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It was developed by Gilead Sciences, Inc. The way they can afford to make it cheap for people who can't pay is by charging high prices for insured Americans. Yo
It was developed by Gilead Sciences, Inc. The way they can afford to make it cheap for people who can't pay is by charging high prices for insured Americans. You can see this with their earlier developed treatment for hepatitis C:
https://en.wikipedia.org/wiki/Gilead_Sciences#Pricing https://en.wikipedia.org/wiki/Gilead_Sciences#Pricing
Gilead came under intense criticism for its high pricing of its patented drug sofosbuvir (sold under the brand name Sovaldi), used to treat hepatitis C. In the US, for instance, it was launched at $1,000 per pill or $84,000 for the standard 84-day course, but it was drastically cheaper in the developing world; in India, it dropped as low as $4.29 per pill.
Low priced HIV drugs for the poor is part PR and part pragmatism. Poor people can't pay the sorts of drug prices that insured Americans do, and poor countries aren't going to enforce drug patents purely for the benefit of American corporations, e.g.:
https://en.wikipedia.org/wiki/Medicines_and_Related_Substances_Control_Amendment_Act,_1997 https://en.wikipedia.org/wiki/Medicines_and_Related_Substanc...
Gilead looks gracious by preemptively embracing the situation that was going to occur anyway (poor patients aren't going to pay high prices).
Privatized progressive tax?
IMHO this is great - broadest shoulders shoulder most.
However, it likely should be more organized? Maybe do more of this research in public institutions and make it freely available to commercialize.
It's been like this, Americans heavily subsidize the world in healthcare/research.
Which becomes annoying when fairly rich Europeans ride these coattails (and defense) while being incessantly snobbish about their healthcare superiority, in large part paid for by us.
Though a big part of the Trump win comes from this - yea some Americans are rich, but a lot of them are really poor and justly mad at how much more expensive things are that we produce.
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Obamacare was actually great in the first year. Every year since it basically went up 20%.
I grew up in a blue collar family. One thing that Dems tend to overlook, I think, is that most people do not want to receive charity. They want to be able to afford things on their own through their own hard work. It hurts their pride to receive anything that could be construed as "welfare." It makes them feel like they, and their country, are failing. So I'm not sure if the Medicaid/ACA approach to healthcare is a particularly good one from a purely psychological standpoint. (Some folks are scared to accept Medicaid because of estate recovery, too.)
In my state, a full 1/3 of the population is on Medicaid ... which seems extremely high for a program originally intended for the poor.
From a financial standpoint, it doesn't seem like either party has succeeded at significantly slowing the growth in healthcare costs overall. How much more can it grow without breaking? The Dems haven't proposed a solution either.
The American healthcare system is expensive partially because it’s not really a market, you’re tied to the insurance your work offers you and there are all kinds of middlemen like the PBMs.
There were two options that have been debated before:
* Obamacare’s deleted “public option” which would’ve essentially provided the baseline standard coverage introduced by the ACA; this got deleted due to opposition from moderates and so private insurers offer these plans instead
* Medicaid for All just proposes this entirely to remove layers of middlemen, but is even more opposed by moderates
——
The problem really is the linkage of health insurance to work, but it’s political suicide to sunset this since the transition period will be incredibly painful
>broadest shoulders shoulder most
Part of the reason the US has a higher GDP is because we work longer hours and take less vacation. "You work harder, therefore you should shoulder more" hardly seems fair.
Europe makes fun of us for our defense spending yet demands protection, makes fun of us for working long hours yet says we should shoulder more, makes fun of us for overspending on health care yet charges us 10X as much for the drugs they manufacture: https://www.healthline.com/health-news/heres-how-much-more-ozempic-costs-in-the-u-s-compared-to-other-countries https://www.healthline.com/health-news/heres-how-much-more-o...
I just can't shake the feeling that Europeans see Americans as suckers.
Just in case you are interested in a European perspective, and aren't just commenting to let off some steam because of perceived injustices:
> we work longer hours and take less vacation.
Yes, but people working longer hours doesn't necessarily translate to more output, especially when quality is taken into account.
Anecdotally, from what I've heard from people working in international companies, the American work culture doesn't seem to be very efficient when looking at the end result. The studies of 32 hour work weeks seem to indicate similar findings, though like the anecdotes, should be taken with a grain of salt of course. But I truly believe that in most cases, a developer who works 10 hours a day will not produce more than one who works 6 hours a day, at least after a couple of days.
>Europe makes fun of us for our defense spending yet demands protection
You do realise that until very recently, America has gained an absurd amount of soft power through this defence spending, right? And was able to convert this soft power into a lot of GDP through indirect subsidies of its international companies? Just because the current administration has squandered this advantage, doesn't mean you did not get out more than you paid for the last couple of decades.
>I just can't shake the feeling that Europeans see Americans as suckers.
I agree with you on that point,but not for the reasons you might think. I see the "temporarily embarrassed millionaire" phenomenon, people constantly against their self-interest and the like, and and it's hard not to. I have relatives in the US, and I still feel sympathy for your people.
But it's getting harder and harder to not see you as suckers when you look at the tariffs or the cuts to welfare, science and education, all while the rich get massive tax cuts. And all is being done in the name of "draining the swamp", by a billionaire who is incredibly well-connected with 90% of the corrupt elite he publicly opposes.
I don’t mind regional pricing, I mean, supply and demand works out differently in different markets, right?
But $84k seems a little pricey. Imagine paying that out of pocket.
> The way they can afford to make it cheap for people who can't pay is by charging high prices for insured Americans
This is a hugely underappreciated aspect of why the cost of health care, including insurance premiums, is so high in the US. Well-meaning folks have called for decades for the US to transition to single-payer, citing the overall lower cost experienced in other countries as a primary motivator. Meanwhile, US companies remain the global leaders in the development of pharmaceuticals and medical equipment. That development is often subsidized by US taxpayers and the remainder is largely recovered from US patients because the single-payer systems in other countries often impose price controls that largely don't exist in the US.
(This is not meant to argue against single-payer in the US. All things being equal, a single-payer system would likely solve many more problems than it would cause. I'm just pointing out what many before me already have about how Americans disproportionately subsidize the development of the healthcare the rest of the world benefits from).
I think there's a case to be made for incentive programs for development of key drugs, akin to the way Operation Warp Speed operated for the COVID vaccines. Provide up-front cash for initial research and large guaranteed returns if a drug is approved; in exchange, the drugs become public domain.
Or, just fund government research endeavors with no profit motive. If we can have a JPL for aerospace engineering, why not for pharmaceuticals?
The status quo is bad, but do you have any evidence for drug development anywhere else in the world, that plays by the rules you’re describing?
I mean China is really rich, runs lots of centralized R&D, and has an excellent research culture, why isn’t it developing cures for everything?
> The way they can afford to make it cheap for people who can't pay is by charging high prices for insured Americans
Well, fuck that. I'm already paying $24K annually for my health care that covers about half of anything short of a catastrophe.
But if they are offering royalty-free production to generic manufacturers, why wouldn't insurance companies simply insist on using the cheaper generic?
>> But if they are offering royalty-free production to generic manufacturers, why wouldn't insurance companies simply insist on using the cheaper generic?
I'm not an expert on this, but my PBM insists on going with stores that have higher prices. If I go with the less expensive store, they do not cover it. Sometimes, it makes sense to co with the less expensive store, but then it doesnt even draw down your annual deductable. Damned if you do, damned if you dont.
This drug is cheaper if you don't buy insurance? What?
The American healthcare system is expensive partially because it’s not really a market, you’re tied to the insurance your work offers you and there are all kinds of middlemen like the PBMs.
I've long argued that this is precisely the problem with the American healthcare system. It's the worst of both worlds. The issue is caused by the fact that we use "insurance" to describe something that is not insurance, but rather a middleman subscription.
Could you imagine how broken any other market would be if saddled with the same system? Imagine if you had no idea what any given property actually cost to rent, but instead just paid into a "housing insurance" plan that took care of it for you and socialized the costs. Add on layers of administrative bureaucracy to determine which properties you qualify for based on your needs, and give it a few decades for prices to adjust to the market distortion. One day we'd find that all the properties are owned by multibillion-dollar housing conglomerates charging prices that are completely impossible for anyone poorer than Jeff Bezos to afford without "insurance". Eventually someone ends up shooting a housing insurance CEO in the street over grievances like Luigi's, e.g. maybe he's stuck sharing a single bedroom with his wife and four kids, or couldn't get approved for a property in the same city as his elderly parents. Meanwhile, the public has been gaslit into defending this Kafkaesque central planning as "free market" because it isn't technically run by the government, ignoring any role of the government in creating and actively propping up the system.
I don't think single-payer is necessarily the optimal solution due to the known impacts on supply / wait times under such systems, but if we're embracing central planning of a sector of the economy regardless, I'd rather the benefits be fully socialized alongside the costs. Right now we're socializing the costs while privatizing many of the benefits — great for profiteers of that system, but not so much for the rest of us. Although single-payer could potentially be a much stronger option in the future if optimized by large-scale anonymized economic data collection and AI-driven pricing, so I'm not necessarily opposed to it in principle.
What I'd also want to consider, however, is a wholesale sunsetting of mandatory "insurance" in its entirety. Make patients bear the costs of their care and incentivize them to shop around for the best prices. Force providers to optimize, innovate, and actually compete with each other to provide the lowest rates — negotiating with suppliers, reevaluating compensation structures, cutting administrative bloat, and embracing technologies like AI and telemedicine would all be viable angles for practices to explore. No one would get away with Gilead-style pricing in a free market, particularly if certain price transparency requirements were imposed. Then add a universal progressive cost-sharing system on top of that to ensure that the poorest aren't left out in the cold. As a practical matter, emergency care prices could be set by states or counties to balance local availability against ensuring that ER patients aren't saddled with excessive debt, continually adjusting for maximum public benefit. In this world, health-related insurance products would still be available for people who really wanted them, but they'd function as actual insurance, and be completely optional without being subject to ACA-style regulation.
US carries a big share of the biomedical load, NIH runs ~$48–50B/yr and the US is the launch market for 2/3 of new‑drug sales, which makes it the main revenue engine, but calling Europe a freeloader skips a lot of facts.
The EU’s Horizon Europe is €95.5B (2021–27) with €16B for ERC alone, national funders like the UK’s NIHR spend ~£1.4B/yr, and Europe’s pharma industry invests ~€50B/yr domestically.
Europe is home to Roche, Novartis, AstraZeneca, Sanofi, GSK, Novo Nordisk, each spending billions annually on R&D (Roche CHF 13.2B, AZ $13.6B, Sanofi €7.4B etc.). Also a big chunk of US list‑price "overpayment" never reaches manufacturers—rebates/discounts were an estimated $335B in 2023—so it’s not all subsidizing innovation.
Innovation is now multipolar: in 2024 more NAS originated from China (28) than from the U.S. (25) or Europe (18). So strong US funding matters, but Europe clearly pays and builds a lot too.
Since a year or two before the individual mandate ended (it was worth the fee), I dropped health insurance and self-pay for self and family; I pay now in a year for actual service what I paid in a month in premiums, mostly to dentist, without feeling any restrictions on seeking healthcare. I don't often need referrals, can self-order procedures directly, and the amount insurance says they "negotiated" is pretty misleading, often comparable to what I pay in cash without insurance. Since ACA was implemented, prior to covid, life expectancy in the US stopped increasing; not to say ACA is directly responsible (without more data), but whatever its net benefits may be are clearly losing out to other signals.
That said, our ... fascinating ... experiences ... in trying to get the government to fix our health systems is certainly no outsider's fault. Europeans and others can feel at ease continuing to mock us.
Ooohh... Wait until you have a really nasty health emergency.
I'm 63, and my wife is near my age. We take this stuff seriously.
I have known many people that have been completely devastated by medical crises. Even with insurance, some types of illness can be catastrophic, financially.
I also have known quite a number of folks that have done an amazing job of taking care of themselves, yet still had medical crises.
It's a lottery either way, I think. I can pay $20k/year for health insurance and limit to $20k/year in expenses (or w/e current annual limit is), or I can save the $20k/year and put it into an unencumbered investment account. The insurance company charges so much that I feel much better about getting out of insurance in my 20s so that I have a pretty decent pile now in my 30s, and going forward, the pile accumulates as my risks do.
-but if I get a terminal, especially long-term illness, it's a wipeout either way; if I'm out $20k/year to the healthcare providers and $20k/year to the insurance company, and can't work -- draining $40k/year in health costs just isn't going to work out for very long, unless I can make it another decade or two.
Edit: I should say, too, I give money directly to my daughter (that is, well before [ideally] I'm ill), specifically so I can declare bankruptcy with less family wealth loss if I should have to, and to help fend off Medicaid clawback.
About 30 years ago, I had a brain tumor that damn near killed me.
Put me in Hospital for 17 days. A week of that, was ICU (lots of machines that go “beep”).
I had an HMO, at the time, and it was a pain, dealing with them, but it ended up costing me almost nothing. I think it would have been almost a million dollars, if out of pocket.
Yes, that very likely would be a run-ender for me, and make me dependent on family and gov't assistance (which is fine; which is something I've planned and plan for; but obviously it'd be nice to not be bankrupt and mooching of my family). I'm glad you got through it; my uncle had a brain tumor found while simultaneously having Alzheimer's (despite only being in his late 50s and a clean and pretty mentally active fellow) -- it didn't work out well.
edit: remainder of original reply removed.
Long time ago. I could probably scare up the paperwork. They didn't really do digital, in those days. I think my MRIs were film-only.
> it uses hashed non-reversible IP address as credentials; I don't store IP addresses
I'm sorry but by my math, there aren't that many publicly routable IP addresses (like 2.5 billion?). Generating and storing rainbow tables for all 2.5 billion publicly routable IP addresses wouldn't take an exorbitant amount of time,
making that part semi-reversible.
Your IP address is hashed when you connect and then a large part of it is lopped off. The part that isn't lopped off is used for ID. There is collision risk; definitely use alternatives if not comfortable with that -- it was made for a small handful of friends in Discord to share >10MB attachments and definitely not for storing folks' medical information.
Edit: On reconsideration, though, given that, I went ahead and removed the link, email address, and solicitation generally. I'm confident nothing would go wrong in the context of the 1000 or so people I imagine would ever see that link before the service is removed/renamed in some years, but I can appreciate the high-value liability of being wrong on that. Thanks.
Your approach would work fine until you have a bigger emergency than you can afford.
The entire original point of insurance was to amortize the costs of the extreme events by spreading the costs across many people.
Are you paying rack rates for pharmaceuticals instead of the PBM rates? That gets expensive really fast.
Nobody pays rack rates. Most pharmacies keep their own PBM access cards (like GoodRx) to scan at the counter if customer doesn't bring their own. Some examples of self-pay prices:
Insulin Lispro 10ml of 100 units/ml (1 vial) - $27.49
Amoxicillin 500mg (21 capsules) - $9.09
Lisinopril/HCTZ 20mg/12.5mg (90 tablets) - $12.15
This isn't very relevant to us though given none of us have any long-term issues (what actually got me to switch off health insurance was getting the EoB paperwork [every week, because the bills never seemed to stop for a long while after I stopped going to the burn clinic] for severely burning my hand in a grease fire; I would've been better off uninsured and shopping around). After a decade at the $20k/year assumption for family of 3's health insurance, we wind up with ~$200k saved up BEFORE investment gains (which, while I'll grant can be negative, we do have a pretty powerful, accessible, and long-term consistent engine in the US). Once I'm in my 40s, I should be able to afford having brain cancer; and if I don't get brain cancer, well, the biggest positive there is not having brain cancer.
> Meanwhile, US companies remain the global leaders in the development of pharmaceuticals and medical equipment. That development is often subsidized by US taxpayers and the remainder is largely recovered from US patients because the single-payer systems in other countries often impose price controls that largely don't exist in the US.
From the first link in the OP you're replying to:
> The United States Senate Committee on Finance launched an 18-month investigation of Gilead's Sovaldi pricing, and argued in its 2015 report that Gilead set prices high in disregard of the human cost and in order to set the stage for a higher eventual price for Sovaldi's successor, Harvoni. The committee's investigation, based in part on internal documents obtained from Gilead, revealed that the company had considered prices ranging from $50,000 to $115,000 per year, trying to strike a balance between revenue and predicted activist and public relations blowback, with little regard to research and development costs.
The pricing was found to be intentionally divorced from R&D costs. They are charging as much as they can because they can, not because of R&D.
$84,000 for a (likely) cure is a huge improvement over ~$300,000 for a liver transplant. This is partly how they established the pricing, they knew that insurers would go for the cost savings.
It's fascinating that "fair" ends up being that the drug developer has to capture the correct amount of the value they are providing the patient, and the patient gets the rest.
> It's fascinating that "fair" ends up being that the drug developer has to capture the correct amount of the value they are providing the patient, and the patient gets the rest.
Keep in mind that the value is only "theirs" by force of IP law which at least officially exists for the benefit of society as a whole. Permitting a situation where people are priced out of a cure because the only available alternative is exorbitantly expensive doesn't seem moral or useful.
If the concern is ensuring corporate investment into R&D then public policy could be adopted to subsidize R&D expenses either up front or after the fact.
The price to the recipient of a liver transplant in India is USD$20k to $35k.
There's no good reason a liver transplant should cost 300k, so yours is a false comparison.
Did you read the comments? OP is comparing costs in USA. The cost of the drug in India is much less
In Czechia, with its public insurance system, the cost of a liver transplant is about 70 000 USD. But our medical professionals make peanuts compared to the US, and they don't need medical malpractice insurance.
I suspect that the lowest realistic cost in the US could be about 150k.
When compared to conservative treatments, transplants are expensive everywhere. A very invasive treatment with a small army of specialists involved.
I don't think that affects the GP point though. If the US is a profit center for pharma, that makes developing drugs more profitable overall, which means more drugs will be developed.
Pharma companies are gamblers. They gamble on the cost of R&D, the market size for the drug, the amount they will be able to charge. The higher the expected value of their profits, the wider variety of drugs look like attractive prospects financially.
> Meanwhile, US companies remain the global leaders in the development of pharmaceuticals and medical equipment
No denying the US plays a huge role in the global pharmaceutical industry - but Europe does too - semaglutide (Ozempic/Rybelsus/Wegovy) was developed by Novo Nordisk, headquartered in Denmark.
The popular ADHD drug lisdexamfetamine (Vyvanse/Elvanse) was developed by a US-based research team, but they ended up being acquired by a British pharmaceutical company (Shire), which in turn was acquired by a Japanese company (Takeda), who owned the patents (which expired last year or the year before, depending on country), and remain one of the major manufacturers of it.
If you want a career in drug development, there are huge opportunities in the EU and Switzerland; by no means are you limited to the US. As usual, in the US you will almost certainly get paid more, but some people find the social setting of Europe more to their liking, and view that as a compensating advantage which makes up for lower pay.
As a former pharmaceutical chemist, the job market in the US is kind of shit, which is why I write code for a living.
> As usual, in the US you will almost certainly get paid more
Switzerland is one of the few countries where getting paid more in the US for the same job would generally not be an "as usual" :) The large majority of equivalent jobs gets paid more in Switzerland, including office ones. The ones that don't are the outliers (which are of course greatly overrepresented here on HN).
This is IME, so feel free to correct me if I'm wrong.
Novo Nordisk charges about 10x as much for Ozempic in the US as it does in the EU:
https://www.healthline.com/health-news/heres-how-much-more-ozempic-costs-in-the-u-s-compared-to-other-countries https://www.healthline.com/health-news/heres-how-much-more-o...