> It is hard to know where to direct my rage. Should I be furious at the drug manufacturers that refuse to develop generics? Should I be angry at the P.B.M.s an

> It is hard to know where to direct my rage. Should I be furious at the drug manufacturers that refuse to develop generics? Should I be angry at the P.B.M.s and insurance companies that juggle prices and formularies to maximize profits, passing along huge co-payments if they don’t get a good enough deal? Should I be indignant at our elected officials who seem content to let our health care system be run by for-profit entities that will always put money before patients? > The answer is all of the above. But what’s most enraging is that drug manufacturers, P.B.M.s and insurance companies don’t have to pick up the pieces from the real-world consequences of their policies. That falls to the patients. I think this is an important and balanced quote. Often in the public debate, drug pricing and access, which are two separate concepts, are conflated. A drug can be priced fairly but be inaccessible to patients because insurance companies and PBMs want to hold costs down. This often happens with drugs that treat lots of people. Because of the high volume, insurers will have massive expense for covering a drug, even at fair (i.e. Cost effective) prices. So they fight tooth and nail (often using the media as a weapon) to reduce price. Drug manufacturers won't lower price (often bc they will lose money if they do), so insurers deny An example of this is CAR-T therapies. Cost effectiveness research shows that cost per QALY is within acceptable ranges but payers make it hard to get the drug. I think the same was true of the curative hep c drugs but don't recall the cost-benefit analyses. These drugs were incredibly effective and many people would benefit from them, so payers saw a huge potential expense and denied care until competitors emerged In some cases though, pricing is the bigger issue. This often happens with established drugs where manufacturers increase prices, or drugs with limited competition. Insulin is an example where both pricing and access are not great, i.e. PBMs / insurers and manufacturers are probably equally at fault Drug pricing and access is a complex and highly competitive negotiation between manufacturers and payers and the media is a powerful weapon used in this negotiation. Lots of lobbying done as well. And there are many behind the scenes players with a stake in the debate (i.e. Hospitals wanting the public to blame drug companies for high healthcare costs). This seems like a balanced article to me, but take articles about healthcare with a healthy dose of skepticism