S
Story
A $20 drug in Europe requires a prescription and $800 in the U.S.
FYI for anyone who isn't familiar with the wacky US insurance situation: Nobody in the US actually pays $800 for the drug. That's the "list price" for insurance companies to pay. Even insurance companies don't pay that price because they negotiate their own rates with the drug companies, which are lower.

Then the drug companies come in and offer a "savings card" which you apply at the pharmacy like another layer of insurance. I searched and Miebo has one too: https://miebo.blsavingscard.com/ You'd have to read all the fine print, but it reveals that the actual cash-pay price is $225 (still high, obviously) and they have a co-pay assistance program that reduces your copay to $0 to incentivize you to get your insurance billed for this drug. So a lot of people who take this drug in the US actually pay $0 because they sign up for this card.

The FDA is partially to blame for this situation: They required a complete New Drug Application before they would let anyone bring it to market, even though it's over the counter in other countries.

The cost of performing a New Drug Application starts in the mid hundreds of millions of dollars range and can extend into the billions for some drugs.

So nobody could feasibly introduce it to the market here without investing $500 million or more up front. At that price, your only viable option is to stick a big price tag on it and try to milk that money back from insurers.

> FYI for anyone who isn't familiar with the wacky US insurance situation: Nobody in the US actually pays $800 for the drug. That's the "list price" for insurance companies to pay. Even insurance companies don't pay that price because they negotiate their own rates with the drug companies, which are lower.

This isn't really true on obamacare/ACA plans, even the high-end ones like gold PPOs. The formularies are much worse than employer-based plans. Insurers are required to cover one drug in each therapeutic category, but its usually an older generic. Most brand name drugs like this one have really bad coverage or not at all, which means the insurer won't even negotiate with the pharmacy to lower the drug.

Yes you can use coupons, sometimes, but the pharmacy can't always process them and the manufacture is always change the conditions and expiring them. I got one for my glaucoma drops directly from my eye doctor, and it was expired immediately when I tried to use it. I have paid $650 (for a 3 month supply, the full retail cost) for my drops when the coupon didn't work, and I couldn't get them any other way - I can't interrupt the med or else my eyes get damaged. So that falsifies your "nobody" assertion.

Anyone know what's going on with the ACA marketplace?

I like to take a peek at it every so often and it's just stupendously worse than employer healthcare. There is no plan in my market (Idaho) which doesn't have extreme out of network deductibles. The cost is also identical to what I and my employer pay for insurance.

Is it just that the ACA is mostly used by sick people or something?

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For one thing, as I understand it, the ACA was pretty effectively sabotaged by removing the mandate, which destroys the math that makes insurance work.

Because pre-existing conditions have to be covered, you're free to wait until you have a serious (expensive) condition, then sign up for an ACA plan. And there's no mandate that spreads that risk around to healthy people, so the population is severely skewed.

I have no definitive data on this, but it seems self-evident that the system can't work well.

this is mostly right, but it's not true that you can just sign up at any time. there's an open enrollment period for the aca marketplace and if you miss it, you won't have the opportunity to buy health insurance until next year.
The individual mandate merely guaranteed a captive audience for health insurance companies. That doesn't do anything for cost. What drives cost is the ACA limiting profits based on the cost of care, thus more expensive care equals more profits. Can you see where this is going?

Five states plus DC still have an individual mandate (ugh), and yes health insurance premiums are spiking there too. A large part of that is due to the tax credits (generously labeled subsidies) expiring – even with an individual mandate health insurance is prohibitively expensive.

Even with the individual mandate, it seems self evident that incentives are for private insurance companies to happily take in the extra premiums from healthy people, and then drop or have prohibitively high premiums after people get sick. The medical loss ratio tries to mitigate this, but just kicks the can down the road where the incentive becomes to dump the money into administrative overhead and self-dealing with providers/pharmacies run by affiliated companies.
As a solo dev, I’ve been on ACA with my family for the past four years. In my market, a major insurance company is not returning for 2026 and the prices have gone bananas. Our premiums are increasing over 40%, all of our copays are more than doubling, and the deductible is astronomical. In many cases the cash pay price is probably cheaper than the insurance negotiated rate.

I’m the plus side, all bronze plans can contribute to HSAs next year.

We compared individual plans off market, but they’re mostly the same without HSA access or they’re targeting people with specific ailments (e.g. the diabetes plan).

On top of that, consolidation of hospital systems has made wait times for GPs months unless you’re lucky enough to find a cancelation. We have some older Canadian ex-pat friends and it seems like our health system has all of the downsides of socialized systems, plus we get to pay Cadillac prices.

I’m really hoping 2026 is so bad that something breaks enough to resolve some fundamental issues with private health costs, but I’m not naive enough to think it’s likely. ACA was such a monumental gift to someone, but it definitely not individuals who need family coverage.

I’ve used ACA plans off and on for about a decade. They’ve mostly been as good (of not better) than the employer plans we had once or twice.

So my guess is this is heavily state dependent. Maryland as a state isn’t hostile to ACA so I think they have solid plans.

I can also only speak for BlueCross plans.

Prices have jumped, see:

    * https://news.ycombinator.com/item?id=44604365
    * https://news.ycombinator.com/item?id=44989706
Many people that use the Marketplace plans don't have employer sponsored health plans available.
It's because health insurance companies need to pad their profits. Because we have a backward system in the US where profits are extracted by everyone without any competition from a not-for-profit. That's why the idea of a public option is so popular (it was originally a Republican idea until it was decided insurance company profits are more desirable). Personally, I don't think any health insurance company should be for-profit. But the for-profit companies sure as hell should have a non-profit competition with the same bargaining power they do.
Pretty sure Kaiser Permanente is not-for-profit, many Blue Cross Blue Shield members are non-profit
Most (and the biggest) BCBS licensees are for-profit. Kaiser is not but is still eye wateringly expensive. For me, a silver plan will be about $700-800 next year. And then you take a look at what a bronze plan covers…
This is correct. BCBS is for profit and most others are. Kaiser Foundation Health Plan is one of the few not for profit insurances and only available in 8 states.
BCBS AL, AR, CA, KS, HI, LA, MA, MI, MN, NC, ND, RI, TN and VT are all not for profit, as far as I can tell.

Not an exhaustive list, just asked AI and quickly checked it's output with google.

Kaiser is the biggest HMO in the country (and available in DC).
> Because we have a backward system in the US where profits are extracted by everyone without any competition from a not-for-profit.

California has an excellent non-profit option, and it depresses prices a bit, but not a huge amount

Yeah, some individual states do have not for profit, and it does help. These are the vast minority of states. That's why it should be available nationwide as a public option.
I think that might be worse than just having the high price. Such a kafka-esque systems just to get medicine.
The best thing about universal healthcare isn't how much money I may or may not have to pay, it's that I literally don't once have to think about a bill or filling out a form to avoid paying too much.

I wouldn't care if I ended up paying more in tax than I would in an insurance model. The benefit is being able to 100% focus on my health instead of navigating a system to try to reduce what I'm paying.

When you're diagnosed with an illness, that's a huge peace of mind.

Trust me it doesn’t work perfectly in other countries. Yes, americas system is messed up but in countries like Sweden you will still have to navigate the system to actually get the healthcare you need. There are people who are denied healthcare in Sweden because the govt has deemed that it’s too expensive to save them (while people with similar conditions and a good insurance in the US are covered).
That may be, but I'm speaking from experience in my country.

Almost 10 years of treatment for a health condition, and the only forms I've ever filled in were:

    1. Legal risk document to say I understood the risks of treatment
    2. Change of address form
    3. Form to say I wouldn't impregnate people while on a certain medication
And honestly, that's it. I've genuinely been able to focus on my health without being bothered by forms.
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Also inflexibility, large backlogs, quality of staff, etc.

In Canada all of our best doctors go to the US and there's often nurse shortages. It's not just a private incentive either, the US gov pays out far more in public healthcare coverage as a percentage of GDP and per capita than Canada and almost all of Europe.

Despite their reputation the US doesn't have a lack of public healthcare spending (ranking #1-3 in the world). It's just their system's insurance regulation is extremely convoluted, creating risky edge-cases and perverse incentives. If they fixed that they would by far have the best healthcare system in the world.

USA spends the most to get worst results. Spending just dont go to people who meed healthcare.

And usa have shortage of nurses. And waitlists. And people actually bankrupt by medical bills. It was number 1 reason for bankrupcy.

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> There are people who are denied healthcare in Sweden because the govt has deemed that it’s too expensive to save them

but how many people are deemed too poor to save in the US, when sweden gov't would've easily have had the same medical procedure provided at low cost?

My mum was diagnosed with stage four lung cancer. Almost three years of radiation, chemotherapy, trail drugs, appointments etc. free transport and accommodation at the major city four hours away when required. Insane prescription drugs that seriously raised the eyebrows of the pharmacist every month.

Never paid a cent, never had a single call or piece of paper for logistics or payment or any of that bs.

She was a teacher her whole life, middle class, no private insurance ever.

It can be, and is, phenomenal in countries that do it right.

Aim higher.

All of that happens in the US, the big difference is that if you get care you stand a good choice of going bankrupt. The largest single reason for bankruptcy in the US is medical care and of that group the largest chunk is folks who previously had insurance but no longer do.
Most countries have both public and private. In Spain I have public and then private on top of that which 220 eur a month for a family of four all services included and no co-pay. The public option works to set a roof on what private insurance can charge.
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> The public option works to set a roof on what private insurance can charge.

Exactly! This is what no one in the US seems to understand. My encounters with private clinics and hospitals in the UK (all 10+ years ago, at this point) were unbelievably luxurious, at prices that (totally, completely free-market driven, mind you) were affordable on middle-class incomes. Or, yeah: there's private medical insurance, also free-marketed to "shockingly reasonable", by US measures. Americans on good salaries have been bamboozled into believing that a single-payer system will trap them into some kind of hell-hole hospital° with no recourse, when in fact the exact opposite is true.

---

°And, of course, the "hell-hole hospital" examples are cherry-picked. Bad on their own, of course, but not representative of a system as a whole, nor recognize that equally awful anecdotes are abundant in the USA.

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Right, and in my country you can even mix and match it.

I went to see my GP, paid for by public health, they referred me to a specialist.

I chose to pay €100 to see a private doctor who was available sooner (the next day) and had better ratings.

They referred me for an MRI which was done at another private provider, paid for by public health.

I went back to the private doctor and paid for a non-surgical treatment, which wasn't available on public health.

If that doesn't work, later I can opt for surgery, paid for by public health.

And even more importantly: There is one system that tracks all diagnoses, treatment, medication etc used by both public and private healthcare providers, so medical history is available instantly to everyone.

Honestly one of my main healthcare related complaints about living in Canada is not having centralized health records. Sometimes Europe feels like living 2 decades in the future lol.
Depends in the country. The Spanish system is completely siloed as the competence of health is by region and they all run their own systems
Unfortunately a lot of us do understand this, but our representatives (who definitely know this) don't care or are actively opposed to making improvements other than reducing taxes (which hurts more than helps, IMO).
Looks at Nancy Pelosi
Not limited to healthcare btw. This is also how I feel about my public transport card, unlimited data on my cellphone plan, and so on.

I'll take a queue over bankruptcy any day. And these queues people complain about are triaged - if you're dying you skip to the front. The complaints about waiting hours are from people with broken arms, and at least they get seen and their arms get fixed, for free or a nominal price.

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And yet, the average American pays more in taxes for public healthcare (medicare, medicaid) that they don't receive any of, than the average European pays in taxes for (some kind of) universal healthcare.

It's so bizarre seeing Americans in the debate not wanting "crazy high taxes like in Europe", because the US already spends twice as much public money per capita as the OECD average.

The dirty secret of course is that healthcare as a good is much more expensive to produce in the US than elsewhere, and a large chunk of that is because the private insurance system adds a ton of unnecessary overhead. And yet all the healthcare insurance companies in the US talk about making healthcare "affordable for all". Yeah, no, they're leeches. They're rent-seekers. They drive up the cost of everything.

The US has a massively progressive tax system. On a net tax basis about 50% of the country pays nothing. Sure, they pay sales tax and employment taxes, but they also receive some mix of earned income tax credits, child tax credits, snap, medicaid, housing, etc. There is no real way for the US to have a single payer tax system without more people actually becoming net tax payers.
You can't just ignore the money people are spending on healthcare right now. Every expenditure on private healthcare (insurance, copays, etc.) would be collected as tax going forward. That would be roughly $10-$20k annually?

Many more people would become net tax payers overnight without actually spending more money.

Yeah this is something people in favor of single payer healthcare in the U.S. don’t want to acknowledge. In most other countries, the middle 50% of taxpayers pay a much higher percentage of their income than in the U.S. Everyone somehow thinks we can make it work just by raising taxes on “the rich” (where that is usually defined as anyone making more money than them). But if it was that easy, then why does Canada and most European countries have so much higher taxes on the middle class?

Now I’m not inherently against increasing taxes (for all) if it gave us a much better healthcare system, but you have to be intellectually honest about who would have to pay those higher taxes. It’s not just Elon Musk.

I'm curious what the actual number is. I have health insurance through my work and I pay over $1,500 a month for that (and still have out of pocket costs). That's $18,000 a year. That's a substantial percentage of my income which essentially is just a tax going to the insurance company instead of the government. Now if it cost a couple thousand more a year and I didn't have to worry about getting claims denied for random reasons, I'd take that deal. If it's $5,000-10,000 more a year? Then I'd have qualms.
The US spends more money on healthcare than any other country (per capita and in PPP-adjusted terms), with the lowest life expectancy out of all of its peers [1].

Make of that what you will, but that tells me that after cutting out all the corporate abuse and inefficiency, the average person should be spending about the same for similar standard of care, except without all the bureaucracy and stress.

[1] https://en.wikipedia.org/wiki/List_of_countries_by_total_hea...

While it’s true that the U.S. spends way too much on healthcare (more than any other country as you said), the fact that it has a mediocre life expectancy is almost entirely due to things that have little to do with the quality of health care. Much more driving than most other countries resulting in more auto accidents and thus deaths, way more guns resulting in more murders and suicides, etc. Drug overdoses, in particular opiates, are probably the biggest one than can arguably be linked to healthcare.
In many countries where "universal healthcare" actually exists, you end up with waiting lists and rationed care. Choose your poison.
The US also has "waiting lists and rationed care".
Absolutely. I'd prefer to go to the pharmacy and just pay my $20 and go.
That's usually how it works for me in the US. I go in to the pharmacy, and at least half the time they say 'no cost' and hand me my medication. Sometimes I pay a $25 copay. And if I get an expensive drug from Eli Lilly (e.g. Zepbound) then Eli Lilly pays Walgreens up to $1950/year on my behalf and I never even know about it. The only way I figured it out myself was trying to figure out why my insurance said they paid X, and I paid Y, but I had actually only paid $25. Took a trip onto a Zepbound subreddit to learn about the backdoor payment thing. "Savings card" but not actually a card.
Do you prefer sunny (Greece) or snowy (Norway)? You can just pay your $20 and go. It is an option.
I'm happy in both (Australia). But thanks!
I prefer to pay thousands in tariffs and/or private companies, thank you very much. I'm not a communist.
Sir, your visa application is denied anyways.
Yes Sir Mr President Sir.
Probably not just medicine. I heard that prices in US shops are different than final price at the counter.
It's the efficiency of capitalism at work.

It's more efficient to allocate capital to systems and processes that delay or stop you claiming on your insurance than it is to actually pay out a genuine claim.

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This has nothing to do with capitalism, and everything to do with regulatory capture and archaic rules established in a bygone era for a purpose that has since been outlived.
These "savings cards" have a maximum annual benefit applied to them so for those on insurance that do not cover those expensive medications or who are self-paying use up the benefits before year end and do in fact eventually pay full sticker price.
I was on a blood thinner and the medication was very pricey. Didn't have insurance and the "savings card" covered fuck all unless you had insurance. There are three blood thinners on the US market and they all cost a lot.
> There are three blood thinners on the US market and they all cost a lot.

What about Warfarin? Its $21 for 30 pills, according to https://www.goodrx.com/warfarin

Warfarin needs blood tests at least every 2 or 3 weeks. I bet those tests are not cheap in the USA. Furthermore you can't have any food with significant amounts of vitamine K or its precursors. There are pills that cost more but don't require any of that. And actually they cost very little or zero, at least in my European country. Prescription only, of course.
>I bet those tests are not cheap in the USA.

Within 5 minutes of searching I found a PT time with INR test for $24 [0]. Add in the testing fee and it's probably around $30.

[0] https://www.ultalabtests.com/test/prothrombin-time-with-inr-...

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If you don’t have insurance, you’re essentially fucked in the US but this thread is not referencing that situation. My CAT scan was billed for $10,000 but what I paid was about $200 with insurance. Without insurance I would owe $10k.
> Without insurance I would owe $10k.

Without insurance you would be _billed_ $10k but in reality you likely end up paying less than that. It's still scandalous, mind you.

Why stop the conversation here? And if you don't have insurance but go to an ER (can't be turned away) and end up getting some expensive procedure you can't afford, you can just tell them that you're broke and they negotiate way, way down, or even just forgive it. And it's setup like this to ensure only people who have proper full time jobs or who can write a good enough sob story can get care. Because so many of the people in charge of this mess are far more obsessed with blocking out people they can't get enough data on or who aren't working, then figuring out reasonable public prices that make some effort to strike some fair market balance. So that if you have some savings and aren't employed, you are forced to find any job with benefits so you aren't left bankrupt, which makes taking care of health struggles harder as you have to work instead of take care of yourself.
> go to an ER (can't be turned away)

This won’t work too well for most stuff. They don’t have to treat anything you present with, and don’t have to fully treat even e.g. a heart attack. They just have to stabilize you. So they can turn you away under most medical circumstances. Like you’re not going to get free chemo or (non-emergency) prenatal care or what have you. They also can triage you into the “maybe in twelve hours… maybe” group until you go away if you don’t seem like you’re dying, or likely to pay.

It’s priced that way because Medicare has to get the best price by law. Everyone else gets a lessor discount, with cash payers getting nothing by default.

It makes sense - the largest payer should get the best price. But it doesn’t make sense because it’s not really a market.

We’d have much better outcomes with a Medicare for all model, and then private insurance could actually be priced with an insurance model and be used as a fringe benefit again.

The insurance company is not a charity. You will (or already have) pay the full price.
Im 41 and haven't been to a doctor since I was 10. I have had insurance coverage my whole life. So technically I (my employer on my behalf I guess) have paid for many other people's services. I have been a huge net positive for insurance companies. Other people get way more services than they ever paid.
Not necessarily; your costs are pooled with others like any other insurance. Some will pay more over time, others less.
Nobody in my family has any kind of crazy chronic conditions. A few surgeries, a couple of c-sections, a week in the NICU, a few short stays in some hospitals. We've experienced nearly half a million in healthcare benefits from our insurance companies over the years. I don't think I'm ever going to pay enough in premiums to cover these costs.
Lucky them... Having the privilege to... checks notes be sick.
I'm just pointing out this line:

> You will (or already have) pay the full price.

Isn't true for a lot of people.

Depending on your situation, if non emergency and you were able to ask the cash price beforehand you might be surprised that you can get the same CT scan for less than what insurance ultimately paid. At least that’s my experience ($450 vs $1200). You may have to ask at a diagnostic imaging place, not the hospital since the hospitals can never tell you what anything costs they aren’t set up for it. (Of course I went through insurance since I didn’t want to pay out of pocket, but it was an interesting lesson in one of the reasons why healthcare is unnecessarily expensive in the US.)
Was $10k before or after the insurance negotiated discount? Pre-discount prices mean nothing: I had the same tests ordered twice (needed the results urgently), once through my PCP/HMO and once paid to a walk-in doctor's office in cash. The cash price was $700. My PCP claimed a price of insurance $3500, who then negotiated it down to a "discounted" $710. So the worst of both worlds would have been a high deductible plan.
The way you have those loopholes and you have to watch out for them else you're on the hook for thousands of dollars is nuts. I mean, sure, you _might_ get a good deal or you might get completely screwed. This is absolutely not normal or fair. A society of gotcha's induces a lot of inefficiency. And as much as the US sometimes rails against inefficiency, it seems it's only a problem when you're not used to it.
Then you switch to a difference card.

That's pretty much the entire business model of GoodRx.

> FYI for anyone who isn't familiar with the wacky US insurance situation: Nobody in the US actually pays $800 for the drug. That's the "list price" for insurance companies to pay. Even insurance companies don't pay that price because they negotiate their own rates with the drug companies, which are lower.

Sure, we do not pay $800 at the pharmacy when we go to pick up the prescription, but every cent the insurance company pays, we are paying by proxie with added admin costs.

This varies wildly by medication; and makes a ton of assumptions that all happen to benefit the drug company's position/parrots their PR.

For example, my partner needs $100/pill medication, which also had a "savings card." That card only lasts for 12-months or 8-pills (whichever comes first). Then it is $100/pill. After insurance (High Deductible), we pay out of pocket $100/pill up until $3200. Insurance discount: 0%.

So the cash price and the insurance price are identical, except the insurance price counts towards deductible. UK price of the same medication? £10/pill, and that isn't via the NHS, that is full-price private (NHS could be as low as FREE, depending on several factors).

You pay by paying the premium. Your employer pays, but that money comes from your potential salary.
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what about the poor people? the ones that can't really afford insurance. i've heard multiple times that epipen prices are crazy expensive and that's a really basic drug.
If you’re really poor, you can get Medicaid. It’s the working poor who earn too much for Medicaid who are really shafted. The ACA tried to fix that for as many as it could, by expanding Medicaid to households making more money; the Republicans shut down the government to fight that expansion. It’s maddening.
Gov shutdown wasn’t about medicaid expansion, which is done at the state level. It was about expanding ACA subsidies to those making more than 400% of the federal poverty level.
If you're really poor you end up going to the emergency room and get a $20k bill that you never end up paying
I got my last Epi-Pen for free, since in my state Medicaid has no copay for prescriptions or else it's $2 or $3.
If you're poor you just wait until you're borderline dying and then go to the E.R. and get charged $120,000 and then never pay it and then have debt collectors calling you for the rest of your life.

Or you're on Medicaid if you live in a sane state.

Medicaid is available in all 50 states.
It is not available to all poor people in all states

https://www.cbpp.org/research/health/the-medicaid-coverage-g...

All the non-expansion states make it available too; just at a lower income threshold or other requirements.

Making a statement that most poor people in America can’t get epi-pens is false. Most poor people can for free.

> Making a statement that most poor people in America can’t get epi-pens is false. Most poor people can for free.

There are 26 million uninsured in the US and deductibles also exist for everyone so this is just blatantly false

I guess it depends on how you define “poor” and “uninsured”. Considering most of America offers Medicaid expansion or ACA plans, being uninsured is basically a choice.
Im sure the 4 million uninsured kids could’ve sold lemonade on the weekends or something
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There's undoubtedly a significantly lower cash price if you don't have insurance (GP mentions $225). The before insurance prices are meaningless; they're a negotiating tactic between pharma companies and insurers.
All that handwaving and apology but yet

>the actual cash-pay price is $225

So still 11x the price, plus whatever the prescription costs.

Unforgiveable.

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Well but that $225 feeds and clothes a lot of the people who spend all day designing these cards and systems around that
Including Oracle, probably.
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The FDA bears much of the responsibility for that cost, which GP explained.
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> The FDA is partially to blame for this situation: ...

> The cost of performing a New Drug Application starts in the mid hundreds of millions of dollars range and can extend into the billions for some drugs.

> So nobody could feasibly introduce it to the market here without investing $500 million or more up front. At that price, your only viable option is to stick a big price tag on it and try to milk that money back from insurers.

It's interesting that you seem so passionate about this because you're totally incorrect. The cost of a NDA for a novel prescription drug requiring clinical data (the most expensive application) is ~$4.5mil. In fact, the estimated TOTAL revenue to the FDA from ALL PD application fees in FY 2025 is ~$1.3billion (or, just under 300 novel prescription drugs). So, obviously, FDA fees can't be as much as you're claiming.

What you're actually describing is the total cost of the entire drug development pipeline (research, design, lab costs, chemical costs, application costs, marketing costs, etc.) to develop a brand new, novel drug. And it's only ~$200m, increasing to $500m if you include dead ends / failures in the process, and ~$900m if you include both failures and capital costs--yep, that's right the capital costs alone are almost as much as the entire rest of the drug development pipeline.

See: https://jamanetwork.com/journals/jamanetworkopen/fullarticle...

And that's for novel Prescription Drugs.

> They required a complete New Drug Application before they would let anyone bring it to market, even though it's over the counter in other countries.

No. In that case they would pay the FDA OMUFA fees, not the FDA PDUFA fees, which are ten to fifty times cheaper than the PDUFA fees.

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>So a lot of people who take this drug in the US actually pay $0 because they sign up for this card.

You do typically pay for insurance or otherwise have a reduced salary because your employer provides insurance, so saying you pay $0 isn’t really fair.

> So a lot of people who take this drug in the US actually pay $0 because they sign up for this card.

They do not pay $0 because the insurance company raises the rates for all of their customers to cover the cost of all the red tape and time spent negotiating with drug companies over their bullshit. The insurance companies aren't eating those costs, they're profiting from them and it's us who end up footing the bill. By the time you factor in the unnecessary time, staff, record keeping, etc. the actual cost for the $20 drug will be even more than the $800 sticker price.

No matter how our crooked system twists things to make it look otherwise they always make you pay. One way or another.

Yep. And it's worse than that.

80% of prescriptions are controlled by 3 companies. You can look up the FTC report on it. All three of them own or are owned by insurance companies.

The insurance companies had their profit percentage capped, and so the only way they could increase profits was by increasing their share of the pie. So they bought medical providers and prescription companies.

Now the insurance company is both the buyer and the seller, but not the one who pays. We pay. So they raise the prices of the drug, raise the cost of insurance, and make a lot more money while staying in their profit percent cap.

All the way around, this is the opposite of a free market and the FTC should be breaking these companies up. And as everybody knows, all the way around, it is immoral, too.

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I know people who have paid list prices for drugs because their insurance wouldn’t cover them.
The real question is: how much does the drug cost, independent of who pays for it?
> Nobody in the US actually pays $800 for the drug.

The lowest I can buy this drug for is $819.26.

Period.

> That's the "list price" for insurance companies to pay.

$819.26 - $893.72 is the actual price (range) I must pay if I want to purchase this med.

Period. The tales to the contrary fell apart the moment they were scrutinized.

> Then the drug companies come in and offer a "savings card" which you apply at the pharmacy like another layer of insurance.

No. They don't. They pretend to. It is a lie, as delivered.

The manufacturer (Miebo) has a discount program. Miebo promises my cost for the eye drops will be ...

..."as low as $0"

But below that we are told this deal only for Eligible Commercially Insured Patients.

The ones with insurance that pays for the med.

This American, on the other hand, will pay $819.26 - $893.72.

Despite endless hints that there are pharma industry cards all over the place for the millions of millions of us who pay 100% out-of-pocket, there aren't.

What there are: Tightly bounded programs, primarily for newly released and evergreened drugs. Generally the discounted cost is still more than the nearly identical drug they're trying to replace.

> The FDA is partially to blame for this situation:

Not in a meaningful way. Even Dodge vs Ford is a greater factor. Even the stinking DEA does more harm to out of pocket drug consumers (because it does that harm ceaselessly).

> The cost of [ ... parrots pharma's trivially debunked talking points about why US Drug Consumers Must Get Gouged... ] back from insurers.

No. ref: https://jamanetwork.com/journals/jamanetworkopen/fullarticle...

Analysis of ref: https://www.csrxp.org/dose-of-reality-new-study-debunks-big-...

job creation and Arbeitsbeschaffungsmaßnahmen. berry cool
Every time drug prices come up on here someone posts this explainer without mentioning the eye watering cost of the insurance.
Except when for example your insurer choses to have certain exclusions.

For example, my insurer does not cover weight loss medication. So starting next year, I'm on the hook for the $650 / month.

I could of course stay fat, get diabetes and then get on Mounjaro, which is covered.

  • loeg
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What med do you plan to pay $650/mo for? Tirzepatide is $300-450/mo straight from Lilly[0] and semaglutide is similar from Novo[1]. (This is another price cut after Lilly dropped prices already in February[2].) It would not be shocking to see prices continue to fall in 2026 as semaglutide goes off-patent in Canada and maybe some of the in-pipeline drugs from other manufacturers come to market.

[0]: https://www.reuters.com/business/healthcare-pharmaceuticals/...

[1]: https://www.reuters.com/business/healthcare-pharmaceuticals/...

[2]: https://investor.lilly.com/news-releases/news-release-detail...

Their autoinjectors are $650. But I did not know we could now get vials for my dose.

This is great. I appreciate your comment. I really do. This medication has been a godsend.

Not true. No one pays up front, our previous pay for those prices.
It's a very interesting drug. There are a lot of concerns right now around PFAS in water supplies, for example, and Miebo/Evotears are pure PFAS (perfluorohexyloctane) that's instilled directly in the eye, giving you a dose somewhere around a million times higher than levels of concern in drinking water.

But it is absolutely revolutionary if you have dry eyes. Quotes include "I feel like my eye is actually too wet now"

What the fuck... what's stopping this from poisoning our water supply?
The absolute miniscule volume
Pfas are measured in ppb or even ppt
And water supply is measured in km^3
so 1 liter of eye drop per 1ppt of km^3
That would be 1 liter of the active ingredient, not 1 liter of the eye drop. Also I don't believe that 1 ppt of this stuff is harmful when people are putting it directly in their eyes without severe harm.
There's only a single ingredient, these eyedrops are 100% pure PFAS

And people put asbestos on their christmas trees back in the day - I don't think "obvious harm" is a high enough standard.

I think obvious harm at 1 trillion parts per trillion is a pretty good standard to meet if you want to claim harm at 1 part per trillion.
Maybe, maybe not, maybe like teflon, the real poison is an intermediate ingredient, but I think its bullshit that we're just creating chemicals that linger in our water supply for eternity. You literally cannot find anyone in America without traces of the dangerous variant of the PFAS in their blood stream. Like every sip of water is some ridiculous dupont cocktail and we have to tolerate it because people have dry eyes and want non stick pans. Why cant you just use theratears?
> You literally cannot find anyone in America without traces of the dangerous variant of the PFAS in their blood stream.

You also can't find anybody in the world without traces of lead, arsenic, uranium, radium, and other chemical elements in their blood.

> Why cant you just use theratears?

Because they don't work.

It's most definitely going to accumulate inside the body, although slowly.
Yes, but too slowly to matter. Average person consumes 1.5 liters per day of water, so if you live to 100 that's 55000 liters. At 1 ppt that's 1 ng / liter, or 55 ug over a lifetime. That's multiple orders of magnitude less than one drop of the stuff to your eye.
We will know after the drops have been out for over a decade, and actual real-world safety data studies get published.

Meanwhile, Restasis (cyclosporine A) (or a generic) works well, and doesn't have to be applied all day long, just two or three times a day. It does burn the eye initially, but it's not harmful, and the burning goes slowly away over time. It does take a few months to start working.

Good thing there are 3*10^21 atoms of H2O in a water drop
PFAS are expressed as a mass fraction, not mole fraction.
Ok and there are around that many atoms of pfas per tear drop?
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How many gallons of Miebo/Evotears do you think are manufactured every year?
Multiply that by the t in ppt. How many trillions of gallons of water do you think an average city uses every year?
Is all the Miebo/Evotears that’s manufactured being dumped directly into the drinking water supply?
Where do you think it goes after it gets to your eyes? The valid choices are:

A. Absorbed into your body forever.

B. Becomes a part of the water cycle.

C. Is broken down.

And even choice A eventually becomes choice B, ideally after significant time though.

One thing you can be sure of is that the vats of PFAS being produced year after year for this drug aren't going away anytime soon. They're called "forever chemicals" for a reason.
Being dispersed in the environment is not the same as being concentrated into our drinking water supply with each measure resulting in 1ppt contamination of a trillion measures of water.
I suggest that you read about food chains and water cycles.
How do you think pfas got into the water supply in the first place.
Largely firefighting foams, industrial and manufacturing, and landfill sources, but it's still an interesting problem. They don't really break down (that's why they're so useful both in a materials science sense and as a medication) which implies they'll stick around for an extremely long time.
Teflon is also PFAS. The whole PFAS scare is overblown.
> The whole PFAS scare is overblown.

You have absolutely no idea of what you're talking about. If you actually think the scare is overblown, I dare you to drink the whole bottle of that eyedrop.

> You have absolutely no idea of what you're talking about.

I do.

1. "PFAS" is a technically incorrect term. 2. It's ridiculously broad. Teflon is PFAS, sevoflurane is PFAS, and so on.

> If you actually think the scare is overblown, I dare you to drink the whole bottle of that eyedrop.

They literally use the same liquid to FILL THE EYEBALLS after retinal surgery. It's been approved for 25 years. A bottle of eyedrops has 4 milliliters of it, and it would do essentially nothing if swallowed.

The only relevant subdivision of PFAS is by chain length: small, medium, large. Even so, they all accumulate in the environment. Just because you with your short term selfish interest doesn't take any responsibility for the world at large, willing to totally destroy it for small personal gain, does not mean that others don't either. All PFAS are very harmful in the environment because it's like paperclips that keep being made but not ever being unmade. Medium and long chain are also harmful in the human body due to significant accumulation.

Teflon does not get a free pass. It is a toxin. The last I recall, it causes brain damage in children. There is a reason why sane people avoid nonstick cookware.

> The only relevant subdivision of PFAS is by chain length: small, medium, large.

PFOA and PFOS have 8-member fluorinated chains. And they are dangerous, with clear dose-dependent effects.

PFHO has a 6-member fluorinated chain, and it has no known toxic effects.

> Even so, they all accumulate in the environment.

So does silicon oxide. Or a lot of other "terminal" compounds. The questions that need to be asked are:

1. Are they dangerous by themselves?

2. Do they bioaccumulate?

3. Do they stay mobile in the environment (i.e. don't get sequestered)?

In case of PFHO, it's not dangerous. It does not bioaccumulate because of its poor absorption. And it's also not mobile.

> The last I recall, it causes brain damage in children.

No, it doesn't.

Don't confuse silicon oxide with a PFAS. It is quite the negligent and hazardous fallacy to put them in the same bucket. One has been around for billions of years. The other hardly has any research, and will take at least a decade more of data and research before we know what's it is capable of.

You are in no way smart enough to understand and consider all the pathways, uptake mechanisms, and consequences that are affected by the PFAS compound across all of biological life. Knowing just one or two over just a few years does not make you competent in it or qualified to make a broad safety comment.

The same argument applies to literally everything, including doing nothing.
PFAS is to my knowledge the only human-created unnatural class of compounds that does not deteriorate in the environment. So no, the argument applies exclusively to PFAS.
It's also used to replace the intraocular fluid. In that case you'll get trillions times that.

This is why the PFAS scare is quite a bit silly. "PFAS" is such a broad category that it's ridiculous.

Surely the sheer number and amount of different PFAs being distributed around the planet without knowing about long term effects is the ridiculous bit. The argument that because we dump a lot of it must mean that it's safe is just wishful thinking. Remember when lead was added to fuel and large amounts of lead were then pumped into the air? It had very noticeable effects on criminality in people.
The question is in the amount of them. PFOA and PFOS were literally dumped in kiloton quantities into the environment without much thought about their toxicity. They were used in firefighting foam that was just flushed into the sewer.

So yeah, removing that source of pollution is good. At the same time, the effects of even the worst offender (PFOS) are at most mild. Wildlife and epidemiological studies found significant effects only in areas that are at least billions of times more contaminated with PFAS than can ever accumulate in the environment if the waste streams are managed properly.

Instead of putting and accumulating PFAS in your body, just get punctal cauterization. No drops will be needed thereafter.
I have punctal plugs. They helped quite a bit, but for most people with dry eyes it's the lack of the lipid layer that is causing problems. Not the lack of water.
Punctual plugs are not as great as cauterization for multiple reasons. Firstly, plugs keep dropping off and getting lost over time. Secondly, they probably won't seal the gap fully.

The lipid emission will heal partially if one supplements vitamin A (10k IU) softgel, omega-3 triglyceride ester, taurine, and at least 4K IU of vitamin D3. It will heal enough to work. The D3 in this dose is for freezing autoimmune degeneration.

I have severe dry eye and I never need any drops except if I am wearing contact lenses.

Before committing to plugs, I tried temporary plugs made of (essentially) collagen. They completely seal the tear ducts, and they were just as effective as my current plugs. And my plugs have been in place for 10 years so far.

> The lipid emission will heal partially if one supplements vitamin A (10k IU) softgel, omega-3 triglyceride ester, taurine, and at least 4K IU of vitamin D3. It will heal enough to work.

Omega-3 acids help a tiny bit, and I'm getting D3 and A from multivitamins. And I'm doing all other recommended stuff: eyelid washing, compresses, IPL, etc. Over the years, I tried discontinuing all of that a few times, and my symptoms worsened as a result. But not by much.

PFHO is the most effective "artificial tears" type product. Nothing comes close to it.

> PFHO

Here we go again with the PFAS. It is the stuff to prefer the least, not the most.

> I'm getting D3 and A from multivitamins

That fails completely because they almost always don't have softgel oil-dissolve forms or the right dose at all. They're generally very far from it. It is exactly what leads to the autoimmune issue of dry eyes in the first place.

Yeah, yeah. Sure.

> That fails completely because they almost always don't have softgel oil-dissolve forms or the right dose at all

I tried tons of forms. My current ones are gel-filled capsules. Rather large ones, at that.

Sorry, but there's a huge amount of scholarly literature on this question. I've read tons of it over the years, and there is NO magical supplement that does anything but mildly improve the situation.

Forms alone won't accomplish anything if the dose isn't correct. With regard to vitamin A, some people confuse it with beta carotene, with the latter not working so well for this effect. Vitamin A even has evidence backing it as per PMC6462169. It does take a few weeks to begin to work. Even mild improvements stack up. It may not eliminate the need for an additional intervention, but it can mean the difference between whether the additional intervention will work or fail.
Again, I read that and tried various forms.

Yes, they do help a bit. No, they don't help a lot. The study you cited find only a weak effect on some endpoints.

Same for fish oil and various omega-3 acids. The effects are either weak or in some cases non-existent ( https://www.nejm.org/doi/full/10.1056/NEJMoa1709691 ).

It is together that things work better. It is silly to look only at an individual effect.
You could try this:

Visomitin (Emoxipine/Mexidol) eye drops are a Russian-developed antioxidant medication known for treating dry eyes, fatigue, radiation damage, and improving vision, working to protect eye cells from damage (oxidative stress), but it's not widely available or FDA-approved in the US, requiring international purchase or specific prescriptions, often used for cataracts or post-surgery recovery, focusing on cell protection rather than just lubrication like many Western OTC drops.

> Visomitin (Emoxipine/Mexidol) eye drops are a Russian-developed antioxidant medication known for treating dry eyes, fatigue, radiation damage, and improving vision

I wouldn't recommend it. A quick search shows that it's not proven to do anything at all but it's also advertised as being the cure for parkinson's, asthma, back pain, high cholesterol levels, anxiety, blood clots, glaucoma, and Huntington’s disease while also making you smarter and improving your memory. This sounds like classic snake oil. Something I'd expect to see being sold alongside Horny Goat Weed and kratom at a gas station rather than an actual medication dispensed by a pharmacist. As fucked up as the American healthcare system is I guess you really have to hand it to Russia sometimes.

I wouldn't be too sure or cocky because it does have a very broad mechanism of action that does cast a wide net. Humility is warranted.
I'd happily be proved wrong, but all the usual red flags are there. About the best that can be said for it at the moment is that there doesn't seem any more evidence that it's harmful than there is for it being helpful. Hopefully it gets the research to back up the claims. It certainly purports to be effective for conditions there's plenty of interest in developing effective and safe treatments for so you'd think that nations around the globe would be eager to look into it.
The West and the globe doesn't work that way. There is little to no money in something that can't be patented. For this reason, at least no pharma firm will pay for any trials with it, and so it can't easily ever get FDA approved. Naivete does not help.
If a drug isn't one of the following it should be available over the counter.

1. heinously addictive

2. incredibly dangerous when not used exactly correctly

3. an antibiotic (due to the resistance externality)

And for drugs that do meet one of these conditions, doctors should be able to write lifetime prescriptions for cases where the medication is used to treat a permanent condition. This probably covers 95% of non-antibiotic prescriptions. The savings from removing the gatekeepers in terms of time and money would be massive and the costs would be minimal.

Then who would feed the gatekeepers?
How does it go?

"First, they came for the gatekeepers. Then, they came for the billionaires."

We'd have to grant some form of blanket immunity to drug companies the way we currently do with vaccines.

Also, aren't most mostly benign drugs dangerous when combined with the wrong other mostly benign drugs? The gatekeeping protects against that.

Maybe sometimes, but a 5 second google search also protects against that 100% of the time. https://www.drugs.com/drug_interactions.html So I'd rather skip the gatekeepers.
Before pearl clutching about individual abuse of antibiotics, let’s go after factory farms abusing them at scale.

I should be allowed to buy front line antibiotics from the grocery store. It’s infuriating that this is not possible..

What a brave thing to say on a message board which thinks having a conversation with a chatbot should be illegal lest you ask it how to deal with emotions.
It’s very simple. In the US your pharmacy has a contract with the drug supplier that prevents the pharmacist from telling you that you could buy the drug without insurance for $10 while he charges you the $20 copay. As long as this is legal and your pharmacist’s duty isn’t to you the patient, don’t waste time worrying about the details.
This has been illegal since 2018. I think you'll find that pharmacies have a book to show you every price if you ask.

See S. 2554, the "Patient Right to Know Drug Prices Act"

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I am grateful to every pharmacist / pharmacist assistent who's sotto voce ignored that immoral "rule".

On the flip side, before I transferred my prescriptions to my (excellent) locally-owned small pharmacy, I checked that these are drugs on which the respective Pharmacy Benefits Manager allows them to make a profit rather than a loss. That reminds me that I'll need to repeat that conversation when our insurance changes in January.

However, it’s not all roses. Try getting melatonin in the UK. You can buy it almost anywhere in the US. Same for any first generation antihistamines. Or a jar of painkillers - packets are limited to 16 here. Or lidocaine cream. Whenever I go to the US, I have a shopping list to restock our medicine cabinet.
Selling painkillers in 16 pill packets is a problem? It's readily available and very cheap (paracetamol and ibuprofen) generic brands. Never in my life this has been an issue
You can get larger packs of painkillers OTC by speaking with a pharmacist (OTC in the literal sense) or ordering online. For example, Boots sells a 96 count 400mg ibuprofen.

https://www.boots.com/boots-ibuprofen-caplets-400mg-96s-1026...

> Whenever I go to the US, I have a shopping list to restock our medicine cabinet

Ha, that's funny, I do something kind of like that when I go to the UK. Though it's just one medicine -- Kwells. Easily available OTC there, not available at all here in the US except as a prescription-only transdermal patch.

Aha! I have heard Americans say they buy Buscopan for IBS when in the Uk as it’s not available at all in the US and it has the same active ingredient! I had no idea it was good for nausea too.
I think Buscopan is different. Apparently hycosine hydrobromide (Kwells, Scopolamine) can cross the blood-brain barrier, while hyoscine butylbromide (Buscopan, a derivative of hycosine hydrobromide) cannot. The effect on the body seems pretty dissimilar.
+1

This is the "exception that proves the rule" I guess

One of the best OTC medicine for motion sickeness hand down

Dramamine is (almost literally) a bad joke

What's the deal with Dramamine? It's pushed everywhere but it has zero effect on me, I even tried 4 pills at once, nothing at all
I think it is generally pretty effective for most people. Science says it is roughly comparable to hycosine.

For me, I find that one Dramamine I (dimenhydrinate) pill is very effective at preventing motion sickness, but it will put me to sleep quite reliably a couple hours later. Two pills and I can play Unreal Tournament 2004 until I'm too tired to sit up. I'd be quite concerned though with 3 or 4 pills about hallucinations -- and from my understanding, the hallucinations you get on dimenhydrinate are not good.

Dramamine II (aka Less Drowsy), which is meclizine, is a little less effective but usually adequate, but still reliably makes me really sleepy the rest of the day.

Kwells (hycosine) is the least effective overall for me, but I can take a little more if I need to, and it does not make me drowsy at all. I would take original dramamine every time based on effectiveness if not for the drowsy part.

That's a very selective example. The US controls TONS of hormones, Melatonin just got grandfathered in. If anything the UK system is more self-consistent than the US, even if I think both systems over-protect hormones with a low risk profile (like Melatonin in the UK).

As a counter-example, up until fairly recently you could buy Co-codamol (codeine, an opioid) in the UK off-the-shelf (i.e. no script). Which is a controlled substance.

See how people can use selective examples to play the "one system good, one system bad" game?

Co-codamol 8/500 (8 mg codeine and 500 mg paracetamol) is still available in the UK without a prescription. As far as I'm aware, though, it's always been OTC (over-the-counter, ie. you have to ask the pharmacist) rather than off the shelf.

The big change recently (mid 2010s) was that the pharmacist now has to verbally warn against driving, whereas previously it was just a prominent warning on the packaging & advice leaflet.

I wasn’t playing a game, but if we must, you can buy jars of naproxen off the shelf in the US as well - prescription only here. And antibiotic ointment, antitussives, antibiotic eye drops, and benzocaine throat spray, just to pick what I see in our cabinet. I only share my own experience though, but I find US pharmacies to be streets ahead in both variety and depth. If other people have other experiences, that is fine and I believe them.

One big benefit, though, is you can legally import or bring in POMs from overseas, a luxury the US does not have.

In terms of access to drugs, the differences between countries is incoherent, not really a "good vs bad" situation. A lot of it has to do with the different ways nations fumble their endless (yet fruitless) attempts to limit abuse and recreational use.

But in terms of cost, the US system is bad. If we as a nation want to invest in drug development, we should do so. Instead we ask grandma and grandpa and the chronically ill to flip the bill. Hard to think of a worse approach.

I save my shopping list for Puerto Vallarta where I'll buy a small amount of benzos instead of battling it out with a US doctor for a prescription. But don't try that in Guadalajara - it's in the same state but the restrictions are far stricter.

And if you're a fan of Benadryl (diphenhydramine), don't expect to buy it in Latin America. It virtually doesn't exist.

> Try getting melatonin in the UK.

Maybe in UK but I had not problem with that on the actual continent.

Theoretically speaking how much would the components cost if one made it themselves? [1][2] My interests are purely academic as I have no need for this.

[1] - https://fourthievesvinegar.org/

[2] - https://www.youtube.com/watch?v=5rQklSmI_F0 [video][1hr16m][DEFCON 32]

According to another comment this product is pure 1-(perfluorohexyl)octane [1]. There's no practical way to make it at home, but it can be had for $980-$750/kg from an industrial supplier, depending on how many kilograms you commit to buy at once:

https://www.chemicalbook.com/ProductDetail_EN_1-perfluorohex...

Add analytical lab services to analyze it for purity and you could still get a lifetime supply for the price of a couple of brand-name bottles. This is the sort of thing that some Americans have been doing to get cheap GLP-1 peptide drugs from overseas too.

[1] https://en.wikipedia.org/wiki/Perfluorohexyloctane

About 30 years in federal prison, probably.
There should be a civil war in the U.S. for this alone.
We in America should change our name to "The United States of Greed" and be done with it. There would be less confusion that way.
This ear drops solution, which is a general purpose ear drop for ear pain and irritation, can be bought over the counter in any medical shop and costs Rs. 15 in India (0.17USD). 7 years ago, when I last bought it, it was under Rs. 10 in India. https://www.1mg.com/drugs/ciplox-eye-ear-drops-197483?srslti...

The equivalent of the same in the US, I was told 200USD in the US using Insurance, and I bought it for 40USD via GoodRx App without Insurance. https://www.goodrx.com/ciprofloxacin

What's to stop congress from passing a blanket "most favored nation" law for VA + medicare on all pricing, inclusive of insurance rates and discounts? Seems like it would be fair and useful.
The US Congress doesn’t pass laws anymore. Let alone fair and useful ones.
The same thing that stops them from just joining the rest of the first world nations and giving us universal healthcare. Greed.
We're working our way towards it little by little. We're up to ... around 40% on public healthcare now? Or thereabouts.

Maybe the next dem president will write an executive order directing the HHS to drop the enrollment age for Medicare to zero.

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Or the metric system.
This exists throughout government procurement and it is part of the reason list prices are so high.

The overhead of selling to the government is significantly higher than selling to private companies. So the government simultaneously demands the lowest price while having a much higher cost of sales that needs to be covered by that price. A price that would cover the cost of selling to the government would be non-competitive if selling it to a private company because you may be competing with other companies that don't have to anchor their prices to the cost of doing business with the government.

To work around this companies post a very high list price, no lower than what they charge the government as required by MFN regulations. They then effectively steeply discount those prices when selling to other entities via various mechanisms to more accurately reflect the lower cost of sales. The list price is a fiction required to satisfy "most favored nation" pricing laws, no one is expected to pay it.

tl;dr: In many cases the basic economics requires the government to be charged more than average because they are expensive customers with high overhead. MFN regulations don't make this reality go away so companies have to creatively structure their pricing to satisfy regulations without requiring non-government customers to pay for government overhead.

Trump already lowered costs of medicine by 1200%, what more do you want?

We're gonna be so rich!

"Most favored nation" is to the Trump addled brain like sugar water to a bee. It sounds vaguely like "Go USA" while having nothing to do with the actual problem at hand. Just wait for those 400% 500% price reductions to kick in then. The problem is the fuckup that is your domestic healthcare market, not anything to do with international trade.
>"most favored nation"

There is a weird thing Americans often do when confronted with the incredibly high price of medicine and medical care in the US of imagining that every other country is actually responsible for this (hence the "most favored" nonsense). That it's zero sum and every other country is laughing and taking Americans for a ride and underpaying, and therefore Americans have to cover the bill.

This is the angle Trump has taken in some of his incredibly ignorant and stupid screeds on this topic (as with every single position he has on anything): Get everyone else to pay more and somehow the US pays less!

This...isn't at all how it works, or what the problem is. Americans pay more because of the whole massive scam of your Medical Insurance Racket, where everything has imaginary inflated prices and an absolutely massive middle-tier of suits having nothing to do with medicine are taking their cut. This is your problem, reflected almost nowhere else on the planet, and it is domestic caused and will need to be fixed domestically. Criticizing Europe or Canada or anyone else will never, ever fix the utterly, insanely broken and profoundly stupid American system.

But it won't. It's simply incredibly how easily Americans can be fooled into voting against their own best interests, year after year.

out of curiosity, how much would this drug cost in Europe if they had required prescriptions as well

the article does a good job of showing the self serving double speak and the lack of pursuing an OTC option in the US, but I want to compare costs directly, since the article also acknowledges that OTC would have been much cheaper than $800 in the US too

Europe doesn't have a single health service. There are going to be different prices in different countries under different schemes.

In my EU country I get a subsidy of at least two thirds on most drug prices with a state prescription. But the nominal cost is already negotiated down by state purchasing, and I suspect there's some EU cooperation there. So it's impossible to say what the "normal" price would be.

The cost of the paperwork depends on your doctor. I pay €3 for new paperwork a few times a year.

You can get many drugs OTC here without a prescription - more expensive, but it always surprises tourists who suddenly discover they can get many common meds (except for things like antibiotics and steroids) just by asking.

Not a meaningful difference. I can't recall a time when I got prescription drugs in EU and had to pay a lot.
And Medicare cannot negotiate drug prices until 2026 (). Medicare is also banned from re-importing drugs from other countries (ex Canada) at lower prices. Thank you president GWB, the Alliance to Improve Medicare, and AARP (!!!!) https://pmc.ncbi.nlm.nih.gov/articles/PMC1126891/

() Biden's inflation act gave Medicare permission to start negotiating drug prices in 2026. Who know what the current US Administration will do though.

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"Before insurance" prices aren't real! The headline is misleading; the first sentence of the article is misleading. It drives me crazy. Most Americans absolutely do not understand how insurance works and journalists do their damnedest to keep it that way by constantly misleading them.
If Americans didn't pay $800 for it, how would Europeans afford it?

</sarcasm>

Such an easily debunkable line with even the tiniest bit of critical thinking.

You’re basically saying the drug companies subsidise a loss in Europe by over charging Americans, right?

As the drug company is a private and doesn’t have to sell everywhere, why wouldn’t they just skip the loss making Europeans and just sell to Americans? They’d make more profit that way!

That must mean they make some profit from the European prices, otherwise they wouldn’t be bothering.

It's a bit more complicated than that. R&D for new drugs is incredibly expensive while the cost to actually produce most drugs is reasonably low.

The price of drugs that make it to market needs to not only cover the cost to produce the drug, but also the cost of R&D and the cost of R&D of all the drugs that fail to get to market.

Now this gets complicated when a company sells in different markets with actors that have different negotiating power. It makes sense to sell in any market where the company can get a profit per unit sold without including R&D. But if none of the markets allow enough profit to cover R&D, then it's not really worth developing any new drugs at all anymore.

That's why people say that the US is basically subsidizing drug development. It's not that it's not profitable to sell in the rest of the world, it's just that margins are much lower which allows for a lot less risk-taking on R&D.

> why wouldn’t they just skip the loss making Europeans and just sell to Americans?

this argument is easily dismissible for any product that has high fixed costs but low marginal costs

which applies to a lot of drugs

Chill dude. I added a </sarcasm> tag.

But to engage seriously:

> You’re basically saying the drug companies subsidise a loss in Europe by over charging Americans, right?

No - once they know how to manufacture a drug, it's dirt cheap for them to do so - they're still making a profit in Europe. The purpose of billing Americans a huge amount (other than they can get away with it), is to fund the research + trials for the next generation of drugs.

Of course, even this argument doesn't hold water. I remember when pharmaceuticals spent more on advertising/marketing than on R&D (may still be the case).

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It's true in general, but not the reason this specific drug is more expensive here.
Drug costs are dominated by the fixed costs of development. $20/dose may very well cover the marginal cost of production while being far too little to make the overall venture profitable.
Drug companies net profit margin is 2x that of a typical company. EU and America have equal size populations.

Back of envelope, if the total cost of that drug went solely to profit, and profits were cut in half, it would cost $200 for both Europeans and Americans if we paid the same price.

So yeah, we are kind of subsidizing the lower prices for Europe.

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Why is it eye medication seems to be the market with the slimier moves? Sudden memories to when Allegran sold the patents for Restasis to the Awkwesasne-Mohawks to try to protect it with soverign immunity.

https://en.wikipedia.org/wiki/The_St._Regis_Mohawk_Tribe_and...

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The drug in question is perfluorohexyloctane, which is part of a class of substances known as PFAS or „forever chemical“. I‘m a chemist, I love modern medicine and material technologies based on chemistry, and I don’t hesitate to take vaccines or other meds, and I also happen to have SEVERE dry eyes syndrome - but hell no, I’m not going to put that stuff into nature!
The volumes in question are milliliters per month. And perfluorohexyloctane has been used in much larger quantities for intraocular fluid replacement for about 3 decades without negative side effects.

The whole PFAS scare is waaaaay too overblown.

Precisely. Just because a medicine is an approved medicine increasingly shouldn't automatically mean that any sensible patient should ever use it. The PFAS in question is not even short chain, it is medium chain, which means it's likely to accumulate inside the body, albeit at a slow pace. One doesn't even have to be a chemist to know these things.
our american version comes with 4000% more freedom
Nothing says capitalism and free market like good extortion on health products and services. That's the way to go USA.
There is no free market at play here. This is the result of FDA regulations not allowing anyone to sell it unless they did a New Drug Application first, which could cost a billion or more. Therefore nobody in the free market was allowed to sell it without putting up the capital first, which they have to collect back now.

You could actually order this from amazon.de up until recently and have it shipped to you. That seems to have disappeared, though.

This is true. When you look at actually free markets -- like the gray markets in bodybuilding drugs, "nootropics," peptides, etc. -- you'll find that there's usually a race to the bottom on price, and that everything is easily affordable out of pocket. Quality also tends to be okay, as lab reports are one of the primary ways that customers rank and differentiate between brands.

And these aren't necessarily old pharma hand-me-downs. There are lots of novel and strange drugs (9-MBC, lol) that you can buy for next to nothing.

> There are lots of novel and strange drugs (9-MBC, lol) that you can buy for next to nothing

Indeed, plenty of peptides that aren't really well tested in humans (in some cases, like at all). And some that have tests in foreign countries but are not recognized by the FDA (like Selank and Semax, which are nootropics). And if you want to get ahead of the curve, you can buy things like retatrutide already even though it hasn't quite completed Phase III tests yet so Lilly isn't able to sell it to you. If you hunt a little, you can even buy orforglipron now.

It is quite fascinating to watch. A lot of people are very willing to experiment on themselves. And it seems like GLP1s end up being a gateway drug -- people go to the gray market to get it cheap, and then they cave to temptation and try some of the other stuff they can get the same way.

That's not true, most of the gray markets you have to be careful with the quality of the product. Also, there are regulations on Europe, like with insulin but in USA is much more expensive than in Europe.
Where is a good place to start looking to access these gray markets?
An easy, somewhat expensive (if you do not know the trick) entry point that is easily accessible to anyone is nexaph.com. You can pay full retail (quite expensive) or go to their Telegram (listed at the bottom of their page) and wait for a pre-sale, where it'll be a little above half the price on the web page.

Still more expensive than the rest of the random Chinese vendors, but the upshot is that participation rates are very good for Nexaph and so there's a lot of testing done -- especially for GLP1s. For example, the current batch of Tirzepatide 60mg will have a 3- or 4-vial COA done by Nexaph themselves, another 3-vial random sample tested by customers (but then compensated by Nexaph), and at least one and maybe two big group tests with 7+ vials doing a full range of mass/purity/endo/sterility testing.

I've not seen too many other vendors that get such a high participation rate. And even for this company, for non-GLP1 peptides it's still tested pretty well but not to the same extent.

Even at their expensive price point, you could buy a few kits (10 vials ea) and pay $1000 for a full suite of tests and still be into it about $80/vial total, where a vial is ~65mg and lasts most people at least a month. Do the math on that -- compared even to cheap compounded tirz it is a fraction of the cost. There is good reason why a lot of people are taking that route now.

And back to your original question - once you are on the Telegram group, ask around and people will invite you to other Telegram and Discord groups for various vendors.

Or go to glp1forum.com and a lot of the same vendors will have posts there with information on contacting them.

peptidesciences.com among many others.
Drugs and healthcare products should definitely be regulated so people get quality products with provable efficacy. Saying that, how the hell does an application for a new drug with the FDA cost $1Bn?! Clearly something is wrong there.
I costs $1 billion because the FDA requires an enormously expensive 3 phase trial program before you are even allowed to submit the application. There is no way to make this cheaper without relaxing the requirements.
Are you saying a completely free market for drugs would be a good thing?

An NDA requires peer-reviewed studies, and something that looks at least a little like scientific rigour.

Of course we could just not bother with that.

Is that really a smart thing to do?

Require phase 1 only. That proves safety, but not efficacy. Require the companies to publicly release all data from their evaluations to the public. It's my right to decide on the risk / reward tradeoff, not some worthless bureaucrat to decide for me.
Free market is the $20 over the counter in Europe, not the USA way.
I know, the problem with drugs in USA is the control a few corporations have over the politicians and the market, that's the reason health care and all related things are so expensive there compared to Europe.
I doubt it. The company probably would make more money selling it at 20 bucks at CVS to anyone who wants it than $800 per prescription.
People from USA always complaining about the excessive regulations in Europe but suddenly it's the USA that has worse and more excessive. It doesn't add up. And why it's another medicament like insulin much cheaper in Europe than in USA, doctors and politicians bought by big corp manipulating the market. Big pharma is an extortion racket and the USA is their field, now they want to export that model to Europe.
As someone mentioned already, list prices are completely fictitious. Their purpose is to anchor medical payers during reimbursement negotiations and satisfy PBMs (see below). The allowed price (the price that the payer pays to the drug company) is much, much lower, 70-90% or so in many cases. Thus, juxtaposing OTC and list price is not an apples-to-apples comparison.

That being said, US drug prices are 2-4 times higher than they are elsewhere. In fact, the US market essentially subsidizes international drug markets, where it is much more difficult to charge higher rates due to regulations and lower purchasing power. This also means that, even if the allowed price in the US were known in this example, it would still have to be PPP adjusted to be compared.

Prescription card coupons such as those you get from GoodRx et al apply only to cash prices. These are sometimes lower and sometimes higher than what you’d pay out of pocket with your insurance. to compare, you’d basically have to ask the pharmacy to ring up a drug twice, once with cash price + coupon and once with insurance price.

“Copay assistance” are programs by drug manufacturers, PBMs, or employers to defray the cost of drug prices. This is usually done for specialty drugs that are much more expensive and can often only be purchased from a mail order pharmacy designated by the payer. For example, United Health (left pocket) will only cover the drugs if you get them from their Optum Specialty Pharmacy (right pocket).

As for numbers, here an example: I’m receiving a monthly specialty drug that my insurance is billed ~$9,000/month. In order to arrive at that figure, the drug company proposed, say, a $50k/month list price, and my insurer countered with $9k, using the size of their member pool as leverage. Of course, the drug manufacturer knew they would arrive at approx that figure, which is why they started negotiating that high. Well, sorta. The PBM gets compensated based on a % of the “savings” (spread between list price and final price), so naturally, they want as high as possible a list price, because 5% of a big amount (in my example: $50k-$9k = $41k) than 5% of a smaller amount. Because the PBM often has most of the leverage, the drug manufacturers (most of whom actually dislike PBMs) have to go along with this stupidity.

How much of the $9k I pay depends on a variety of factors, including my insurance plan, which has a specialty drug tier. This means the drug is not handled via the cost sharing accounting mechanism (deductible/copay).

Now, through that specialty tier, my monthly responsibility is set at approx $1,300. I’m not privy to the math behind this, because my insurer has outsourced all drug-related administration to a PBM, which is only loosely regulated and doesn’t even have to issue explanation of benefit statements that would normally disclose the full accounting.

Of the $1,300, I pay nothing, because the drug manufacturer provides me with a copay assistance card. Again, they must keep the list price high to placate the PBM.

I’ve simplified a few things here. For instance, there are now alternative comp models for PBMs. But for those, PBMs have also found ways to manipulate the system in their favor (eg colluding with drug manufacturers). There’s also often a wholesaler involved in the “value” chain.

But by and large, this is roughly how it works…

And yes, individual market plans are substantially inferior. Not only do they have lower actuarial values and higher cost per $ of coverage (which is unavoidable, because they are not risk pools) and narrower networks, but they also usually have built-in mechanisms to further prune away coverage in many subtle ways (they have that in common with self-insured plans): - more prior approvals, - “step therapy” (must first not tolerate cheaper drugs before can receive pricier drug), - not covering the pricier drug tier at all, etc.

These things shave some dollars off the premium, which appeals to price-elastic consumers and employers.

The whole medicine industry in North America needs an overhaul. Canada isn't better. The ER delays aren't because of anything but a (intentional?) convoluted process that causes them. Same with prescriptions. Why aren't pharmacists allowed to issue them? Why not even utilize AI (which is superior to any human when it comes to memorizing and correlating, both essential in diagnosis) and have a human to double check it just in case? The reason is obvious. It's lobbying and gatekeeping, from making it hard to become a doctor, to the pharmaceutical industry profits, insurance, among many others, to simply "monetize" every single step of the process and profit off people's misery.
Yeah, but in the US I can buy pseudoephedrine over the counter and the sky doesn't fall. Believe it or not French regulations, but there's no epidemic of strokes among sufferers of the common cold. Yes, the US system is broken in places, but at least it's a lot less boneheadedly paternalistic about availability of obviously safe drugs.
I’m also surprised by the prescription gatekeepers in America. Many things are over the counter elsewhere.
Not only drug costs. I’m being charged 1300$ for an STD test because my insurance company and my doctor can’t agree on a “code”.

It’s totally fucked.

Don't worry, soon the same drug will cost $900 in Europe. But hey, still cheaper than an iPhone.
What's the price on TrumpRx.gov?
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in some part of europe, we have national healthcare so basically people don't think they are paying their medications, like there was some magic money.

in that case, you don't care if you drug cost 10€ or 2000€ because you aren't spending a single € from your own wallet, at least if you don't factor in taxes.

Contrary to the USA where it's a much more responsible market, people do pay for the medications or they get it paid by their own insurance but it cost them directly a lot of money.

I would think that americans would be much more vigilant about what medication they take, the price it cost, and so would have much lower pricing. That's just how free market work, and technically there are many medication manufacturer and many customer.

Is it the proof that a true unregulated free market doesn't work ? if left unsupervised, big companies are going to buy smaller companies until they are monopoly or make secret, behind the door, deal to keep price up.

It's what the USA is made on, the idea of freedom and free market. i believe the idea of unregulated market is more recent, think the 70's, but surely in the 50 years since then american would have pushed back against it and not elected people like Trump who are all in.

> I would think that americans would be much more vigilant about what medication they take

This is why I always check to make sure it's fiscally responsible before I start chemotherapy, or before buying that emergency inhaler for asthma, or before accepting paralytics and anesthesia when undergoing surgery. How fortunate that in America diabetics have the freedom to die rather than take overpriced insulin. Let the free market decide which child with leukemia deserves a bone marrow transplant and which deserves a casket! That's a much more responsible market than just having everybody chip in a small amount so that nobody needs to worry about the cost of the medications they need to live. Sure, in America millions will die or be bankrupted by healthcare costs every year, but that's better than spending a single $ from your own wallet if even a tiny fraction of it might help pay for someone else's medications right?

> Sure, in America millions will die or be bankrupted by healthcare costs every year, but that's better than spending a single $ from your own wallet if even a tiny fraction of it might help pay for someone else's medications right?

I do believe your question is false, we don't spend a tiny amount of our money on healthcare.

Around 20% of our revenue, in France, goes to the universal healthcare.

And yes, I would rather manage that money myself because I believe I am better at doing so that my government. Isn't that one the core beliefs of Americans ?

The issue is that there must an actual free market, enforced by government, and not some kind of oligarchy where drug price are kept artificially high amongst reseller.

> Around 20% of our revenue, in France, goes to the universal healthcare.

I wish we only had to pay 20%!

For those of us who are lucky enough to have health insurance 27% of our paychecks go to it which still doesn't pay for much of what we need. People with insurance commonly need to pay around $30 for every visit to a doctor. That's just the cost to walk in the door and doesn't cover many of the services/treatment your doctor will give you beyond a check up and common types of lab work.

Our poor healthcare system results in a lot of illness and over 60% of Americans need to take prescription drugs every day. Most of the people taking drugs are taking 4 or more. The insurance that takes almost 30% of our income doesn't fully cover those either. Each drug that is covered by your insurance will typically require you pay $10-$20 each month when you pick them up at the pharmacy. It's common for Americans to have to spend $40-$80 for their medications every month. A third of Americans can't afford to fill their prescriptions and are forced to suffer and get sicker. A quarter of Americans report having to put off medical treatment for serious conditions because it is unaffordable.

People without insurance have it much much worse.

That doesn't even include the costs of things like eye care (glasses), dental care, emergencies, specialized treatments, surgeries, ambulance rides, etc. The single greatest cause of finical ruin in America is the cost of healthcare. If people only ever had to pay 20% no one would go bankrupt, or lose their home, or die because of healthcare costs.

Having to pay only 20% of your income to medical expenses would be a dream come true in the US. Please trust me as an American, your system is better by far. Or don't trust me and listen to the countless experts who will tell you that our healthcare system is garbage and that yours is better. That doesn't make your system ideal by any means, but don't envy us or look to us as an example.

> I would rather manage that money myself because I believe I am better at doing so that my government. Isn't that one the core beliefs of Americans?

Not really? Things at a certain scale are impossible for individuals to manage alone. Healthcare expenses are one of those things. Maybe you could shave some percentage points off of your own healthcare spending, but that would cause you to end up in a situation like we have where large numbers of people can't get the care they need at all and are ruined by the expense. For the nation, that's much worse. Even for you it would be worse because having a bunch of sick people living in poverty all around you has far reaching effects. Your odds of getting sick increase. Homelessness increases. Crime increases. Living in a society where people are healthy and taken care of is well worth the extra 5% or even 10% you'd save.

A "free market" is one that exists without any enforcement/interference by the government. I agree that government should intervene to stop the greedy oligarchs from keeping drug prices high, but that would be the literal opposite of a free market. You don't want a free market, you just want better regulation of the healthcare industry and I don't blame you. I do too.

I mean you're joking but there are maybe ~20 brands who produce and sell inhalers. Maybe I need the inhaler but I also have a certain amount of choice, and presumably some are more expensive than others. Insulin is a famous example, because you can buy a vial for ~$30 or a nicer one for $300. They all effectively do the same thing but there is a quality difference between them, usually in regards to release time and how often you'd have to take it.

There are some market pressures in healthcare when multiple companies can compete, although it's so heavily regulated it can be hard to see the market pressures in practice. Consumers often do have some amount of choice though

I just checked insulin price in France, we have SANOFI 100 UI/ml 15ML for the price of 20€.

How is it possible to have 300$ Vial ? Sanofi ain't exactly a charity and they are doing extremely well financially, 300$ is obscene. If they sell it at 300$, there must be people buying it. Who are they ?

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> I would think that americans would be much more vigilant about what medication they take, the price it cost, and so would have much lower pricing.

> Is it the proof that a true unregulated free market doesn't work ?

The market is heavily regulated (frequently crazily) by the FDA, and the actual amount anything costs is heavily obscured from the eyes of any consumers by the fog of bureaucracy and insurance.

Many people have 3-4 tiers of fixed copays that the insurance company makes up - some pharmacies won't even tell you when there is a cash price or a "coupon" that would be cheaper than your insurance copay! And pharmacies don't publish a plain list of what the cash prices are, and it would be hard for most people to even produce the tier formulary, it's buried as a PDF in some obscure page of a horrible website. So we just go to the pharmacy and see what it'll cost us.

Also, one major insurer owns a major pharmacy benefits manager and one of the big 2 pharmacy chains, so they use that to put their thumb on the scale however they can, while the other insurers and PBMs play games to lock consumers into restrictive exclusive deals that are to their detriment.

Anyway we don't have a market at all when it comes to healthcare, because the majority of price information is withheld from consumers until the opportunity to make any choice, if it even existed, is well past.

FDA’s regulations are basically unrelated to the healthcare system and what makes American healthcare so expensive.

GP is right that monopolization and vertical integration (as you allude to in your comment) is much more salient.

The FDA is not only related to it, but quite central. The main expense in drug development is getting through the FDA approval process.
No, not really.

The main expense is proving your drug works. It’s not really fair to describe that as incurred by FDA regs.

And in any case: drugs are (surprisingly) not a major driver of healthcare costs in the US.

The things that are uniquely costly in American healthcare are administrative overhead and doctors + nurses.

Go read KFF reporting on it.

> Contrary to the USA where it's a much more responsible market, people do pay for the medications or they get it paid by their own insurance but it cost them directly a lot of money.

That's the idea, but in practice there are so many layers of indirect government incentives, disincentives, and direct interventions that market is no longer effective for this purpose.

It's virtually impossible to find out how much a medical procedure actually costs. Most hospitals and clinics refuse to even estimate as a policy, which has led to the creation of things like pre-paid services for labor and delivery. Those are quite rare.

I'm 100% in favor of allowing the market to work - but at this point, we have the worst of both worlds and the best of neither. Either extreme would be better than what we have.

> It's virtually impossible to find out how much a medical procedure actually costs. Most hospitals and clinics refuse to even estimate as a policy, which has led to the creation of things like pre-paid services for labor and delivery. Those are quite rare.

That's absolutely incredible. Yeah if you can't even get a pricing,i don't see how you could make any decision whatsoever.

The funny thing is that when you have one big customer (a country) - you get good prices.

When you have 30 insurance companies, 10000 companies buying insurance policies and millions of individuals - you get shit prices.

That's why the drug in question is 200 USD in US (after deductions) and 20 in Europe (including taxes).

Part of the problem is that the way our healthcare system is setup, it's not even a remotely free market. It's pretty much a worst of all worlds situation.
Americans pay multiples more per capita, and receive worse healthcare based on outcomes compared to European nations. The UK on average has better oral health than the USA, but Americans love to joke about British teeth... I think the US believes it's own "free market" propaganda too much. Clearly socialised universal healthcare (which every G20 nation does outside the US) is a better system.
You're painting with a fairly broad brush. Opinions in the US are diverse, and generally more in support of socialized healthcare than against.

We're not far from half the US population having what amounts to universal healthcare already, even without making it official. I sometimes wonder how high it will get before people come to the realization that we're already close enough to that point and going the rest of the way is viable.

It does not work that way, though, because as a practical matter, the majority of routine medications in the US are generics now and quite cheap, maybe $25 out of pocket (and frequently zero) with even basic insurance. The crazy prices happen for the edge cases. Things that happen often enough that you may know someone affected by it, but are still a minority of most people's experience.
> I would think that americans would be much more vigilant about what medication they take, the price it cost, and so would have much lower pricing. That's just how free market work, and technically there are many medication manufacturer and many customer.

(Not american) This assumes they have a choice, no? Do these medications have real alternatives?

> in some part of europe, we have national healthcare so basically people don't think they are paying their medications, like there was some magic money.

Europe is a big place, buddy. Which particular part are "we" from today?

NHS England has NICE (National Institute for Health and Care Excellence), which does the cost-benefit analysis for all medicines prescribed, nationally. It frequently decides medicines aren't worth the money. If you, as a private citizen, want that particular medicine, you can waste your own money on it. NHS England does not have a moral hazard problem.

The NHS also spends money trying to convince people to exercise, eat well, lose weight, not smoke, look for early signs of cancer, etc., because they find that relatively tiny amounts of money on these campaigns results in massive, massive savings from not having to treat so much preventable disease later in life.

i think healthcare is one market where capitalism just doesn't work well at all. for those areas, it actually makes sense to introduce hard or soft price ceilings.
> Contrary to the USA where it's a much more responsible market,

This is satire? I can’t tell anymore.

I mean the USA is the only country where someone can allegedly murder a healthcare executive for denying treatment and popular culture is engaged in drooling about how well the alleged killer fills out a tailored shirt.

When I say market, I'm referring to economic and more specifically to health market.
Right, but it's not more responsible is it? It's plainly kafkaesque with lots of impositions that always serve only to benefit the gatekeepers. Which is why they hated Obamacare, because it is less bad.
The US is a GDP ponzi scheme disguised as an economy. The silly prices exist to shuffle money between pharmaceutical companies, PBMs, insurers, pharmacies, hospitals, and who knows what other intermediaries. Everyone takes a cut and can put large revenues on their balance sheet.

The US today is structurally dependent on this sort of cash migration. If all Americans suddenly began to save 10%+ of their income every month (also structurally impossible for most), GDP would dramatically contract.

These things aren't broken. They are by design.

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