> In particular, how easy will distribution be, considering that HIV is extremely easily preventable but it still spreads, because of lack of distribution of knowledge, I assume.
This is a huge problem in the US. Truvada must be taken everyday to prevent HIV, and in 2015, it cost $1400 for a 30 day supply. In 2021, it costs between $1900 and $2500+ for a 30 day supply in the US.
Elsewhere in the world, Truvada might cost $40. In Australia, Truvada costs $8 for a 30 day supply[1].
The only other drug approved for PrEP in the US is Descovy, which is manufactured by Gilead, too, and costs $2300+ minimum for a 30 day supply.
No guarantee the price will go down in the US as a result.
An epilepsy medication I took, once the patents completely expired (both on the regular and extended release versions), the generics ended up costing me more to pick up while the branded version rose in price as well.
It typically takes about 6 months to 3 years for generic drug prices to decline due to how we approve generics in the USA. Most people don't know that we have an insane policy whereby the first generic drug applicant receives an extended period of market exclusivity.
"Most people don't know that we have an insane policy whereby the first generic drug applicant receives an extended period of market exclusivity."
The US has some of the lowest cost generics in developed nations - prices tend to be lower than the EU. The US has some of the highest generic drug penetration of developed nations. [1] That's because of things like the 180 generic drug exclusivity and mandatory generic substitution laws.
The 180 exclusivity is a big part of that. If you open the flood gates to any generic manufacturer, the margins disappear so quickly that some manufacturers won't even bother to try. By dangling a massive carrot whereby the generic manufacturers can quickly recoup costs and make a large profit, it drives generic companies to compete to the enter the market.
When Lipitor went off patent, eleven generic companies entered the market and prices dropped 95%.
The US generic market is one of the best functioning in the world.
> Elsewhere in the world, Truvada might cost $40. In Australia, Truvada costs $8 for a 30 day supply[1].
AUD 6.60 in Australia is the cost for those eligible for the concession PBS rate (those that are on welfare, pension etc.). It's AUD 41.30 for everyone else.
This is all thanks to our government negotiating a good rate with the manufacturer and then subsidizing the costs. This is not what all governments do, unfortunately.
I looked up pricing of Truvada vs. Descovy through my insurance, and weirdly Truvada would be a $40 copay, yet Descovy is $0 as insurance covers the entire obscene amount ($~2200 for a 30 day supply).
Medical insurance companies know they get a slice of the pie, so the size of the pie is really, really important to future growth.
Also, can't help but wonder if your insurance company has an ownership interest in Descovy...somewhere. $2200 is cheap if you're paying it to yourself. And the pie grows.
Yeah, that's my mildly paranoid writing for the week, methinks.
Why doesn't the US pass a law that prevent such large deprecencies? Is it because the legal landscape is different and pharmaceuticals companies worry about the cost of litigation in the US?
Because Big Pharma lobbies to prevent such laws from being imposed. There’s even a law that prevents Medicare from negotiating down the price of drugs, with obvious consequences.
Because the GOP is ideologically opposed to price controls (except when it's in the form of subsidies to their state's pet industry of course). Something, something, free market distortions I think is the usual reason.
I think you’re misguided if you think this is a partisan issue. It’s an American issue where neither party has really adequately done anything about affordable healthcare and gouging like this.
Everything that has been done or been tried has had to pass or be written under the specter of the filibuster though. It fundamentally limits the type of options that get through. The only major change in the last decade was Obamacare which is remarkably similar to the system passed under a the Republican Governorship of Mitt Romney.
Democrats have some options they'd like to do that might help but cannot because of the filibuster. Reconciliation which is the only way around the filibuster guaranteed is pretty limited in scope due to the rules around it. Whether those could pass a vote if there was no filibuster is unknown because they all get completely blocked by Republican filibuster.
> The only major change in the last decade was Obamacare which is remarkably similar to the system passed under a the Republican Governorship of Mitt Romney.
Which itself was a state level implementation of a program the insurance industry and national Republicans were talking up as an alternative in the 90s when, i the wake of the failure of Clinton’s healthcare reform, it seemed there was enough residual demand for something to be done in that regard nationally that they thought they needed to bring something to the table.
> Democrats have some options they'd like to do that might help but cannot because of the filibuster.
Repetitively, issues are raised and forgotten by politicians, and never actually solved by the party in power. For various reasons, many people have come to believe propaganda about the filibuster. For example, Sen. Warren and others say that the filibuster is racist and a relic of the past, yet Democrats (including Warren) filibustered the Republican's $500 billion coronavirus relief bill in September of last year. They were really saving their votes to send you money after the election. They also filibustered a Republican police-reform bill last year.
While the parties do not necessarily hold the same platforms as each other, many of the Senators literally went to school in order to become politicians. They are not your friends. They are prevaricating in order to remain in power and make money. Not all - but many of them. Warren has some redeeming qualities, but facts are facts. She has been a Senator since 2013 and has had her own share of "clarified statements".
Definition: A wedge issue is a divisive political issue, especially one that is raised by a candidate for public office in hopes of attracting or alienating an opponent's supporters.
These wedge issues are used to keep people's emotions going, so as to vote for one party and hate the other. Then, the issues are not solved a the times they could. There is a reason for the existence of an actual term, wedge issue, for the concept - because it constantly happens.
The filibuster is a set of rules that both parties agreed to. One might well ask why Democrats in the senate agreed to this rule once again, knowing full well it would impede their ability to accomplish their publicly touted platform over the next few years.
Kind of, the filibuster isn't so much in the rules as it's a consequence of other rules and (imo) a poorly designed government. The Senate was originally setup with truly unlimited debate, this is a pretty bad idea on the face of it because it allows a pretty small group to potentially completely stall the whole of the US government's law making apparatus. [0] So cloture was added which added a way to officially close debate on a bill to avoid that. It requires more coordination but still introduces an extra veto point into the government that most modern democracies don't have. It's an extremely powerful tool for the minority.
That very power is a reason I think there's a few hold outs on the Democrat side that don't want to get rid of it. The senate is naturally stacked against the democrats as the parties are currently aligned so a few don't want to risk giving up that power. There's also a number who (at least claim to) believe that the unlimited debate is an important part of the Senate.
Personally I think it's a relic that's getting in the way of passing the exact legislation that will make Democrats more popular (and make it easier to vote to counteract some extremely blatant voter suppression happening in red states).
[0] consider 3 senators working 8 hour shifts of 8 on 16 off. That would be maintainable for a very long time.
The US govt is heavily calibrated on the side of minority political factions in order to protect minorities from “oppressive” majority rule. It’s annoying when it gets in the way of the majority but also fundamental to how the US operates. What recent events tell me is that we’re looking to the federal government to do more than it is/was meant to do. If that’s dated so be it but I dont understand why states have to wait around for the federal government to solve healthcare.
For starters the Federal level has access to waaay more money and sources of money (including just 'printing' money, investment taxes, etc.) than any state and the larger the population the more power a government has in bargaining. It's also much easier for companies and people to just abandon a state to avoid paying new taxes than it is for them to leave the US entirely.
The power of the minority was a crappy compromise to get the less densely populated states (not coincidentally southern slave owning states) to sign on to the constitution. The original Articles of Confederation were even worse requiring basically unanimity to pass federal laws and taxes. The whole job of the Senate was to appease those same states. Do any other countries have this kind of explicit carve out for land (essentially) getting an equal weight?
> It’s annoying when it gets in the way of the majority but also fundamental to how the US operates.
I think a government where the majority party can't actually implement any kind of agenda is a fundamentally broken government.
> I dont understand why states have to wait around for the federal government to solve healthcare.
Because they're ironically forbidden by federal law. Several legislators in CA would love to bring a statewide single-payer healthcare bill forward, but funding it would require using federal Medicare dollars in ways that require permission from the US Congress. Guess how likely that'll be forthcoming?
> I think a government where the majority party can't actually implement any kind of agenda is a fundamentally broken government.
I think this is a big sustaining source of disillusion with the US government. Cynical minorities have a pretty easy way to make people hate the opposition by just blocking everything, this was even explicitly acknowledged by McConnel as their strategy. Block everything no matter how small.
I get it and don't agree with what the current republican party is doing, but that’s almost besides the point. If we can’t get an agenda accomplished then perhaps it’s too overarching to be agreeable to or considered fundamental by most of Americans.
Now, it’s also possible that we’re suffering from the two party hell we’ve created and that we have an overstated (too large) minority party that doesn't reflect the wishes of any reasonable fraction of our people... I tend to think this is more of a problem than people realize. We need voting reform to bring more plurality into govt operations and lawmaking.
> If we can’t get an agenda accomplished then perhaps it’s too overarching to be agreeable to or considered fundamental by most of Americans.
Republican Senators don't seem to care if an agenda is supported by a majority of registered Republican voters.
Anyhow, the Senate must be reformed or abolished. Land does not require representation. Give every state a guaranteed 2 senators, I suppose, but some reasonable formula should be implemented that apportions more populous states additional senators.
The obvious answer is eventually they will be out of power again and will want it. In fact until a few years ago they had it for judges, but they got rid of it when Republicans filibustered. Then when Trump nominated a judge they didn't like, well they discovered the filibuster was gone by their own doing and they were powerless.
That's not true. Mitch McConnell got rid of the SCOTUS 'filibuster' lowered it to 51 votes - pretty hypocritically based on his statements but you can't take McConnell's word you have to look at what has power.
Harry Reid previously lowered cloture threshold for non SCOTUS appointments, but only after Republicans act(ed) in bad faith and refused to "Advice and Consent."
They refused to confirm 2 very important seats for 'cost savings' and claimed that the DC circuit was 'underworked.' This is in the context of anti-Obama everything and no matter how milquetoast the nominee was.
that obvious answer is not a good one. when democrats got material gains for working people they controlled congress from 1933 to 1980 except for two years. getting rid of the filibuster and packing the supreme court to pass and see to fruition real material gains would make democrats the ruling party for the foreseeable future. they don't do that because that's not what they want.
The obvious answer isn't really applicable here, though it does cross the lips of plenty of moderates. The reality is that the Democratic party is forced into being a "big tent" party of "everyone left of the Republicans," which represents a simply massive spectrum, and therefore they have less consensus than the Republican party. Take, for example, Joe Manchin, a Democrat from West Virginia who drew some ire after FiveThirtyEight found he sided with Trump's priorities 58% of the time. He's been vocal that he would never agree to eliminate the filibuster, because he's basically a Republican in all but name.
As an international who is not as familiar with American politics (but wants to understand), why is this comment being down voted? Are the claims incorrect? Are they unsubstantiated?
As the person who wrote it, I'm not sure; I think this one of those things that's colored by opinion as much as fact. I would like to hear someone say what they think.
The bit about Manchin is fact, though. They can't change the rule without him, and he doesn't want to eliminate the filibuster. He did say that he would consider modifying it to make it more difficult, however.
It's being downvoted because it ignores the same issues on in the Republican party. Anyone who thinks either party is some monolithic blocks that all votes the same way hasn't been paying attention.
Manchin is doing theater to appeal to his voter base, who are indeed largely not in his party.
He's being far more cooperative than, say, Liebermann was while passing the ACA, and his actual goal is to say he's fighting those out of control big city liberals by keeping the filibuster, but the changes he'll allow will make it completely different and more or less how it was in the 90s.
Sinema also wants to keep it and seems to actually be a true believer, which is dumb and not even what her voters want, so who knows what's up with that.
I always forget about Sinema, which is something I need to stop doing because, as you say, she's probably the true believer.
I don't think we can be too charitable towards Manchin considering his other stances. That said, you raise a good point: changing the filibuster doesn't really change his position; he's still an essential vote to pass any legislation in a tied senate, so he benefits from either outcome. I suppose, all other things being equal, it makes sense for him to nominally oppose ending the filibuster for the sake of his base.
Because they're just as correct when you switch the labels.
With two parties both jockey for position in being as close to center as possible while still appearing unique. To leave the center is to sacrifice those voters to the opposition. This is why first past the post voting is stable yet nearly useless.
Democrats consist of actual liberals, marxists, authoritatians, etc.
Republicans consist of actual fiscal conservatives, the religious, libertarians, etc.
Both are unhappy alliances and occasionally fracture and spill one of these constituencies and the opposition rushes to appeal to them.
Obamacare has an annual out of pocket cost cap of ~$6300 on healthcare including prescriptions.
Sure, that is still pretty high, but it basically saved my life. If not for Obamacare I would need to come up with over 300k per year to not get very sick.
This isn't an either party is the same situation. One party would let me be seriously ill. One would give me a possible solution.
The problem is that it can always be taken away from you. Remember, the Affordable Care Act ruling is supposed to come out this summer.
I am on an orphan drug myself (subcutaneous immunoglobulin, which I am self-infusing at the moment...) which costed $278,000/year under contract, when I lived in the US. Of course the provider bills a much higher amount. But the figure I gave is the one that is paid out, over the course of a year.
You should know that the third leading cause of death in the US is believed to be preventable medical errors. This has been corroborated via multiple follow-up studies, just google "third leading cause of death US medical errors". But, here is the original article: https://www.bmj.com/content/353/bmj.i2139
You can go to the "best hospitals", have the "best insurance", and "be able to pay for care", but you cannot evade a statistic like that. The medical error rate is on par with developing countries, by the way.
Also, 7-8% of the general population collectively has some sort of rare disease, which is theoretically treated by orphan drugs. There are now orphan drugs that cost $2 million/year per person, and the cost is so extortionate that it is literally going to screw over the US health system. Such meds have to be taken for life.: https://www.nytimes.com/2019/08/25/health/drug-prices-rare-d...
Also, life expectancy does not look so good in the US.
US was 43rd worldwide in life expectancy in 2016. In 2040, we are expected to be 64th.
Honestly, this kind of stuff is why I emigrated and I am a dual US|EU (Croatian) citizen. As an EU citizen, I have Freedom of Movement rights to live/work/retire in 30+ countries within the EU and EFTA (minus Liechtenstein--has an immigration quota).
Because of your health status, Canada, Australia, and New Zealand are off limits because they have strict medical inadmissability clauses in their immigration laws. I would stay away from the UK too, because they could implement such rules post-Brexit.
But, I have studied healthcare systems, logistics of healthcare, along with rules for acquiring citizenship, for hundreds of hours. If you want any help or advice, feel free to shoot me an email (check my profile).
You know about the filibuster right? Republicans can filibuster (force infinite 'debate' though modern rules don't require people to actually talk during a filibuster any more [0]) anything they don't want to pass and it's up to extremely centrist (barely) Democrats like Joe Manchin if the filibuster remains. Without removing that it takes 10 Republican votes to stop debate on any bill.
There are some work arounds but they're limited to things that one person decides are sufficiently budget related enough to go through the reconciliation process that prevents filibusters. And that is a thrice a year option at most.
[0] I get why since senators have all sorts of commitments to their time even counting just Senate business but it means a there's basically no cost to doing one where there was.
To be clear, the Biden administration issued a regulatory rule freeze memorandum, and that's one of the things that was frozen. Has any decision since been made whether to implement the rule?
Worth noting that no one pays $1400 a month. Their insurance covers it, just like insurance covers you in Australia or Germany or Canada or anywhere else.
But then, doesn't that mean everyone with coverage pays for it?Insurance pays for it, and everyone with coverage pays for these high costs through high premiums -- public healthcare in Canada doesn't pay for drugs, and even without insurance the cost of those drugs tends to be substantially cheaper, at least in the few scenarios I've been exposed to.
I mean 225,000 Americans are on it, and multiply that by 1400 x 12, and you're already way past Truvada's global annual revenue. The numbers don't work out.
Americans do subsidize European and African prices though, there's no doubt about that.
More likely it means you pay (or more appropriately, your insurance company pays) the negotiated rate, which is often far, far less than the published retail cost of a medication.
Those big monthly $$s get investors excited tho.
This is to say nothing of the public / private debate.
There are millions of people with deductibles that are in the $2000 - $8000+ range, and even higher for family plans. Those people are certainly paying $1400 for several months until their insurance kicks in. Then, in the next coverage year, they get to spend that $1400 several times again, and they continue that pattern each year.
If their insurance doesn't cover it, they're also paying $1400.
If you are insured and look at medical bills in the US you generally see an obscene top line cost, a very large discount that the insurance company negotiates, and your personal copay. That discount doesn’t really seem to come from somewhere.
It costs quite a lot to take any given new drug to market (one study suggested a median of 0.985 billion, and a mean of 1.3 billion), and most of them do not make it. They must recoup expenses somehow, or go broke, and then ... no new drugs. To that end, they get a limited period of exclusivity over their invention.
Now, is this done efficiently? I don't know. Perhaps the FDA approval process could be less costly. Or we could limit litigation in some manner. And so on.
But they're sure not gonna churn out new drugs for the cost of some generics.
While I can appreciate that drugs _do_ cost money to manufacture, it does not mean that people should be expected to pay hundreds or thousands for a drug that is vital to their health.
The money comes from somewhere. You can make it direct or you can make it indirect, but it is still coming from one bank account or another.
Essentially, the US is footing the bill for the world. If you look at overseas pharmacies, PReP has been available (as are many drugs) at very cheap prices for quite a while now. Some countries just ignore the drug patents and go on their merry way. Our current method of accounting inside the US has people pay into insurance, which then pays out for these particular drugs.
Instead of making a smart-ass comment, I was prompted by your reply to look.
Some non-profit pharmas do exist, but it appears that they are largely focused on generics or orphan drugs. I have seen some press-release stuff on how some of them could work in drug discovery, but it was always a team-up with someone else, and I couldn't find what new drugs had actually made it to market from non-profit pharmas.
I suppose the only way to really prove this one way or another would be to select the last thousand drugs to market globally, note the country of origin and the company, and whether or not they were for-profit or not. Perhaps build out on that -- how much did it cost to bring that to market? How many failed per pharma?
So two valid arguments to have: drug discovery, & whether 'market incentives' give us cheaper & more drugs.
My main point is looking at this holistically profit is a huge % and a terrible incentive for both what drugs are pushed and trialed and how much they can gouge us to benefit their shareholders.
Gilead is 79%... More than 2x apple. [1]
That is ethically wrong.
Government already funds (most seems like this research article sats? [2]) early stage research e.g. discovery. Then the drug companies take the best looking candidates but they have gross incentives to pick the most potential profit, not the most benefit to society (like HIV a so far lifetime disease where our lives are dependent on this medicine) - why pay to research a prodrug or big stage 3 trial on a drug you cant make money on.
In terms of 'market incentive' on the manufacturing side manufacturing costs themselves are tiny [4] and if anything my intuition is it has a net negative effect on quality. these companies try to penny pinch and push the every lessoning government oversight to its limits & offshore production with dangerous JIT supply chains and single source failures. Plus Republicans refuse to allow the government to negotiate or 'interfere' with 'the market' in the name of 'market incentive' kudos to trump to buck the party though.
and it also seems setting up a non-profit is currently hostile by the system our government has concocted because of pharma lobby & their ad persuasion $ [3]
We had a president that addressed this but people didn't like that he sent 'nasty' tweets. then his successor overturned the order and we all celebrated.
Can you please stop posting unsubstantive and/or flamebait comments to HN? You started out with a good post (https://news.ycombinator.com/item?id=24915604), but since then have been breaking the site guidelines.
I remember him making a lot of noise about making insulin super cheap or giving us the best and cheapest health plan to replace obamacare, he had a full 4 years in office to accomplish this, including two years with complete control of congress. So what exactly did he accomplish?
Trump waited until 2020 to sign a bunch of fake healthcare EOs that had little chance of being implemented. What was he doing the previous 3 years on healthcare beyond trying to strip all of it away???
He only did this to distract from COVID and even when he wrote the EOs everyone said they were going to get jammed up in the courts forever.
I'm not going to play pretend about things trump really truly wanted to do but waited 3.5 years until the middle of a pandemic, and then never implemented.
OK, I'm legitimately curious to know more. I do remember him talking about "making insulin as cheap as water" or something like that, but can you point me to the actual executive order or bill he was trying to pass that dealt with this issue of lowering the cost for prescriptions? A source about Biden overturning whatever it was would be great as well.
I don't preclude Trump from having actually done something meaningful, but a lot of what he does is vain and self-promoting, so I could easily see this being a case where he tried to put something into effect that looks good on the surface but doesn't actually accomplish anything, or doesn't accomplish it in a sustainable way and thus would need to be revoked to prevent prices going up in the long term.
Interesting that the UK-based Independent did this reporting without mentioning that the NHS still hasn't issued approval for Truvada to be provided outside of trial programs.
Cost to the enduser seems to be the most important metric when you want people at risk to actually take the stuff to prevent the spread of a deadly disease.
I don't know anyone who's actually paying for PrEP here in the US because pretty much every provider's going to cover it, no? It's more expensive treat HIV than it is to prevent it, so if you're an at-risk individual your insurance doesn't want you getting it
Several insurance companies like UnitedHealthCare had to be sued into covering PrEP. Not many insurance companies are going to happily cover a medication that can cost ~$30,000+ a year to fill.
Even now, United is making it clear that they don't intend to cover new PrEP medication like Descovy even though the medication doesn't cause as much renal damage and failure as Truvada does: https://www.beckershospitalreview.com/payer-issues/unitedhea...
If you have a high deductible insurance plan, it is not going to be fun to pay for your first few months of PrEP entirely out of pocket. Many people are priced out of PrEP because of that, as are the uninsured and underinsured.
Exactly. It's like assuming everyone has a Mercedes, a smartphone, or a butler. M4A is also not a solution for universal healthcare because Medicare isn't very good: it requires multiple types of paid co-insurance, rations healthcare, and doesn't pay doctors enough to motivate them to help patients. Medicare is a bare-bones, half-measure that doesn't offer a healthcare system. The common refrain of "It's better than nothing" is an invalid rationalization to settle for substandard healthcare.
FDA, however, has a policy explaining that it typically does not object to personal imports of drugs that FDA has not approved under certain circumstances, including the following situation:
The drug is for use for a serious condition for which effective treatment is not available in the United States;
>> You are gonna die and they have something not in the USA that could save your ass
There is no commercialization or promotion of the drug to U.S. residents;
>> You are fine as long as you do not compete with US drug companies
The drug is considered not to represent an unreasonable risk;
>> This could literally mean anything. Who defines what unreasonable risk means? And you are comparing the risk of the unapproved drug with what exactly? You are certainly not comparing with the risk of death by not having access($$) to some drug you need
The individual importing the drug verifies in writing that it is for his or her own use, and provides contact information for the doctor providing treatment or shows the product is for the continuation of treatment begun in a foreign country;
>> Again you are forbidden to compete with US drug companies
and
Generally, not more than a 3-month supply of the drug is imported.
>> And even if the drug could save your life and it's not available in the US you still have to play this stupid traveling game every three months. I'm sure most people with chronic illnesses love to burn their money being forced to travel due to some arbitrary regulation
This is a huge problem in the US. Truvada must be taken everyday to prevent HIV, and in 2015, it cost $1400 for a 30 day supply. In 2021, it costs between $1900 and $2500+ for a 30 day supply in the US.
Elsewhere in the world, Truvada might cost $40. In Australia, Truvada costs $8 for a 30 day supply[1].
The only other drug approved for PrEP in the US is Descovy, which is manufactured by Gilead, too, and costs $2300+ minimum for a 30 day supply.
[1] https://www.independent.co.uk/news/world/americas/us-politic...