the VA and Medicare, and people using those services generally pay less than the rest of Americans. In the end, it is largely a policy choice, as having a single payer could get better negotiated deals on drugs.
https://www.healthsystemtracker.org/brief/how-medicare-negot...
Thanks for adding this information and yes this is exactly the point I was trying to make. Nationalized systems have better outcomes when they control the supply, demand, and pricing. If that doesn’t work manufacture it ourselves at a discount.
Bah! Begone with your socialist mumbo jumbo! Fox News Entertainent channel tells me about you communist and your “single payer” sham all the time! We have the best healthcare! Merica!
This is satire btw.
"If Canada is getting a 30% discount we can make it up by baking it into the hundreds of smaller negotiations with American providers."
Drug maker thinking
Do you believe that the deals they make are unprofitable given the discount? Do you think the other countries are keeping guns to their heads or what? The discounts are there because they can be, not because other countries want to pay below the break-even price. It is in the US where the drug companies can invest in the government just enough to recoup that with massive premiums in the convoluted medical system.
Nobody's forcing US pharama companies to sell to those countries at those prices, they choose to, because it makes them more money.
Foreigners aren't the reason American healthcare sucks. Stop looking for people to blame abroad, all the sources of your problems are in the presidency, congress, and in the boardroom that directs the former.
Americans really love to tell themselves they are paying for others. You victimize yourselves, and then blame externalities. Fix you own issues.
This is not like IT where the Americans are completely dominant and clearly superior.
The European pharma companies are doing more than fine, despite their main market being heavily regulated and price-controlled.
The less charitable explanation is that US companies want to charge outrageous prices, and the American system let them to, so they do it.
That's what the USA are: a machine to prioritize profits over people. Sometimes it turns out fine, like for the startup scene. Sometimes it's terrible, like when lives at stake.
Other explanations sound like heavy copium to me.
Many of those European pharma companies do most of their work and make most of their money in the US.
While it's true that the exposure of top European firms can be often 50%+ of total revenue from U.S, that:
- Doesn't make them non viable without the American market, just less rich.
- Doesn't reflect the 5 to 10 times higher price Americans pay for the same drugs.
You can have a healthy industries with plenty of billions to be around and have decently priced drugs.
What you get in the US is uber profitable industries and people scrapping around.
Those European companies make most their profit in the US. They would be much smaller without access to the US market.
Maybe drugs, or these drugs, aren't the most efficient solutions. Shouldn't we direct resources toward more efficient ones?
There are a lot of bad health outcomes built into our society, yes, but by the time people are confronted with the health impacts of cars, agriculture subsidies, for-profit healthcare, etc. it is likely that drugs will be necessary to treat the very real, immediate problems which any given patient has. Reversing the subsidies for things like car-dependency would positively benefit millions of people but it’s a generational change, not something most individuals can do.
I agree about the significance of those large-scale changes; still ...
> Reversing the subsidies for things like car-dependency would positively benefit millions of people but it’s a generational change, not something most individuals can do.
Individuals frequently can chose to not use a car, of course. Still, it's not realistic for everyone or all the time, especially in a society built for automobile use.
> by the time people are confronted with the health impacts of cars, agriculture subsidies, for-profit healthcare, etc. it is likely that drugs will be necessary
My point is that there are other treatments for illness. I doubt it's a coincidence that this patentable technology is so relied on in a hyper-capitalist society; other countries with better health outcomes use far fewer pills, iirc. Who will fund the large-scale study that says a valuable pill is unnecessary?
> Individuals frequently can chose to not use a car, of course
To some extent, yes, but my point was that it’s not realistic for many people because we treat walkable neighborhoods like luxuries. If you wake up in your 40s with a bad back and cardio problems because you live in a suburb and drive everywhere, you can’t roll back the clock and build sidewalks, legalize density, or run decent transit and on average don’t have the money to move somewhere dramatically better.
I think a growing number of people, especially younger ones, realize this is unsustainable but it took generations to get here and it’ll take a while to change trajectories, too. If gas prices had stayed high in the seventies that might have gone differently but a huge percentage of American neighborhoods are designed to minimize physical activity and that’s often enforced by law.
That's what I meant by, it's not realistic for everyone and everywhere.
> I think a growing number of people, especially younger ones, realize this is unsustainable but it took generations to get here and it’ll take a while to change trajectories, too.
Urbanist movements, including walkable communities, are much older than this younger generation. I think within a certain segment - well-educated upper middle class, maybe - it's long had influence.
I think they need to bring those ideas to other segments of society, which they have a hard time doing.
I definitely don’t think that it’s new to the current young generation but I am optimistic that they might have enough political clout to actually make progress. My neighborhood narrowly avoided becoming a highway in the 60s so we have some older folks who have been fighting car culture since before I was born, but there were a lot of people who didn’t really care because it was more affordable in the past, but their kids are a lot more motivated because it’s so financially non-viable now.
In the United States, the other big factor was recognizing how much it wasn’t just car culture but racism driving things. Despite the current moment, I get the impression that a lot of people are more aware of how much avoiding sidewalks and transit was driven by racism and just hurt everyone.
>Maybe drugs, or these drugs, aren't the most efficient solutions. Shouldn't we direct resources toward more efficient ones?
Turns out all the low hanging fruit have already been picked, so the only "more efficient ones" left are stuff like gene therapy, which are absurdly expensive, but still theoretically cheaper than a lifetime of care. Unsurprisingly the high sticker price draws much backlash from the public and politicians.
> all the low hanging fruit have already been picked
What is that based on?
Also, I'm not talking about 'low hanging fruit' necessarily; only solutons that become cost effective for vendors if drug prices aren't so extreme.
There's reason to think there is low-hanging fruit: Research is incentivized for the most profitable solutions for the vendors, not the most cost-effective solutions for patients.
>Also, I'm not talking about 'low hanging fruit' necessarily; only solutons that become cost effective for vendors if drug prices aren't so extreme.
>There's reason to think there is low-hanging fruit: Research is incentivized for the most profitable solutions for the vendors, not the most cost-effective solutions for patients.
High drug prices also mean you can charge more for one-off cures. See, the gene therapy example above.
Because US voters prefer the free market as opposed to government regulation and nationalized healthcare.
It is certainly a market, but I wouldn’t call it a free market.
Healthcare, like real estate, is a dysfunctional marketplace lacking real competition
US voters have no principles. Even republicans started artistically screaming about nationalizing companies when they didn’t want to play ball with the president.
I'm assuming you're European and just want to make an "America bad" post because this is comically ignorant. There wouldn't be mountains of federal code to adhere to if that was the case.
This is a trope among populists: pass legislation around <thing>, observe consequences of doing so, blame the "free market", repeat.
What other countries could teach the U.S. about bringing down drug prices
A look at how European governments negotiate with pharma companies helps explain why Americans pay more for prescription drugs.
https://news.stanford.edu/stories/2024/11/what-other-countri...
Sure, but that article literally contradicts your original point about Americans wanting a "free market" as it lists the complicated nature of existing laws, Medicare, PBMs etc. and the incentives those create.
You could just say "Americans need to vote better and cleanup their laws around this" and yes, that would be ideal, but I don't see that happening anytime soon. It's part of why some want the government to not involve themselves at all: no matter how good the politicians you elect, others can come into office and fuck it all up while everyone is forced to deal with it because they have the monopoly on violence. Not to mention the glacial pace at which our legislative bodies move.
Can you provide evidence for the claim? Polling from pew and Gallup suggest this isn't the case.
I think surveys show voters prefer the opposite, but certain powers are able to overcome that.
> US voters prefer the free market as opposed to government regulation and nationalized healthcare.
Because US voters are dumb. (Just for context, I'm a US citizen).
Free markets don't work when there is inelastic demand for a good or service, and an awful lot of health care (unless you consider 'well, guess I'll just die then' as a reasonable outcome) is inelastic demand.
If you pitched a pharma company with the thesis of "We'll charge US customers less and global customers more", what would stop that from working?
I can think of a number of things.
Except many (most?) pharmas spend more on marketing and sales than R&D. Lobbying is another big expense for most of them.
Rueters doesn't show a paywall for me. The source of the pressure described is in the headline though. I'm not sure why OP editorialized it (as it is against hn guidelines): Exclusive: Drugmakers raise US prices on 350 medicines despite pressure from Trump.
> not sure why OP editorialized it
The article is about drug pricing, which is the part I found interesting (and by extension thought we’d find interesting). I thought taking it out both saved space and made the comments less likely to veer into flamebait.
Thanks for filling that in. I, too, am interested in this topic, because the oligopolistic market in the US, and the multinational corporations in the oligopoly, cause unusual, counter-intuitive and counter-doctrinal economic results. We're not in a recession or depression, so I was curious about causes of downward pressure on prices.
There's a character limit on the titles you can submit, probably wasn't intentionally editorializing. I assumed from the HN title that the pressure was from the Trump admin just based on the current state of US politics.
Char limit is 80, the full title would fit, even with “Exclusive”.
I think its obvious: theres a LOT of love for Trump here in VC circles. So anything speaking ill of his laughable policies, EO's, and other garbage is -1'ed or flagged to oblivion.
If you choose to self censor a headline for fear of getting voted down on news.ycombinator.com, that says as much about you as the -1ers.
What does it say?
That you have no spine, no conviction, mostly.
Ironically the past 6 months now all the political content is just insta dead flagged and removed, the love isn't lost but nobody wants to be the one responsible for defending it.
I'm sure Trump pressure will soon bring those 1000% savings on pharmaceuticals, just hold on.