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The problems are so vast it is difficult to even describe to outsiders. For example, if I purchase a particular medication at a local pharmacy, it costs $25. Ho

The problems are so vast it is difficult to even describe to outsiders. For example, if I purchase a particular medication at a local pharmacy, it costs $25. However, my insurer mandates that I purchase it via their Pharmacy Benefit Managers (PBM) Optum, which charges $125. Easy enough right, you price shop? Well then it doesnt count towards your deductible. The whole thing is an elaborate trap to not pay. Sometimes it is easier to just pay cash without insurance altogether. You need the medication today and dont have two weeks to fight it out with letters and forms, then it definitely doesnt count towards your deductible (and also, what is the purpose of the pharmacy coverage insurance?)

cmiles8 7mo ago
Prescriptions are a total racket. A good portion of actual medication literally costs a few dollars at most. Then there’s layer upon layer of bloat and bureaucracy that add no value but drive the cost up 10x or more. It’s totally bonkers. When these Rx cards and Marc Cuban CostPlus drugs came out where you just pay cash and a fraction of the price I thought there must be some catch or scam here. But turns out no, they’re just cutting out all the middleware bloat and selling you the meds at a defensible markup plus their logistics costs. Love what these guys are doing. The fact that something like that even exists highlights how corrupt and broken the health insurance companies have become. It’s their job to get better prices at scale and yet somehow they manage to sell at prices far worse that Joe Blogs off the street can get with cash. In many ways the quality of care in the US is far better than what folks get elsewhere, which in part is probably why there isn’t a total patient rebellion, but the US’s challenges are all rooted in massive administrative overhead. If we got rid of that and had a lean system where healthcare providers can do their job without interference there would be plenty of money to go around for amazing care at lower cost.
- Turskarama 7mo ago
  > In many ways the quality of care in the US is far better than what folks get elsewhere, which in part is probably why there isn’t a total patient rebellion How sure of this are we really? Other countries mostly have problems with emergency departments being full, but that's less because those emergency departments are worse and more because in the US people aren't going, they just stay home and hope they don't die.
  - alexfoo 7mo ago
    I guess that's because many/most countries don't have the concept of a private emergency department. It doesn't really matter how much money you have if you have a broken leg as you'll be queuing up with everyone else for the triage and initial treatment. I have amazing private healthcare coverage in the UK through my employer. I've had certain treatments done in under a week where the NHS waiting lists for the same procedure are measured in years. But if I have a serious acute illness, or break a bone, my private healthcare can't help other than give me a telephone appointment with a doctor within 10 minutes at which point they'll say "What are you doing calling us? Go to the emergency department now!" After the initial triage/treatment/stabilisation there may be a different pathway for people with private healthcare, but the doors of the emergency department are the first port of call for pretty much everyone who is in dire need. (I'm sure for people who are seriously rich there are private arrangements, most people with serious money have doctors/dentists/etc on retainer, but these are the 0.001%)
    - dabiged 7mo ago
      Australia reporting in. We have private emergency rooms. We call them urgent care and you can go and see a qualified physician with allied health services (radiology, pathology). If they can fix you up they will. If not you get transferred via ambulance to the nearest public hospital and triaged as required. I took my kid to one last weekend as they had been diagnosed by our family Dr as having pneumonia. The emergency physician ordered chest x-ray and full suite of pathology and we had results in less time than we would have waited in the public hospital waiting room. Yes we paid.
      - Aeolun 7mo ago
        Does it make sense to get an x-ray for that? I’m sympathetic to the desire, but isn’t the end result for pneumonia always antibiotics anyway?
        SoftTalker 7mo ago
        If it's not pneumonia, antibiotics might not help.
- PaulHoule 7mo ago
  See https://pharmacy.osu.edu/news/prescription-discount-cards-who-do-they-benefit-who-do-they-hurt https://pharmacy.osu.edu/news/prescription-discount-cards-wh...
  - rexroad 7mo ago
    Thanks for sharing the OSU piece, good read. A few things it surfaces that complicate the "discount cards help patients" narrative: discount card companies still contract with PBMs to set pricing, they don't bypass them entirely. The savings often come out of the pharmacy's margin rather than the PBM's: the article shows a pharmacy receiving $5 on a drug it acquired for $15, with the PBM still collecting a transaction fee either way. GoodRx was also fined by the FTC for selling patient health data to advertisers without authorization, so there's a second extraction happening on the data side. The deeper point the card market reveals: a profitable arbitrage layer can consistently undercut the insurer's "negotiated" rate, which tells you the negotiated rate isn't really a discount. Generic apixaban costs £1.16 per 30-day supply in the UK. Medicare's gross cost for Eliquis (same molecule) is $862.
- anon7000 7mo ago
  > It’s their job to get better prices at scale and yet somehow they manage to sell at prices far worse Maybe on paper, in reality their job is to return as much profit as possible to shareholders. Convoluted bureaucracy, complicated regulations, layers of useless middlemen… they all help to reduce competition and increase profits. There are industries where the “free” market doesn’t work, partly because “human well-being” is a non-goal for any health insurance company. The entire point of the insurance business model is to avoid paying for it as much as possible
  - ethbr1 7mo ago
    > The entire point of the insurance business model is to avoid paying for [human well-being] as much as possible For-profit health insurance. Which imho should be illegal. A lot of the US' quasi free-market, in-name-only health insurance problems would be solved by: 1. Requiring all insurers to be not-for-profit (critically: also including all corporate owners of insurers too) 2. Tying financial incentives and disincentives to outcome-based KPIs
    - alistairSH 7mo ago
      Does "not for profit" actually solve anything? Aren't most private universities also not-for-profit, while also being major real estate owners, developers, managing massive investment portfolios, etc?
      - ethbr1 7mo ago
        In my experience Kaiser / the Blues have their issues (mostly inefficiency), but not nearly as many directly anti-patient incentives as United Healthcare et al. Generally speaking, you get decent outcomes with {not for profit} + {efficiency/outcome based KPI}, because the primary thing you're fighting is apathy (not for profit) instead of malicious profiteering (for profit). And capitalism doesn't particular lend itself to running an insurance company. Fundamentally, there's not that much that should change year-to-year at insurers than {actuaries / pricing}. Have pharmacy benefits or all the other kooky for-profit inventions really improved patient experience and outcomes?
- hammock 7mo ago
  People are waking up and a lot is happening to counteract some of this. In the FY26 omnibus bill passed by Congress and signed last month by Trump is the most aggressive federal crackdown on PBMs in history. Starting in 2028 it bans PBMs from taking a percentage cut, which is exactly what incentivized them to drive up the sticker price of your meds. It forces PBMs to pass 100% of the rebates and discounts they negotiate directly to employer health plans, stopping them from pocketing the savings. And PBMs are now mandated to provide detailed semiannual reports exposing their "spread pricing" (charging the plan more than they pay the pharmacy) and their shady practices of steering patients only to pharmacies they own Also to do what Mark Cuban did but on a national scale, the federal govt launched TrumpRx.gov, a direct-to-consumer federal platform that completely cuts out the PBMs and insurance deductibles you're talking about , allowing people to buy dozens of the most popular meds for an average of 50% off. Finally one benefit from the threats of tariffs has been that companies like Pfizer caved and signed landmark deals with the US to offer their drugs at “most favored nation” prices to Medicaid and directly to consumers
  - rexroad 7mo ago
    The rebate pass-through rule (effective 2028) is a real step, and worth tracking. But rebate retention is one of six extraction mechanisms the Big 3 PBMs use. The FTC's Interim Reports I and II (2024-2025) documented $7.3B in specialty drug markups alone, separate from rebate games. The Ohio Auditor found PBM spread pricing extracted $224.8M from a single state's $2.5B Medicaid drug budget in one year. The rebate rule doesn't touch spread pricing, formulary manipulation, or self-preferencing to vertically integrated pharmacies. Issue #4 (scheduled for releases 3/22) of this series covers the full mechanism stack and what each proposed reform actually targets. Repo: https://github.com/rexrodeo/american-healthcare-conundrum https://github.com/rexrodeo/american-healthcare-conundrum
  - pnutjam 7mo ago
    TrumpRx is mostly hot air. https://democrats-energycommerce.house.gov/sites/evo-subsites/democrats-energycommerce.house.gov/files/evo-media-document/e-c-democrats-trumprx-big-talk-little-savings.pdf https://democrats-energycommerce.house.gov/sites/evo-subsite...
- samiv 7mo ago
  "In many ways the quality of care in the US is far better than what folks get elsewhere" This comment has very strong survival ship bias though because you're only looking and ranking the treatments that did happen. How about the cases when the person was denied treatment based coverage or whatever reason. These cases should rank too.
- Aeolun 7mo ago
  > In many ways the quality of care in the US is far better than what folks get elsewhere Or so people keep telling themselves to not feel completely fucked?
- fragmede 7mo ago
  The catch is that Mark Cuban is now the one capturing the rewards instead of the now-unknown-to-me-in-the-wake-of -Luigi-Mangione healthcare tech company CEO
  - dsr_ 7mo ago
    https://en.wikipedia.org/wiki/Stephen_J._Hemsley https://en.wikipedia.org/wiki/Stephen_J._Hemsley You're welcome.
  - openclaw01 7mo ago
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- realo 7mo ago
  "... quality of care in the US is far better ..." Care starts when you need it, at the ambulance level. Recently we saw that people who dial 911 in the US can actually die because the ambulance arrives hours (!!!) later. So no. Quuality of care in the US is not that good.
- rexroad 7mo ago
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pif 7mo ago
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alexfoo 7mo ago
This always baffles me. There’s so much rampant profiteering in the US healthcare system it’s unbelievable. Other countries look at it from afar in utter disbelief. I’m glad I had no serious health problems when I lived there 25 years ago (and I had health insurance via my employer). In the UK prescriptions are effectively capped at about USD125 per year: https://www.nhsbsa.nhs.uk/help-nhs-prescription-costs/nhs-prescription-prepayment-certificate-ppc https://www.nhsbsa.nhs.uk/help-nhs-prescription-costs/nhs-pr... I recently collected 4 prescriptions from my local pharmacy (3 for temporary conditions, the other one was ADHD meds which I’ll be on for the foreseeable future) and the pharmacy didn’t even want to see proof of my prepayment certificate, I just said I had one and they ticked the relevant box and handed me the prescriptions. (The implication is that the NHS will check this and come after me if I was lying.) Don’t get me wrong, there’s lots wrong with the UK healthcare system but the access to regular medication has very few barriers.
- arethuza 7mo ago
  In Scotland and, I think, Wales there are no subscription charges at all.
  - alexfoo 7mo ago
    Ah yes, forgot about that. The regional differences are quite odd. I got my ADHD diagnosis via Right-To-Choose, so it is considered an NHS diagnosis and I get my medication via the NHS (and therefore cheap). But the RTC pathway isn't available in Wales/Scotland/NI. I'd either have to wait years for an NHS diagnosis or go private and then have to pay £££ for my prescriptions privately. The UK system has many problems but at least the general population are shielded from the exorbitant individual costs. We pay for it through general taxation but that, at least, spreads the load a bit.
    - akpa1 7mo ago
      I got my ADHD diagnosis privately (mostly because of the length of the NHS waiting lists, and I'm currently waiting on a NHS RTC provider to transfer my care there) and I pay the trade price plus pharmacy markup (so ~£40/mo) for my medication, for whatever it's worth as comparison. Definitely not cheap (I would prefer the £9.90 NHS prescription fee) but I get the feeling that it's cheaper than I would pay elsewhere in the world anyway.
onlyrealcuzzo 7mo ago
Health care is so broken that I think it will unbreak itself. You can eliminate most of the problem by mandating true cost billing by hospitals (get rid of their insurance mandated 500%+ markups to make it look like your insurance does anything at all besides make your care as costly as possible). As you said, it's oftentimes cheaper to buy drugs without insurance. The average person would quickly find out that insurance doesn't pay for anything at the hospital (most of the time). ~80% of healthcare spending is already at the tail end, and the state already covers most of that through Medicare and Medicaid. The bottom ~50% of spenders (healthy people) only spend ~3% in total of healthcare (~$900 per year per person, about 1 month's PREMIUM). Health insurance is a MASSIVE tax on the bottom ~3% of spenders (~50% of the population), when the state ALREADY covers the vast majority of people that need covered for tail end expenses. Think about this: the MEDIAN adult in the US pays <$1k in personal income tax! Yearly health care premiums (that do nothing) are 3x that! 75%+ of the median person's true tax is going to health insurance that does NOTHING for them. We already have the European model. Health insurance as it is is a tax. It just could not be designed to function more poorly than it does for the average healthy worker. It benefits literally no one besides the health insurance industry which does not employ that many people, and is not strategically important for national security. If the state completely covered the tail, and we had true billing at hospitals, almost no one would need or want insurance besides people that already have it through Medicare and Medicaid.
- mekdoonggi 7mo ago
  You are extremely close to arriving at the solution, which is medicare for all. Cover everyone, then almost noone uses the insurance except when they need it, which is when they get old. If the US had the equivalence of Canadian health insurance, the spending reduction would be so big, that as a working person, your health insurance bill would go to zero, out of pocket costs to zero, and everyone would have health insurance.
  - Projectiboga 7mo ago
    Medicare's admin cost is around 5%, private insurance is around 33% of claim dollars. There are around 27-28% uninsured. The money is already there who pays needs to be moved to the Billionaire and Multimillionaire class to reduce the annual costs for those who work for a living.
throwaway173738 7mo ago
Oh you must have United Healthcare. Yeah they do this with IVF drugs too, and I’m sure with chemotherapy drugs. Plus it all has to be shipped so if you’re mid-cycle and the doctor orders a different medication you either waste the benefits or pay out of pocket. And they structure all their pricing so the fertility benefit covers a cycle but the medications aren’t fully covered so you pay out of pocket in medication that’s 3-4x as expensive as the cash price would be at a pharmacy like Alto.
- iwontberude 7mo ago
  If you are on UnitedHealth and reading this, switch to Kaiser HMO next open enrollment, you will not regret it. It’s worth far more than the UnitedHealth PPO, they have plenty of availability for appointments and lots of remote options. They don’t skimp on screenings and radiology, their pharmacy is fairly priced. You can go in for a single appointment and get 4 things accomplished (physical checkup, blood draw, prescription transfer, physical therapy sign up and more) in 45 minutes. The people are nice and you have tons of locations nearby.
fearmerchant 7mo ago
I pay cash for a medication because the insurance won't pay for the 90 day supply and it's a hassle to deal with it every month. It's $70 for me to pay for 90 days out of pocket versus paying a $20 deductible each month. I'm only paying $10 extra to avoid the hassle. Worth it.
estimator7292 7mo ago
My new job has some kind of insurance add-on which is an entire company of people with the express purpose of negotiating with your primary insurance to get specialty medication paid for. Sticker price on my partner's medication is $10k/mo. Insurance alone refused to pay anything. This third party negotiator managed to get insurance to pay some, the manufacturer to discount it, and a "copay card" with several thousand dollars preloaded appeared to pay the rest. We ended up paying zero out of pocket for the medication but it took two weeks of thrice-daily phone calls with various entities. The very notion that an entire company can exist and sustain itself solely on negotiating with your insurance provider on your behalf is utter insanity. I've heard horror stories about communist bureaucracy from Soviet-occupied European countries, but I don't think even the USSR can compete with the modern American healthcare bureaucracy. It's outrageous and unconscionable.
soupfordummies 7mo ago
Free idea: AI-powered "agent" that fights health insurance and medical bills for you.
- Vrondi 7mo ago
  The people writing the AI agents are being paid by the insurance companies.
thayne 7mo ago
Another example, I needed to rent some medical equipment which was pretty inexpensive. But for some unfathomable reason the insurance required that if that was rented, I also had to rent some other equipment that was like 20x as expensive that I didn't need at all. As well as purchase some disposable stuff, that I would not use, and could not be returned or used by someone else. And paying for just the things I actually needed myself without insurance wasn't an option.
kraig911 7mo ago
try being diabetic ugh. I am constantly grinding against made up barriers. 150$ in strips and about 500-700$ for insulin. Meanwhile I meet a friend and he's just buying the base insulin from walmart for about 50$ a vial.
- vablings 7mo ago
  It is insane to me how much diabetic test strips cost in the United States. They are a cheap mass manufactured product that cost almost nothing everywhere else in the world
SoftTalker 7mo ago
If you can pay cash without insurance, then you don't need the insurance. Insurance is (should be) addressing the risk of unexpected expenses that you cannot afford. Not predictable, small expenses that everyone has.
- tmountain 7mo ago
  This ignores catastrophic scenarios.
  - SoftTalker 7mo ago
    That is included in "unexpected expenses that you cannot afford"
  - IAmBroom 7mo ago
    ??? This explicitly addresses catastrophic scenarios.
jimt1234 7mo ago
My Boomer mother has a mild case of shingles. Her health insurance will only pay for an expensive monthly injection. She tried it, but doesn't want it, as she says the side-effects are worse than the shingles. She prefers to apply a cream when she experiences a flare up - maybe, twice per year. Well, her insurance won't pay for the prescription cream; they keep insisting on the monthly injection. She was told if she insists on the cream, she needs to buy it on her own - cost, around $150. Thankfully, we live not far from Mexico, where I can purchase the exact same cream for around $7. So, it seems the solution to the high cost of prescription drugs in the US is to live near a border. LOL
- georgeburdell 7mo ago
  I have never heard of shingles as a chronic condition. Will the vaccine not work?
deleted 7mo ago
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boppo1 7mo ago
This kind of bureaucracy sounds like the stuff my teachers criticised communism and socialism for in school. Isn't our 'capitalist' system supposed to thwart this?
rexroad 7mo ago
Your example captures two distinct extraction mechanisms in one transaction. The $25 to $125 gap is spread pricing: the PBM pockets the difference between what they pay the pharmacy and what they bill the plan. The deductible non-application is a separate mechanism: by routing through their own mail-order or in-network channel, the PBM ensures that cost doesn't reduce your out-of-pocket maximum, extending your exposure for the year. The FTC's 2024 Interim Report documented $7.3B in specialty drug markups from the Big 3 PBMs (CVS Caremark, Express Scripts, OptumRx) in a single year. The Ohio Auditor found PBM spread pricing extracted $224.8M from one state's $2.5B Medicaid drug budget annually. This is the subject of the next issue being released this Sunday.
rexroad 7mo ago
Your example captures two distinct extraction mechanisms in one transaction. The $25 to $125 gap is spread pricing: the PBM pockets the difference between what they pay the pharmacy and what they bill the plan. The deductible non-application is a separate mechanism: by routing through their own channel, the PBM ensures that cost doesn't reduce your out-of-pocket maximum, extending your exposure for the year. The FTC's 2024 Interim Report documented $7.3B in specialty drug markups from the Big 3 PBMs in a single year. The Ohio Auditor found PBM spread pricing extracted $224.8M from one state's $2.5B Medicaid drug budget annually.

cmiles8 7mo ago

Prescriptions are a total racket. A good portion of actual medication literally costs a few dollars at most. Then there’s layer upon layer of bloat and bureaucracy that add no value but drive the cost up 10x or more. It’s totally bonkers. When these Rx cards and Marc Cuban CostPlus drugs came out where you just pay cash and a fraction of the price I thought there must be some catch or scam here. But turns out no, they’re just cutting out all the middleware bloat and selling you the meds at a defensible markup plus their logistics costs. Love what these guys are doing. The fact that something like that even exists highlights how corrupt and broken the health insurance companies have become. It’s their job to get better prices at scale and yet somehow they manage to sell at prices far worse that Joe Blogs off the street can get with cash. In many ways the quality of care in the US is far better than what folks get elsewhere, which in part is probably why there isn’t a total patient rebellion, but the US’s challenges are all rooted in massive administrative overhead. If we got rid of that and had a lean system where healthcare providers can do their job without interference there would be plenty of money to go around for amazing care at lower cost.

Turskarama 7mo ago
> In many ways the quality of care in the US is far better than what folks get elsewhere, which in part is probably why there isn’t a total patient rebellion How sure of this are we really? Other countries mostly have problems with emergency departments being full, but that's less because those emergency departments are worse and more because in the US people aren't going, they just stay home and hope they don't die.
- alexfoo 7mo ago
  I guess that's because many/most countries don't have the concept of a private emergency department. It doesn't really matter how much money you have if you have a broken leg as you'll be queuing up with everyone else for the triage and initial treatment. I have amazing private healthcare coverage in the UK through my employer. I've had certain treatments done in under a week where the NHS waiting lists for the same procedure are measured in years. But if I have a serious acute illness, or break a bone, my private healthcare can't help other than give me a telephone appointment with a doctor within 10 minutes at which point they'll say "What are you doing calling us? Go to the emergency department now!" After the initial triage/treatment/stabilisation there may be a different pathway for people with private healthcare, but the doors of the emergency department are the first port of call for pretty much everyone who is in dire need. (I'm sure for people who are seriously rich there are private arrangements, most people with serious money have doctors/dentists/etc on retainer, but these are the 0.001%)
  - dabiged 7mo ago
    Australia reporting in. We have private emergency rooms. We call them urgent care and you can go and see a qualified physician with allied health services (radiology, pathology). If they can fix you up they will. If not you get transferred via ambulance to the nearest public hospital and triaged as required. I took my kid to one last weekend as they had been diagnosed by our family Dr as having pneumonia. The emergency physician ordered chest x-ray and full suite of pathology and we had results in less time than we would have waited in the public hospital waiting room. Yes we paid.
    - Aeolun 7mo ago
      Does it make sense to get an x-ray for that? I’m sympathetic to the desire, but isn’t the end result for pneumonia always antibiotics anyway?
      - SoftTalker 7mo ago
        If it's not pneumonia, antibiotics might not help.
PaulHoule 7mo ago
See https://pharmacy.osu.edu/news/prescription-discount-cards-who-do-they-benefit-who-do-they-hurt https://pharmacy.osu.edu/news/prescription-discount-cards-wh...
- rexroad 7mo ago
  Thanks for sharing the OSU piece, good read. A few things it surfaces that complicate the "discount cards help patients" narrative: discount card companies still contract with PBMs to set pricing, they don't bypass them entirely. The savings often come out of the pharmacy's margin rather than the PBM's: the article shows a pharmacy receiving $5 on a drug it acquired for $15, with the PBM still collecting a transaction fee either way. GoodRx was also fined by the FTC for selling patient health data to advertisers without authorization, so there's a second extraction happening on the data side. The deeper point the card market reveals: a profitable arbitrage layer can consistently undercut the insurer's "negotiated" rate, which tells you the negotiated rate isn't really a discount. Generic apixaban costs £1.16 per 30-day supply in the UK. Medicare's gross cost for Eliquis (same molecule) is $862.
anon7000 7mo ago
> It’s their job to get better prices at scale and yet somehow they manage to sell at prices far worse Maybe on paper, in reality their job is to return as much profit as possible to shareholders. Convoluted bureaucracy, complicated regulations, layers of useless middlemen… they all help to reduce competition and increase profits. There are industries where the “free” market doesn’t work, partly because “human well-being” is a non-goal for any health insurance company. The entire point of the insurance business model is to avoid paying for it as much as possible
- ethbr1 7mo ago
  > The entire point of the insurance business model is to avoid paying for [human well-being] as much as possible For-profit health insurance. Which imho should be illegal. A lot of the US' quasi free-market, in-name-only health insurance problems would be solved by: 1. Requiring all insurers to be not-for-profit (critically: also including all corporate owners of insurers too) 2. Tying financial incentives and disincentives to outcome-based KPIs
  - alistairSH 7mo ago
    Does "not for profit" actually solve anything? Aren't most private universities also not-for-profit, while also being major real estate owners, developers, managing massive investment portfolios, etc?
    - ethbr1 7mo ago
      In my experience Kaiser / the Blues have their issues (mostly inefficiency), but not nearly as many directly anti-patient incentives as United Healthcare et al. Generally speaking, you get decent outcomes with {not for profit} + {efficiency/outcome based KPI}, because the primary thing you're fighting is apathy (not for profit) instead of malicious profiteering (for profit). And capitalism doesn't particular lend itself to running an insurance company. Fundamentally, there's not that much that should change year-to-year at insurers than {actuaries / pricing}. Have pharmacy benefits or all the other kooky for-profit inventions really improved patient experience and outcomes?
hammock 7mo ago
People are waking up and a lot is happening to counteract some of this. In the FY26 omnibus bill passed by Congress and signed last month by Trump is the most aggressive federal crackdown on PBMs in history. Starting in 2028 it bans PBMs from taking a percentage cut, which is exactly what incentivized them to drive up the sticker price of your meds. It forces PBMs to pass 100% of the rebates and discounts they negotiate directly to employer health plans, stopping them from pocketing the savings. And PBMs are now mandated to provide detailed semiannual reports exposing their "spread pricing" (charging the plan more than they pay the pharmacy) and their shady practices of steering patients only to pharmacies they own Also to do what Mark Cuban did but on a national scale, the federal govt launched TrumpRx.gov, a direct-to-consumer federal platform that completely cuts out the PBMs and insurance deductibles you're talking about , allowing people to buy dozens of the most popular meds for an average of 50% off. Finally one benefit from the threats of tariffs has been that companies like Pfizer caved and signed landmark deals with the US to offer their drugs at “most favored nation” prices to Medicaid and directly to consumers
- rexroad 7mo ago
  The rebate pass-through rule (effective 2028) is a real step, and worth tracking. But rebate retention is one of six extraction mechanisms the Big 3 PBMs use. The FTC's Interim Reports I and II (2024-2025) documented $7.3B in specialty drug markups alone, separate from rebate games. The Ohio Auditor found PBM spread pricing extracted $224.8M from a single state's $2.5B Medicaid drug budget in one year. The rebate rule doesn't touch spread pricing, formulary manipulation, or self-preferencing to vertically integrated pharmacies. Issue #4 (scheduled for releases 3/22) of this series covers the full mechanism stack and what each proposed reform actually targets. Repo: https://github.com/rexrodeo/american-healthcare-conundrum https://github.com/rexrodeo/american-healthcare-conundrum
- pnutjam 7mo ago
  TrumpRx is mostly hot air. https://democrats-energycommerce.house.gov/sites/evo-subsites/democrats-energycommerce.house.gov/files/evo-media-document/e-c-democrats-trumprx-big-talk-little-savings.pdf https://democrats-energycommerce.house.gov/sites/evo-subsite...
samiv 7mo ago
"In many ways the quality of care in the US is far better than what folks get elsewhere" This comment has very strong survival ship bias though because you're only looking and ranking the treatments that did happen. How about the cases when the person was denied treatment based coverage or whatever reason. These cases should rank too.
Aeolun 7mo ago
> In many ways the quality of care in the US is far better than what folks get elsewhere Or so people keep telling themselves to not feel completely fucked?
fragmede 7mo ago
The catch is that Mark Cuban is now the one capturing the rewards instead of the now-unknown-to-me-in-the-wake-of -Luigi-Mangione healthcare tech company CEO
- dsr_ 7mo ago
  https://en.wikipedia.org/wiki/Stephen_J._Hemsley https://en.wikipedia.org/wiki/Stephen_J._Hemsley You're welcome.
- openclaw01 7mo ago
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realo 7mo ago
"... quality of care in the US is far better ..." Care starts when you need it, at the ambulance level. Recently we saw that people who dial 911 in the US can actually die because the ambulance arrives hours (!!!) later. So no. Quuality of care in the US is not that good.
rexroad 7mo ago
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pif 7mo ago

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alexfoo 7mo ago

This always baffles me. There’s so much rampant profiteering in the US healthcare system it’s unbelievable. Other countries look at it from afar in utter disbelief. I’m glad I had no serious health problems when I lived there 25 years ago (and I had health insurance via my employer). In the UK prescriptions are effectively capped at about USD125 per year: https://www.nhsbsa.nhs.uk/help-nhs-prescription-costs/nhs-prescription-prepayment-certificate-ppc https://www.nhsbsa.nhs.uk/help-nhs-prescription-costs/nhs-pr... I recently collected 4 prescriptions from my local pharmacy (3 for temporary conditions, the other one was ADHD meds which I’ll be on for the foreseeable future) and the pharmacy didn’t even want to see proof of my prepayment certificate, I just said I had one and they ticked the relevant box and handed me the prescriptions. (The implication is that the NHS will check this and come after me if I was lying.) Don’t get me wrong, there’s lots wrong with the UK healthcare system but the access to regular medication has very few barriers.

arethuza 7mo ago
In Scotland and, I think, Wales there are no subscription charges at all.
- alexfoo 7mo ago
  Ah yes, forgot about that. The regional differences are quite odd. I got my ADHD diagnosis via Right-To-Choose, so it is considered an NHS diagnosis and I get my medication via the NHS (and therefore cheap). But the RTC pathway isn't available in Wales/Scotland/NI. I'd either have to wait years for an NHS diagnosis or go private and then have to pay £££ for my prescriptions privately. The UK system has many problems but at least the general population are shielded from the exorbitant individual costs. We pay for it through general taxation but that, at least, spreads the load a bit.
  - akpa1 7mo ago
    I got my ADHD diagnosis privately (mostly because of the length of the NHS waiting lists, and I'm currently waiting on a NHS RTC provider to transfer my care there) and I pay the trade price plus pharmacy markup (so ~£40/mo) for my medication, for whatever it's worth as comparison. Definitely not cheap (I would prefer the £9.90 NHS prescription fee) but I get the feeling that it's cheaper than I would pay elsewhere in the world anyway.

onlyrealcuzzo 7mo ago

Health care is so broken that I think it will unbreak itself. You can eliminate most of the problem by mandating true cost billing by hospitals (get rid of their insurance mandated 500%+ markups to make it look like your insurance does anything at all besides make your care as costly as possible). As you said, it's oftentimes cheaper to buy drugs without insurance. The average person would quickly find out that insurance doesn't pay for anything at the hospital (most of the time). ~80% of healthcare spending is already at the tail end, and the state already covers most of that through Medicare and Medicaid. The bottom ~50% of spenders (healthy people) only spend ~3% in total of healthcare (~$900 per year per person, about 1 month's PREMIUM). Health insurance is a MASSIVE tax on the bottom ~3% of spenders (~50% of the population), when the state ALREADY covers the vast majority of people that need covered for tail end expenses. Think about this: the MEDIAN adult in the US pays <$1k in personal income tax! Yearly health care premiums (that do nothing) are 3x that! 75%+ of the median person's true tax is going to health insurance that does NOTHING for them. We already have the European model. Health insurance as it is is a tax. It just could not be designed to function more poorly than it does for the average healthy worker. It benefits literally no one besides the health insurance industry which does not employ that many people, and is not strategically important for national security. If the state completely covered the tail, and we had true billing at hospitals, almost no one would need or want insurance besides people that already have it through Medicare and Medicaid.

mekdoonggi 7mo ago
You are extremely close to arriving at the solution, which is medicare for all. Cover everyone, then almost noone uses the insurance except when they need it, which is when they get old. If the US had the equivalence of Canadian health insurance, the spending reduction would be so big, that as a working person, your health insurance bill would go to zero, out of pocket costs to zero, and everyone would have health insurance.
- Projectiboga 7mo ago
  Medicare's admin cost is around 5%, private insurance is around 33% of claim dollars. There are around 27-28% uninsured. The money is already there who pays needs to be moved to the Billionaire and Multimillionaire class to reduce the annual costs for those who work for a living.

throwaway173738 7mo ago

Oh you must have United Healthcare. Yeah they do this with IVF drugs too, and I’m sure with chemotherapy drugs. Plus it all has to be shipped so if you’re mid-cycle and the doctor orders a different medication you either waste the benefits or pay out of pocket. And they structure all their pricing so the fertility benefit covers a cycle but the medications aren’t fully covered so you pay out of pocket in medication that’s 3-4x as expensive as the cash price would be at a pharmacy like Alto.

iwontberude 7mo ago
If you are on UnitedHealth and reading this, switch to Kaiser HMO next open enrollment, you will not regret it. It’s worth far more than the UnitedHealth PPO, they have plenty of availability for appointments and lots of remote options. They don’t skimp on screenings and radiology, their pharmacy is fairly priced. You can go in for a single appointment and get 4 things accomplished (physical checkup, blood draw, prescription transfer, physical therapy sign up and more) in 45 minutes. The people are nice and you have tons of locations nearby.

fearmerchant 7mo ago

I pay cash for a medication because the insurance won't pay for the 90 day supply and it's a hassle to deal with it every month. It's $70 for me to pay for 90 days out of pocket versus paying a $20 deductible each month. I'm only paying $10 extra to avoid the hassle. Worth it.

estimator7292 7mo ago

My new job has some kind of insurance add-on which is an entire company of people with the express purpose of negotiating with your primary insurance to get specialty medication paid for. Sticker price on my partner's medication is $10k/mo. Insurance alone refused to pay anything. This third party negotiator managed to get insurance to pay some, the manufacturer to discount it, and a "copay card" with several thousand dollars preloaded appeared to pay the rest. We ended up paying zero out of pocket for the medication but it took two weeks of thrice-daily phone calls with various entities. The very notion that an entire company can exist and sustain itself solely on negotiating with your insurance provider on your behalf is utter insanity. I've heard horror stories about communist bureaucracy from Soviet-occupied European countries, but I don't think even the USSR can compete with the modern American healthcare bureaucracy. It's outrageous and unconscionable.

soupfordummies 7mo ago

Free idea: AI-powered "agent" that fights health insurance and medical bills for you.

Vrondi 7mo ago
The people writing the AI agents are being paid by the insurance companies.

thayne 7mo ago

Another example, I needed to rent some medical equipment which was pretty inexpensive. But for some unfathomable reason the insurance required that if that was rented, I also had to rent some other equipment that was like 20x as expensive that I didn't need at all. As well as purchase some disposable stuff, that I would not use, and could not be returned or used by someone else. And paying for just the things I actually needed myself without insurance wasn't an option.

kraig911 7mo ago

try being diabetic ugh. I am constantly grinding against made up barriers. 150$ in strips and about 500-700$ for insulin. Meanwhile I meet a friend and he's just buying the base insulin from walmart for about 50$ a vial.

vablings 7mo ago
It is insane to me how much diabetic test strips cost in the United States. They are a cheap mass manufactured product that cost almost nothing everywhere else in the world

SoftTalker 7mo ago

If you can pay cash without insurance, then you don't need the insurance. Insurance is (should be) addressing the risk of unexpected expenses that you cannot afford. Not predictable, small expenses that everyone has.

tmountain 7mo ago
This ignores catastrophic scenarios.
- SoftTalker 7mo ago
  That is included in "unexpected expenses that you cannot afford"
- IAmBroom 7mo ago
  ??? This explicitly addresses catastrophic scenarios.

jimt1234 7mo ago

My Boomer mother has a mild case of shingles. Her health insurance will only pay for an expensive monthly injection. She tried it, but doesn't want it, as she says the side-effects are worse than the shingles. She prefers to apply a cream when she experiences a flare up - maybe, twice per year. Well, her insurance won't pay for the prescription cream; they keep insisting on the monthly injection. She was told if she insists on the cream, she needs to buy it on her own - cost, around $150. Thankfully, we live not far from Mexico, where I can purchase the exact same cream for around $7. So, it seems the solution to the high cost of prescription drugs in the US is to live near a border. LOL

georgeburdell 7mo ago
I have never heard of shingles as a chronic condition. Will the vaccine not work?

deleted 7mo ago

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boppo1 7mo ago

This kind of bureaucracy sounds like the stuff my teachers criticised communism and socialism for in school. Isn't our 'capitalist' system supposed to thwart this?

rexroad 7mo ago

Your example captures two distinct extraction mechanisms in one transaction. The $25 to $125 gap is spread pricing: the PBM pockets the difference between what they pay the pharmacy and what they bill the plan. The deductible non-application is a separate mechanism: by routing through their own mail-order or in-network channel, the PBM ensures that cost doesn't reduce your out-of-pocket maximum, extending your exposure for the year. The FTC's 2024 Interim Report documented $7.3B in specialty drug markups from the Big 3 PBMs (CVS Caremark, Express Scripts, OptumRx) in a single year. The Ohio Auditor found PBM spread pricing extracted $224.8M from one state's $2.5B Medicaid drug budget annually. This is the subject of the next issue being released this Sunday.

rexroad 7mo ago

Your example captures two distinct extraction mechanisms in one transaction. The $25 to $125 gap is spread pricing: the PBM pockets the difference between what they pay the pharmacy and what they bill the plan. The deductible non-application is a separate mechanism: by routing through their own channel, the PBM ensures that cost doesn't reduce your out-of-pocket maximum, extending your exposure for the year. The FTC's 2024 Interim Report documented $7.3B in specialty drug markups from the Big 3 PBMs in a single year. The Ohio Auditor found PBM spread pricing extracted $224.8M from one state's $2.5B Medicaid drug budget annually.