FYI for anyone who isn't familiar with the wacky US insurance situation: Nobody in the US actually pays $800 for the drug. That's the "list price" for insurance companies to pay. Even insurance companies don't pay that price because they negotiate their own rates with the drug companies, which are lower.
Then the drug companies come in and offer a "savings card" which you apply at the pharmacy like another layer of insurance. I searched and Miebo has one too: https://miebo.blsavingscard.com/ You'd have to read all the fine print, but it reveals that the actual cash-pay price is $225 (still high, obviously) and they have a co-pay assistance program that reduces your copay to $0 to incentivize you to get your insurance billed for this drug. So a lot of people who take this drug in the US actually pay $0 because they sign up for this card.
The FDA is partially to blame for this situation: They required a complete New Drug Application before they would let anyone bring it to market, even though it's over the counter in other countries.
The cost of performing a New Drug Application starts in the mid hundreds of millions of dollars range and can extend into the billions for some drugs.
So nobody could feasibly introduce it to the market here without investing $500 million or more up front. At that price, your only viable option is to stick a big price tag on it and try to milk that money back from insurers.
> FYI for anyone who isn't familiar with the wacky US insurance situation: Nobody in the US actually pays $800 for the drug. That's the "list price" for insurance companies to pay. Even insurance companies don't pay that price because they negotiate their own rates with the drug companies, which are lower.
This isn't really true on obamacare/ACA plans, even the high-end ones like gold PPOs. The formularies are much worse than employer-based plans. Insurers are required to cover one drug in each therapeutic category, but its usually an older generic. Most brand name drugs like this one have really bad coverage or not at all, which means the insurer won't even negotiate with the pharmacy to lower the drug.
Yes you can use coupons, sometimes, but the pharmacy can't always process them and the manufacture is always change the conditions and expiring them. I got one for my glaucoma drops directly from my eye doctor, and it was expired immediately when I tried to use it. I have paid $650 (for a 3 month supply, the full retail cost) for my drops when the coupon didn't work, and I couldn't get them any other way - I can't interrupt the med or else my eyes get damaged. So that falsifies your "nobody" assertion.
Anyone know what's going on with the ACA marketplace?
I like to take a peek at it every so often and it's just stupendously worse than employer healthcare. There is no plan in my market (Idaho) which doesn't have extreme out of network deductibles. The cost is also identical to what I and my employer pay for insurance.
Is it just that the ACA is mostly used by sick people or something?
For one thing, as I understand it, the ACA was pretty effectively sabotaged by removing the mandate, which destroys the math that makes insurance work.
Because pre-existing conditions have to be covered, you're free to wait until you have a serious (expensive) condition, then sign up for an ACA plan. And there's no mandate that spreads that risk around to healthy people, so the population is severely skewed.
I have no definitive data on this, but it seems self-evident that the system can't work well.
this is mostly right, but it's not true that you can just sign up at any time. there's an open enrollment period for the aca marketplace and if you miss it, you won't have the opportunity to buy health insurance until next year.
Even with the individual mandate, it seems self evident that incentives are for private insurance companies to happily take in the extra premiums from healthy people, and then drop or have prohibitively high premiums after people get sick. The medical loss ratio tries to mitigate this, but just kicks the can down the road where the incentive becomes to dump the money into administrative overhead and self-dealing with providers/pharmacies run by affiliated companies.
As a solo dev, I’ve been on ACA with my family for the past four years. In my market, a major insurance company is not returning for 2026 and the prices have gone bananas. Our premiums are increasing over 40%, all of our copays are more than doubling, and the deductible is astronomical. In many cases the cash pay price is probably cheaper than the insurance negotiated rate.
I’m the plus side, all bronze plans can contribute to HSAs next year.
We compared individual plans off market, but they’re mostly the same without HSA access or they’re targeting people with specific ailments (e.g. the diabetes plan).
On top of that, consolidation of hospital systems has made wait times for GPs months unless you’re lucky enough to find a cancelation. We have some older Canadian ex-pat friends and it seems like our health system has all of the downsides of socialized systems, plus we get to pay Cadillac prices.
I’m really hoping 2026 is so bad that something breaks enough to resolve some fundamental issues with private health costs, but I’m not naive enough to think it’s likely. ACA was such a monumental gift to someone, but it definitely not individuals who need family coverage.
It's because health insurance companies need to pad their profits. Because we have a backward system in the US where profits are extracted by everyone without any competition from a not-for-profit. That's why the idea of a public option is so popular (it was originally a Republican idea until it was decided insurance company profits are more desirable). Personally, I don't think any health insurance company should be for-profit. But the for-profit companies sure as hell should have a non-profit competition with the same bargaining power they do.
These "savings cards" have a maximum annual benefit applied to them so for those on insurance that do not cover those expensive medications or who are self-paying use up the benefits before year end and do in fact eventually pay full sticker price.
I was on a blood thinner and the medication was very pricey. Didn't have insurance and the "savings card" covered fuck all unless you had insurance. There are three blood thinners on the US market and they all cost a lot.
Warfarin needs blood tests at least every 2 or 3 weeks. I bet those tests are not cheap in the USA. Furthermore you can't have any food with significant amounts of vitamine K or its precursors. There are pills that cost more but don't require any of that. And actually they cost very little or zero, at least in my European country. Prescription only, of course.
If you don’t have insurance, you’re essentially fucked in the US but this thread is not referencing that situation. My CAT scan was billed for $10,000 but what I paid was about $200 with insurance. Without insurance I would owe $10k.
Why stop the conversation here? And if you don't have insurance but go to an ER (can't be turned away) and end up getting some expensive procedure you can't afford, you can just tell them that you're broke and they negotiate way, way down, or even just forgive it. And it's setup like this to ensure only people who have proper full time jobs or who can write a good enough sob story can get care. Because so many of the people in charge of this mess are far more obsessed with blocking out people they can't get enough data on or who aren't working, then figuring out reasonable public prices that make some effort to strike some fair market balance. So that if you have some savings and aren't employed, you are forced to find any job with benefits so you aren't left bankrupt, which makes taking care of health struggles harder as you have to work instead of take care of yourself.
This won’t work too well for most stuff. They don’t have to treat anything you present with, and don’t have to fully treat even e.g. a heart attack. They just have to stabilize you. So they can turn you away under most medical circumstances. Like you’re not going to get free chemo or (non-emergency) prenatal care or what have you. They also can triage you into the “maybe in twelve hours… maybe” group until you go away if you don’t seem like you’re dying, or likely to pay.
It’s priced that way because Medicare has to get the best price by law. Everyone else gets a lessor discount, with cash payers getting nothing by default.
It makes sense - the largest payer should get the best price. But it doesn’t make sense because it’s not really a market.
We’d have much better outcomes with a Medicare for all model, and then private insurance could actually be priced with an insurance model and be used as a fringe benefit again.
Was $10k before or after the insurance negotiated discount? Pre-discount prices mean nothing: I had the same tests ordered twice (needed the results urgently), once through my PCP/HMO and once paid to a walk-in doctor's office in cash. The cash price was $700. My PCP claimed a price of insurance $3500, who then negotiated it down to a "discounted" $710. So the worst of both worlds would have been a high deductible plan.
The way you have those loopholes and you have to watch out for them else you're on the hook for thousands of dollars is nuts. I mean, sure, you _might_ get a good deal or you might get completely screwed. This is absolutely not normal or fair. A society of gotcha's induces a lot of inefficiency. And as much as the US sometimes rails against inefficiency, it seems it's only a problem when you're not used to it.
Im 41 and haven't been to a doctor since I was 10. I have had insurance coverage my whole life. So technically I (my employer on my behalf I guess) have paid for many other people's services.
I have been a huge net positive for insurance companies. Other people get way more services than they ever paid.
Nobody in my family has any kind of crazy chronic conditions. A few surgeries, a couple of c-sections, a week in the NICU, a few short stays in some hospitals. We've experienced nearly half a million in healthcare benefits from our insurance companies over the years. I don't think I'm ever going to pay enough in premiums to cover these costs.
Depending on your situation, if non emergency and you were able to ask the cash price beforehand you might be surprised that you can get the same CT scan for less than what insurance ultimately paid. At least that’s my experience ($450 vs $1200). You may have to ask at a diagnostic imaging place, not the hospital since the hospitals can never tell you what anything costs they aren’t set up for it. (Of course I went through insurance since I didn’t want to pay out of pocket, but it was an interesting lesson in one of the reasons why healthcare is unnecessarily expensive in the US.)
The best thing about universal healthcare isn't how much money I may or may not have to pay, it's that I literally don't once have to think about a bill or filling out a form to avoid paying too much.
I wouldn't care if I ended up paying more in tax than I would in an insurance model. The benefit is being able to 100% focus on my health instead of navigating a system to try to reduce what I'm paying.
When you're diagnosed with an illness, that's a huge peace of mind.
Trust me it doesn’t work perfectly in other countries. Yes, americas system is messed up but in countries like Sweden you will still have to navigate the system to actually get the healthcare you need. There are people who are denied healthcare in Sweden because the govt has deemed that it’s too expensive to save them (while people with similar conditions and a good insurance in the US are covered).
Also inflexibility, large backlogs, quality of staff, etc.
In Canada all of our best doctors go to the US and there's often nurse shortages. It's not just a private incentive either, the US gov pays out far more in public healthcare coverage as a percentage of GDP and per capita than Canada and almost all of Europe.
Despite their reputation the US doesn't have a lack of public healthcare spending (ranking #1-3 in the world). It's just their system's insurance regulation is extremely convoluted, creating risky edge-cases and perverse incentives. If they fixed that they would by far have the best healthcare system in the world.
Most countries have both public and private. In Spain I have public and then private on top of that which 220 eur a month for a family of four all services included and no co-pay. The public option works to set a roof on what private insurance can charge.
> The public option works to set a roof on what private insurance can charge.
Exactly! This is what no one in the US seems to understand. My encounters with private clinics and hospitals in the UK (all 10+ years ago, at this point) were unbelievably luxurious, at prices that (totally, completely free-market driven, mind you) were affordable on middle-class incomes. Or, yeah: there's private medical insurance, also free-marketed to "shockingly reasonable", by US measures. Americans on good salaries have been bamboozled into believing that a single-payer system will trap them into some kind of hell-hole hospital° with no recourse, when in fact the exact opposite is true.
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°And, of course, the "hell-hole hospital" examples are cherry-picked. Bad on their own, of course, but not representative of a system as a whole, nor recognize that equally awful anecdotes are abundant in the USA.
Right, and in my country you can even mix and match it.
I went to see my GP, paid for by public health, they referred me to a specialist.
I chose to pay €100 to see a private doctor who was available sooner (the next day) and had better ratings.
They referred me for an MRI which was done at another private provider, paid for by public health.
I went back to the private doctor and paid for a non-surgical treatment, which wasn't available on public health.
If that doesn't work, later I can opt for surgery, paid for by public health.
And even more importantly: There is one system that tracks all diagnoses, treatment, medication etc used by both public and private healthcare providers, so medical history is available instantly to everyone.
Honestly one of my main healthcare related complaints about living in Canada is not having centralized health records. Sometimes Europe feels like living 2 decades in the future lol.
Unfortunately a lot of us do understand this, but our representatives (who definitely know this) don't care or are actively opposed to making improvements other than reducing taxes (which hurts more than helps, IMO).
And yet, the average American pays more in taxes for public healthcare (medicare, medicaid) that they don't receive any of, than the average European pays in taxes for (some kind of) universal healthcare.
It's so bizarre seeing Americans in the debate not wanting "crazy high taxes like in Europe", because the US already spends twice as much public money per capita as the OECD average.
The dirty secret of course is that healthcare as a good is much more expensive to produce in the US than elsewhere, and a large chunk of that is because the private insurance system adds a ton of unnecessary overhead. And yet all the healthcare insurance companies in the US talk about making healthcare "affordable for all". Yeah, no, they're leeches. They're rent-seekers. They drive up the cost of everything.
The US has a massively progressive tax system. On a net tax basis about 50% of the country pays nothing. Sure, they pay sales tax and employment taxes, but they also receive some mix of earned income tax credits, child tax credits, snap, medicaid, housing, etc. There is no real way for the US to have a single payer tax system without more people actually becoming net tax payers.
You can't just ignore the money people are spending on healthcare right now. Every expenditure on private healthcare (insurance, copays, etc.) would be collected as tax going forward. That would be roughly $10-$20k annually?
Many more people would become net tax payers overnight without actually spending more money.
Yeah this is something people in favor of single payer healthcare in the U.S. don’t want to acknowledge. In most other countries, the middle 50% of taxpayers pay a much higher percentage of their income than in the U.S. Everyone somehow thinks we can make it work just by raising taxes on “the rich” (where that is usually defined as anyone making more money than them). But if it was that easy, then why does Canada and most European countries have so much higher taxes on the middle class?
Now I’m not inherently against increasing taxes (for all) if it gave us a much better healthcare system, but you have to be intellectually honest about who would have to pay those higher taxes. It’s not just Elon Musk.
I'm curious what the actual number is. I have health insurance through my work and I pay over $1,500 a month for that (and still have out of pocket costs). That's $18,000 a year. That's a substantial percentage of my income which essentially is just a tax going to the insurance company instead of the government. Now if it cost a couple thousand more a year and I didn't have to worry about getting claims denied for random reasons, I'd take that deal. If it's $5,000-10,000 more a year? Then I'd have qualms.
The US spends more money on healthcare than any other country (per capita and in PPP-adjusted terms), with the lowest life expectancy out of all of its peers [1].
Make of that what you will, but that tells me that after cutting out all the corporate abuse and inefficiency, the average person should be spending about the same for similar standard of care, except without all the bureaucracy and stress.
While it’s true that the U.S. spends way too much on healthcare (more than any other country as you said), the fact that it has a mediocre life expectancy is almost entirely due to things that have little to do with the quality of health care. Much more driving than most other countries resulting in more auto accidents and thus deaths, way more guns resulting in more murders and suicides, etc. Drug overdoses, in particular opiates, are probably the biggest one than can arguably be linked to healthcare.
That's usually how it works for me in the US. I go in to the pharmacy, and at least half the time they say 'no cost' and hand me my medication. Sometimes I pay a $25 copay. And if I get an expensive drug from Eli Lilly (e.g. Zepbound) then Eli Lilly pays Walgreens up to $1950/year on my behalf and I never even know about it. The only way I figured it out myself was trying to figure out why my insurance said they paid X, and I paid Y, but I had actually only paid $25. Took a trip onto a Zepbound subreddit to learn about the backdoor payment thing. "Savings card" but not actually a card.
It's more efficient to allocate capital to systems and processes that delay or stop you claiming on your insurance than it is to actually pay out a genuine claim.
This has nothing to do with capitalism, and everything to do with regulatory capture and archaic rules established in a bygone era for a purpose that has since been outlived.
> FYI for anyone who isn't familiar with the wacky US insurance situation: Nobody in the US actually pays $800 for the drug. That's the "list price" for insurance companies to pay. Even insurance companies don't pay that price because they negotiate their own rates with the drug companies, which are lower.
Sure, we do not pay $800 at the pharmacy when we go to pick up the prescription, but every cent the insurance company pays, we are paying by proxie with added admin costs.
This varies wildly by medication; and makes a ton of assumptions that all happen to benefit the drug company's position/parrots their PR.
For example, my partner needs $100/pill medication, which also had a "savings card." That card only lasts for 12-months or 8-pills (whichever comes first). Then it is $100/pill. After insurance (High Deductible), we pay out of pocket $100/pill up until $3200. Insurance discount: 0%.
So the cash price and the insurance price are identical, except the insurance price counts towards deductible. UK price of the same medication? £10/pill, and that isn't via the NHS, that is full-price private (NHS could be as low as FREE, depending on several factors).
what about the poor people? the ones that can't really afford insurance. i've heard multiple times that epipen prices are crazy expensive and that's a really basic drug.
If you’re really poor, you can get Medicaid. It’s the working poor who earn too much for Medicaid who are really shafted. The ACA tried to fix that for as many as it could, by expanding Medicaid to households making more money; the Republicans shut down the government to fight that expansion. It’s maddening.
Gov shutdown wasn’t about medicaid expansion, which is done at the state level. It was about expanding ACA subsidies to those making more than 400% of the federal poverty level.
If you're poor you just wait until you're borderline dying and then go to the E.R. and get charged $120,000 and then never pay it and then have debt collectors calling you for the rest of your life.
Or you're on Medicaid if you live in a sane state.
There's undoubtedly a significantly lower cash price if you don't have insurance (GP mentions $225). The before insurance prices are meaningless; they're a negotiating tactic between pharma companies and insurers.
> The FDA is partially to blame for this situation: ...
> The cost of performing a New Drug Application starts in the mid hundreds of millions of dollars range and can extend into the billions for some drugs.
> So nobody could feasibly introduce it to the market here without investing $500 million or more up front. At that price, your only viable option is to stick a big price tag on it and try to milk that money back from insurers.
It's interesting that you seem so passionate about this because you're totally incorrect. The cost of a NDA for a novel prescription drug requiring clinical data (the most expensive application) is ~$4.5mil. In fact, the estimated TOTAL revenue to the FDA from ALL PD application fees in FY 2025 is ~$1.3billion (or, just under 300 novel prescription drugs). So, obviously, FDA fees can't be as much as you're claiming.
What you're actually describing is the total cost of the entire drug development pipeline (research, design, lab costs, chemical costs, application costs, marketing costs, etc.) to develop a brand new, novel drug. And it's only ~$200m, increasing to $500m if you include dead ends / failures in the process, and ~$900m if you include both failures and capital costs--yep, that's right the capital costs alone are almost as much as the entire rest of the drug development pipeline.
> So a lot of people who take this drug in the US actually pay $0 because they sign up for this card.
They do not pay $0 because the insurance company raises the rates for all of their customers to cover the cost of all the red tape and time spent negotiating with drug companies over their bullshit. The insurance companies aren't eating those costs, they're profiting from them and it's us who end up footing the bill. By the time you factor in the unnecessary time, staff, record keeping, etc. the actual cost for the $20 drug will be even more than the $800 sticker price.
No matter how our crooked system twists things to make it look otherwise they always make you pay. One way or another.
80% of prescriptions are controlled by 3 companies. You can look up the FTC report on it. All three of them own or are owned by insurance companies.
The insurance companies had their profit percentage capped, and so the only way they could increase profits was by increasing their share of the pie. So they bought medical providers and prescription companies.
Now the insurance company is both the buyer and the seller, but not the one who pays. We pay. So they raise the prices of the drug, raise the cost of insurance, and make a lot more money while staying in their profit percent cap.
All the way around, this is the opposite of a free market and the FTC should be breaking these companies up. And as everybody knows, all the way around, it is immoral, too.
It's a very interesting drug. There are a lot of concerns right now around PFAS in water supplies, for example, and Miebo/Evotears are pure PFAS (perfluorohexyloctane) that's instilled directly in the eye, giving you a dose somewhere around a million times higher than levels of concern in drinking water.
But it is absolutely revolutionary if you have dry eyes. Quotes include "I feel like my eye is actually too wet now"
That would be 1 liter of the active ingredient, not 1 liter of the eye drop. Also I don't believe that 1 ppt of this stuff is harmful when people are putting it directly in their eyes without severe harm.
Maybe, maybe not, maybe like teflon, the real poison is an intermediate ingredient, but I think its bullshit that we're just creating chemicals that linger in our water supply for eternity. You literally cannot find anyone in America without traces of the dangerous variant of the PFAS in their blood stream. Like every sip of water is some ridiculous dupont cocktail and we have to tolerate it because people have dry eyes and want non stick pans. Why cant you just use theratears?
Yes, but too slowly to matter. Average person consumes 1.5 liters per day of water, so if you live to 100 that's 55000 liters. At 1 ppt that's 1 ng / liter, or 55 ug over a lifetime. That's multiple orders of magnitude less than one drop of the stuff to your eye.
We will know after the drops have been out for over a decade, and actual real-world safety data studies get published.
Meanwhile, Restasis (cyclosporine A) (or a generic) works well, and doesn't have to be applied all day long, just two or three times a day. It does burn the eye initially, but it's not harmful, and the burning goes slowly away over time. It does take a few months to start working.
One thing you can be sure of is that the vats of PFAS being produced year after year for this drug aren't going away anytime soon. They're called "forever chemicals" for a reason.
Being dispersed in the environment is not the same as being concentrated into our drinking water supply with each measure resulting in 1ppt contamination of a trillion measures of water.
Largely firefighting foams, industrial and manufacturing, and landfill sources, but it's still an interesting problem. They don't really break down (that's why they're so useful both in a materials science sense and as a medication) which implies they'll stick around for an extremely long time.
You have absolutely no idea of what you're talking about. If you actually think the scare is overblown, I dare you to drink the whole bottle of that eyedrop.
> You have absolutely no idea of what you're talking about.
I do.
1. "PFAS" is a technically incorrect term.
2. It's ridiculously broad. Teflon is PFAS, sevoflurane is PFAS, and so on.
> If you actually think the scare is overblown, I dare you to drink the whole bottle of that eyedrop.
They literally use the same liquid to FILL THE EYEBALLS after retinal surgery. It's been approved for 25 years. A bottle of eyedrops has 4 milliliters of it, and it would do essentially nothing if swallowed.
I have punctal plugs. They helped quite a bit, but for most people with dry eyes it's the lack of the lipid layer that is causing problems. Not the lack of water.
Punctual plugs are not as great as cauterization for multiple reasons. Firstly, plugs keep dropping off and getting lost over time. Secondly, they probably won't seal the gap fully.
The lipid emission will heal partially if one supplements vitamin A (10k IU) softgel, omega-3 triglyceride ester, taurine, and at least 4K IU of vitamin D3. It will heal enough to work. The D3 in this dose is for freezing autoimmune degeneration.
I have severe dry eye and I never need any drops except if I am wearing contact lenses.
Before committing to plugs, I tried temporary plugs made of (essentially) collagen. They completely seal the tear ducts, and they were just as effective as my current plugs. And my plugs have been in place for 10 years so far.
> The lipid emission will heal partially if one supplements vitamin A (10k IU) softgel, omega-3 triglyceride ester, taurine, and at least 4K IU of vitamin D3. It will heal enough to work.
Omega-3 acids help a tiny bit, and I'm getting D3 and A from multivitamins. And I'm doing all other recommended stuff: eyelid washing, compresses, IPL, etc. Over the years, I tried discontinuing all of that a few times, and my symptoms worsened as a result. But not by much.
PFHO is the most effective "artificial tears" type product. Nothing comes close to it.
Here we go again with the PFAS. It is the stuff to prefer the least, not the most.
> I'm getting D3 and A from multivitamins
That fails completely because they almost always don't have softgel oil-dissolve forms or the right dose at all. They're generally very far from it. It is exactly what leads to the autoimmune issue of dry eyes in the first place.
> That fails completely because they almost always don't have softgel oil-dissolve forms or the right dose at all
I tried tons of forms. My current ones are gel-filled capsules. Rather large ones, at that.
Sorry, but there's a huge amount of scholarly literature on this question. I've read tons of it over the years, and there is NO magical supplement that does anything but mildly improve the situation.
Visomitin (Emoxipine/Mexidol) eye drops are a Russian-developed antioxidant medication known for treating dry eyes, fatigue, radiation damage, and improving vision, working to protect eye cells from damage (oxidative stress), but it's not widely available or FDA-approved in the US, requiring international purchase or specific prescriptions, often used for cataracts or post-surgery recovery, focusing on cell protection rather than just lubrication like many Western OTC drops.
> Visomitin (Emoxipine/Mexidol) eye drops are a Russian-developed antioxidant medication known for treating dry eyes, fatigue, radiation damage, and improving vision
I wouldn't recommend it. A quick search shows that it's not proven to do anything at all but it's also advertised as being the cure for parkinson's, asthma, back pain, high cholesterol levels, anxiety, blood clots, glaucoma, and Huntington’s disease while also making you smarter and improving your memory. This sounds like classic snake oil. Something I'd expect to see being sold alongside Horny Goat Weed and kratom at a gas station rather than an actual medication dispensed by a pharmacist. As fucked up as the American healthcare system is I guess you really have to hand it to Russia sometimes.
I'd happily be proved wrong, but all the usual red flags are there. About the best that can be said for it at the moment is that there doesn't seem any more evidence that it's harmful than there is for it being helpful. Hopefully it gets the research to back up the claims. It certainly purports to be effective for conditions there's plenty of interest in developing effective and safe treatments for so you'd think that nations around the globe would be eager to look into it.
If a drug isn't one of the following it should be available over the counter.
1. heinously addictive
2. incredibly dangerous when not used exactly correctly
3. an antibiotic (due to the resistance externality)
And for drugs that do meet one of these conditions, doctors should be able to write lifetime prescriptions for cases where the medication is used to treat a permanent condition. This probably covers 95% of non-antibiotic prescriptions. The savings from removing the gatekeepers in terms of time and money would be massive and the costs would be minimal.
What a brave thing to say on a message board which thinks having a conversation with a chatbot should be illegal lest you ask it how to deal with emotions.
It’s very simple. In the US your pharmacy has a contract with the drug supplier that prevents the pharmacist from telling you that you could buy the drug without insurance for $10 while he charges you the $20 copay. As long as this is legal and your pharmacist’s duty isn’t to you the patient, don’t waste time worrying about the details.
I am grateful to every pharmacist / pharmacist assistent who's sotto voce ignored that immoral "rule".
On the flip side, before I transferred my prescriptions to my (excellent) locally-owned small pharmacy, I checked that these are drugs on which the respective Pharmacy Benefits Manager allows them to make a profit rather than a loss. That reminds me that I'll need to repeat that conversation when our insurance changes in January.
Theoretically speaking how much would the components cost if one made it themselves? [1][2] My interests are purely academic as I have no need for this.
According to another comment this product is pure 1-(perfluorohexyl)octane [1]. There's no practical way to make it at home, but it can be had for $980-$750/kg from an industrial supplier, depending on how many kilograms you commit to buy at once:
Add analytical lab services to analyze it for purity and you could still get a lifetime supply for the price of a couple of brand-name bottles. This is the sort of thing that some Americans have been doing to get cheap GLP-1 peptide drugs from overseas too.
However, it’s not all roses. Try getting melatonin in the UK. You can buy it almost anywhere in the US. Same for any first generation antihistamines. Or a jar of painkillers - packets are limited to 16 here. Or lidocaine cream. Whenever I go to the US, I have a shopping list to restock our medicine cabinet.
You can get larger packs of painkillers OTC by speaking with a pharmacist (OTC in the literal sense) or ordering online. For example, Boots sells a 96 count 400mg ibuprofen.
> Whenever I go to the US, I have a shopping list to restock our medicine cabinet
Ha, that's funny, I do something kind of like that when I go to the UK. Though it's just one medicine -- Kwells. Easily available OTC there, not available at all here in the US except as a prescription-only transdermal patch.
Aha! I have heard Americans say they buy Buscopan for IBS when in the Uk as it’s not available at all in the US and it has the same active ingredient! I had no idea it was good for nausea too.
I think Buscopan is different. Apparently hycosine hydrobromide (Kwells, Scopolamine) can cross the blood-brain barrier, while hyoscine butylbromide (Buscopan, a derivative of hycosine hydrobromide) cannot. The effect on the body seems pretty dissimilar.
That's a very selective example. The US controls TONS of hormones, Melatonin just got grandfathered in. If anything the UK system is more self-consistent than the US, even if I think both systems over-protect hormones with a low risk profile (like Melatonin in the UK).
As a counter-example, up until fairly recently you could buy Co-codamol (codeine, an opioid) in the UK off-the-shelf (i.e. no script). Which is a controlled substance.
See how people can use selective examples to play the "one system good, one system bad" game?
I wasn’t playing a game, but if we must, you can buy jars of naproxen off the shelf in the US as well - prescription only here. And antibiotic ointment, antitussives, antibiotic eye drops, and benzocaine throat spray, just to pick what I see in our cabinet. I only share my own experience though, but I find US pharmacies to be streets ahead in both variety and depth. If other people have other experiences, that is fine and I believe them.
One big benefit, though, is you can legally import or bring in POMs from overseas, a luxury the US does not have.
In terms of access to drugs, the differences between countries is incoherent, not really a "good vs bad" situation. A lot of it has to do with the different ways nations fumble their endless (yet fruitless) attempts to limit abuse and recreational use.
But in terms of cost, the US system is bad. If we as a nation want to invest in drug development, we should do so. Instead we ask grandma and grandpa and the chronically ill to flip the bill. Hard to think of a worse approach.
I save my shopping list for Puerto Vallarta where I'll buy a small amount of benzos instead of battling it out with a US doctor for a prescription. But don't try that in Guadalajara - it's in the same state but the restrictions are far stricter.
And if you're a fan of Benadryl (diphenhydramine), don't expect to buy it in Latin America. It virtually doesn't exist.
This ear drops solution, which is a general purpose ear drop for ear pain and irritation, can be bought over the counter in any medical shop and costs Rs. 15 in India (0.17USD). 7 years ago, when I last bought it, it was under Rs. 10 in India.
https://www.1mg.com/drugs/ciplox-eye-ear-drops-197483?srslti...
The equivalent of the same in the US, I was told 200USD in the US using Insurance, and I bought it for 40USD via GoodRx App without Insurance.
https://www.goodrx.com/ciprofloxacin
What's to stop congress from passing a blanket "most favored nation" law for VA + medicare on all pricing, inclusive of insurance rates and discounts? Seems like it would be fair and useful.
This exists throughout government procurement and it is part of the reason list prices are so high.
The overhead of selling to the government is significantly higher than selling to private companies. So the government simultaneously demands the lowest price while having a much higher cost of sales that needs to be covered by that price. A price that would cover the cost of selling to the government would be non-competitive if selling it to a private company because you may be competing with other companies that don't have to anchor their prices to the cost of doing business with the government.
To work around this companies post a very high list price, no lower than what they charge the government as required by MFN regulations. They then effectively steeply discount those prices when selling to other entities via various mechanisms to more accurately reflect the lower cost of sales. The list price is a fiction required to satisfy "most favored nation" pricing laws, no one is expected to pay it.
tl;dr: In many cases the basic economics requires the government to be charged more than average because they are expensive customers with high overhead. MFN regulations don't make this reality go away so companies have to creatively structure their pricing to satisfy regulations without requiring non-government customers to pay for government overhead.
"Most favored nation" is to the Trump addled brain like sugar water to a bee. It sounds vaguely like "Go USA" while having nothing to do with the actual problem at hand. Just wait for those 400% 500% price reductions to kick in then. The problem is the fuckup that is your domestic healthcare market, not anything to do with international trade.
There is a weird thing Americans often do when confronted with the incredibly high price of medicine and medical care in the US of imagining that every other country is actually responsible for this (hence the "most favored" nonsense). That it's zero sum and every other country is laughing and taking Americans for a ride and underpaying, and therefore Americans have to cover the bill.
This is the angle Trump has taken in some of his incredibly ignorant and stupid screeds on this topic (as with every single position he has on anything): Get everyone else to pay more and somehow the US pays less!
This...isn't at all how it works, or what the problem is. Americans pay more because of the whole massive scam of your Medical Insurance Racket, where everything has imaginary inflated prices and an absolutely massive middle-tier of suits having nothing to do with medicine are taking their cut. This is your problem, reflected almost nowhere else on the planet, and it is domestic caused and will need to be fixed domestically. Criticizing Europe or Canada or anyone else will never, ever fix the utterly, insanely broken and profoundly stupid American system.
But it won't. It's simply incredibly how easily Americans can be fooled into voting against their own best interests, year after year.
And Medicare cannot negotiate drug prices until 2026 (). Medicare is also banned from re-importing drugs from other countries (ex Canada) at lower prices. Thank you president GWB, the Alliance to Improve Medicare, and AARP (!!!!) https://pmc.ncbi.nlm.nih.gov/articles/PMC1126891/
() Biden's inflation act gave Medicare permission to start negotiating drug prices in 2026. Who know what the current US Administration will do though.
"Before insurance" prices aren't real! The headline is misleading; the first sentence of the article is misleading. It drives me crazy. Most Americans absolutely do not understand how insurance works and journalists do their damnedest to keep it that way by constantly misleading them.
The drug in question is perfluorohexyloctane, which is part of a class of substances known as PFAS or „forever chemical“. I‘m a chemist, I love modern medicine and material technologies based on chemistry, and I don’t hesitate to take vaccines or other meds, and I also happen to have SEVERE dry eyes syndrome - but hell no, I’m not going to put that stuff into nature!
The volumes in question are milliliters per month. And perfluorohexyloctane has been used in much larger quantities for intraocular fluid replacement for about 3 decades without negative side effects.
Precisely. Just because a medicine is an approved medicine increasingly shouldn't automatically mean that any sensible patient should ever use it. The PFAS in question is not even short chain, it is medium chain, which means it's likely to accumulate inside the body, albeit at a slow pace. One doesn't even have to be a chemist to know these things.
As someone mentioned already, list prices are completely fictitious. Their purpose is to anchor medical payers during reimbursement negotiations and satisfy PBMs (see below).
The allowed price (the price that the payer pays to the drug company) is much, much lower, 70-90% or so in many cases. Thus, juxtaposing OTC and list price is not an apples-to-apples comparison.
That being said, US drug prices are 2-4 times higher than they are elsewhere. In fact, the US market essentially subsidizes international drug markets, where it is much more difficult to charge higher rates due to regulations and lower purchasing power. This also means that, even if the allowed price in the US were known in this example, it would still have to be PPP adjusted to be compared.
Prescription card coupons such as those you get from GoodRx et al apply only to cash prices. These are sometimes lower and sometimes higher than what you’d pay out of pocket with your insurance. to compare, you’d basically have to ask the pharmacy to ring up a drug twice, once with cash price + coupon and once with insurance price.
“Copay assistance” are programs by drug manufacturers, PBMs, or employers to defray the cost of drug prices. This is usually done for specialty drugs that are much more expensive and can often only be purchased from a mail order pharmacy designated by the payer. For example, United Health (left pocket) will only cover the drugs if you get them from their Optum Specialty Pharmacy (right pocket).
As for numbers, here an example: I’m receiving a monthly specialty drug that my insurance is billed ~$9,000/month. In order to arrive at that figure, the drug company proposed, say, a $50k/month list price, and my insurer countered with $9k, using the size of their member pool as leverage. Of course, the drug manufacturer knew they would arrive at approx that figure, which is why they started negotiating that high. Well, sorta. The PBM gets compensated based on a % of the “savings” (spread between list price and final price), so naturally, they want as high as possible a list price, because 5% of a big amount (in my example: $50k-$9k = $41k) than 5% of a smaller amount. Because the PBM often has most of the leverage, the drug manufacturers (most of whom actually dislike PBMs) have to go along with this stupidity.
How much of the $9k I pay depends on a variety of factors, including my insurance plan, which has a specialty drug tier. This means the drug is not handled via the cost sharing accounting mechanism (deductible/copay).
Now, through that specialty tier, my monthly responsibility is set at approx $1,300. I’m not privy to the math behind this, because my insurer has outsourced all drug-related administration to a PBM, which is only loosely regulated and doesn’t even have to issue explanation of benefit statements that would normally disclose the full accounting.
Of the $1,300, I pay nothing, because the drug manufacturer provides me with a copay assistance card. Again, they must keep the list price high to placate the PBM.
I’ve simplified a few things here. For instance, there are now alternative comp models for PBMs. But for those, PBMs have also found ways to manipulate the system in their favor (eg colluding with drug manufacturers). There’s also often a wholesaler involved in the “value” chain.
But by and large, this is roughly how it works…
And yes, individual market plans are substantially inferior. Not only do they have lower actuarial values and higher cost per $ of coverage (which is unavoidable, because they are not risk pools) and narrower networks, but they also usually have built-in mechanisms to further prune away coverage in many subtle ways (they have that in common with self-insured plans):
- more prior approvals,
- “step therapy” (must first not tolerate cheaper drugs before can receive pricier drug),
- not covering the pricier drug tier at all, etc.
These things shave some dollars off the premium, which appeals to price-elastic consumers and employers.
Such an easily debunkable line with even the tiniest bit of critical thinking.
You’re basically saying the drug companies subsidise a loss in Europe by over charging Americans, right?
As the drug company is a private and doesn’t have to sell everywhere, why wouldn’t they just skip the loss making Europeans and just sell to Americans? They’d make more profit that way!
That must mean they make some profit from the European prices, otherwise they wouldn’t be bothering.
It's a bit more complicated than that. R&D for new drugs is incredibly expensive while the cost to actually produce most drugs is reasonably low.
The price of drugs that make it to market needs to not only cover the cost to produce the drug, but also the cost of R&D and the cost of R&D of all the drugs that fail to get to market.
Now this gets complicated when a company sells in different markets with actors that have different negotiating power. It makes sense to sell in any market where the company can get a profit per unit sold without including R&D. But if none of the markets allow enough profit to cover R&D, then it's not really worth developing any new drugs at all anymore.
That's why people say that the US is basically subsidizing drug development. It's not that it's not profitable to sell in the rest of the world, it's just that margins are much lower which allows for a lot less risk-taking on R&D.
> You’re basically saying the drug companies subsidise a loss in Europe by over charging Americans, right?
No - once they know how to manufacture a drug, it's dirt cheap for them to do so - they're still making a profit in Europe. The purpose of billing Americans a huge amount (other than they can get away with it), is to fund the research + trials for the next generation of drugs.
Of course, even this argument doesn't hold water. I remember when pharmaceuticals spent more on advertising/marketing than on R&D (may still be the case).
Drug costs are dominated by the fixed costs of development. $20/dose may very well cover the marginal cost of production while being far too little to make the overall venture profitable.
Drug companies net profit margin is 2x that of a typical company. EU and America have equal size populations.
Back of envelope, if the total cost of that drug went solely to profit, and profits were cut in half, it would cost $200 for both Europeans and Americans if we paid the same price.
So yeah, we are kind of subsidizing the lower prices for Europe.
The whole medicine industry in North America needs an overhaul. Canada isn't better. The ER delays aren't because of anything but a (intentional?) convoluted process that causes them. Same with prescriptions. Why aren't pharmacists allowed to issue them? Why not even utilize AI (which is superior to any human when it comes to memorizing and correlating, both essential in diagnosis) and have a human to double check it just in case? The reason is obvious. It's lobbying and gatekeeping, from making it hard to become a doctor, to the pharmaceutical industry profits, insurance, among many others, to simply "monetize" every single step of the process and profit off people's misery.
Yeah, but in the US I can buy pseudoephedrine over the counter and the sky doesn't fall. Believe it or not French regulations, but there's no epidemic of strokes among sufferers of the common cold. Yes, the US system is broken in places, but at least it's a lot less boneheadedly paternalistic about availability of obviously safe drugs.
There is no free market at play here. This is the result of FDA regulations not allowing anyone to sell it unless they did a New Drug Application first, which could cost a billion or more. Therefore nobody in the free market was allowed to sell it without putting up the capital first, which they have to collect back now.
You could actually order this from amazon.de up until recently and have it shipped to you. That seems to have disappeared, though.
This is true. When you look at actually free markets -- like the gray markets in bodybuilding drugs, "nootropics," peptides, etc. -- you'll find that there's usually a race to the bottom on price, and that everything is easily affordable out of pocket. Quality also tends to be okay, as lab reports are one of the primary ways that customers rank and differentiate between brands.
And these aren't necessarily old pharma hand-me-downs. There are lots of novel and strange drugs (9-MBC, lol) that you can buy for next to nothing.
> There are lots of novel and strange drugs (9-MBC, lol) that you can buy for next to nothing
Indeed, plenty of peptides that aren't really well tested in humans (in some cases, like at all). And some that have tests in foreign countries but are not recognized by the FDA (like Selank and Semax, which are nootropics). And if you want to get ahead of the curve, you can buy things like retatrutide already even though it hasn't quite completed Phase III tests yet so Lilly isn't able to sell it to you. If you hunt a little, you can even buy orforglipron now.
It is quite fascinating to watch. A lot of people are very willing to experiment on themselves. And it seems like GLP1s end up being a gateway drug -- people go to the gray market to get it cheap, and then they cave to temptation and try some of the other stuff they can get the same way.
That's not true, most of the gray markets you have to be careful with the quality of the product. Also, there are regulations on Europe, like with insulin but in USA is much more expensive than in Europe.
An easy, somewhat expensive (if you do not know the trick) entry point that is easily accessible to anyone is nexaph.com. You can pay full retail (quite expensive) or go to their Telegram (listed at the bottom of their page) and wait for a pre-sale, where it'll be a little above half the price on the web page.
Still more expensive than the rest of the random Chinese vendors, but the upshot is that participation rates are very good for Nexaph and so there's a lot of testing done -- especially for GLP1s. For example, the current batch of Tirzepatide 60mg will have a 3- or 4-vial COA done by Nexaph themselves, another 3-vial random sample tested by customers (but then compensated by Nexaph), and at least one and maybe two big group tests with 7+ vials doing a full range of mass/purity/endo/sterility testing.
I've not seen too many other vendors that get such a high participation rate. And even for this company, for non-GLP1 peptides it's still tested pretty well but not to the same extent.
Even at their expensive price point, you could buy a few kits (10 vials ea) and pay $1000 for a full suite of tests and still be into it about $80/vial total, where a vial is ~65mg and lasts most people at least a month. Do the math on that -- compared even to cheap compounded tirz it is a fraction of the cost. There is good reason why a lot of people are taking that route now.
And back to your original question - once you are on the Telegram group, ask around and people will invite you to other Telegram and Discord groups for various vendors.
Or go to glp1forum.com and a lot of the same vendors will have posts there with information on contacting them.
Drugs and healthcare products should definitely be regulated so people get quality products with provable efficacy. Saying that, how the hell does an application for a new drug with the FDA cost $1Bn?! Clearly something is wrong there.
I costs $1 billion because the FDA requires an enormously expensive 3 phase trial program before you are even allowed to submit the application. There is no way to make this cheaper without relaxing the requirements.
Require phase 1 only. That proves safety, but not efficacy. Require the companies to publicly release all data from their evaluations to the public. It's my right to decide on the risk / reward tradeoff, not some worthless bureaucrat to decide for me.
I know, the problem with drugs in USA is the control a few corporations have over the politicians and the market, that's the reason health care and all related things are so expensive there compared to Europe.
out of curiosity, how much would this drug cost in Europe if they had required prescriptions as well
the article does a good job of showing the self serving double speak and the lack of pursuing an OTC option in the US, but I want to compare costs directly, since the article also acknowledges that OTC would have been much cheaper than $800 in the US too
Europe doesn't have a single health service. There are going to be different prices in different countries under different schemes.
In my EU country I get a subsidy of at least two thirds on most drug prices with a state prescription. But the nominal cost is already negotiated down by state purchasing, and I suspect there's some EU cooperation there. So it's impossible to say what the "normal" price would be.
The cost of the paperwork depends on your doctor. I pay €3 for new paperwork a few times a year.
You can get many drugs OTC here without a prescription - more expensive, but it always surprises tourists who suddenly discover they can get many common meds (except for things like antibiotics and steroids) just by asking.
Why is it eye medication seems to be the market with the slimier moves? Sudden memories to when Allegran sold the patents for Restasis to the Awkwesasne-Mohawks to try to protect it with soverign immunity.
in some part of europe, we have national healthcare so basically people don't think they are paying their medications, like there was some magic money.
in that case, you don't care if you drug cost 10€ or 2000€ because you aren't spending a single € from your own wallet, at least if you don't factor in taxes.
Contrary to the USA where it's a much more responsible market, people do pay for the medications or they get it paid by their own insurance but it cost them directly a lot of money.
I would think that americans would be much more vigilant about what medication they take, the price it cost, and so would have much lower pricing. That's just how free market work, and technically there are many medication manufacturer and many customer.
Is it the proof that a true unregulated free market doesn't work ? if left unsupervised, big companies are going to buy smaller companies until they are monopoly or make secret, behind the door, deal to keep price up.
It's what the USA is made on, the idea of freedom and free market. i believe the idea of unregulated market is more recent, think the 70's, but surely in the 50 years since then american would have pushed back against it and not elected people like Trump who are all in.
> I would think that americans would be much more vigilant about what medication they take
This is why I always check to make sure it's fiscally responsible before I start chemotherapy, or before buying that emergency inhaler for asthma, or before accepting paralytics and anesthesia when undergoing surgery. How fortunate that in America diabetics have the freedom to die rather than take overpriced insulin. Let the free market decide which child with leukemia deserves a bone marrow transplant and which deserves a casket! That's a much more responsible market than just having everybody chip in a small amount so that nobody needs to worry about the cost of the medications they need to live. Sure, in America millions will die or be bankrupted by healthcare costs every year, but that's better than spending a single $ from your own wallet if even a tiny fraction of it might help pay for someone else's medications right?
I mean you're joking but there are maybe ~20 brands who produce and sell inhalers. Maybe I need the inhaler but I also have a certain amount of choice, and presumably some are more expensive than others. Insulin is a famous example, because you can buy a vial for ~$30 or a nicer one for $300. They all effectively do the same thing but there is a quality difference between them, usually in regards to release time and how often you'd have to take it.
There are some market pressures in healthcare when multiple companies can compete, although it's so heavily regulated it can be hard to see the market pressures in practice. Consumers often do have some amount of choice though
> I would think that americans would be much more vigilant about what medication they take, the price it cost, and so would have much lower pricing.
> Is it the proof that a true unregulated free market doesn't work ?
The market is heavily regulated (frequently crazily) by the FDA, and the actual amount anything costs is heavily obscured from the eyes of any consumers by the fog of bureaucracy and insurance.
Many people have 3-4 tiers of fixed copays that the insurance company makes up - some pharmacies won't even tell you when there is a cash price or a "coupon" that would be cheaper than your insurance copay! And pharmacies don't publish a plain list of what the cash prices are, and it would be hard for most people to even produce the tier formulary, it's buried as a PDF in some obscure page of a horrible website. So we just go to the pharmacy and see what it'll cost us.
Also, one major insurer owns a major pharmacy benefits manager and one of the big 2 pharmacy chains, so they use that to put their thumb on the scale however they can, while the other insurers and PBMs play games to lock consumers into restrictive exclusive deals that are to their detriment.
Anyway we don't have a market at all when it comes to healthcare, because the majority of price information is withheld from consumers until the opportunity to make any choice, if it even existed, is well past.
> Contrary to the USA where it's a much more responsible market, people do pay for the medications or they get it paid by their own insurance but it cost them directly a lot of money.
That's the idea, but in practice there are so many layers of indirect government incentives, disincentives, and direct interventions that market is no longer effective for this purpose.
It's virtually impossible to find out how much a medical procedure actually costs. Most hospitals and clinics refuse to even estimate as a policy, which has led to the creation of things like pre-paid services for labor and delivery. Those are quite rare.
I'm 100% in favor of allowing the market to work - but at this point, we have the worst of both worlds and the best of neither. Either extreme would be better than what we have.
Americans pay multiples more per capita, and receive worse healthcare based on outcomes compared to European nations. The UK on average has better oral health than the USA, but Americans love to joke about British teeth... I think the US believes it's own "free market" propaganda too much. Clearly socialised universal healthcare (which every G20 nation does outside the US) is a better system.
You're painting with a fairly broad brush. Opinions in the US are diverse, and generally more in support of socialized healthcare than against.
We're not far from half the US population having what amounts to universal healthcare already, even without making it official. I sometimes wonder how high it will get before people come to the realization that we're already close enough to that point and going the rest of the way is viable.
Part of the problem is that the way our healthcare system is setup, it's not even a remotely free market. It's pretty much a worst of all worlds situation.
It does not work that way, though, because as a practical matter, the majority of routine medications in the US are generics now and quite cheap, maybe $25 out of pocket (and frequently zero) with even basic insurance. The crazy prices happen for the edge cases. Things that happen often enough that you may know someone affected by it, but are still a minority of most people's experience.
> I would think that americans would be much more vigilant about what medication they take, the price it cost, and so would have much lower pricing. That's just how free market work, and technically there are many medication manufacturer and many customer.
(Not american) This assumes they have a choice, no? Do these medications have real alternatives?
> in some part of europe, we have national healthcare so basically people don't think they are paying their medications, like there was some magic money.
Europe is a big place, buddy. Which particular part are "we" from today?
NHS England has NICE (National Institute for Health and Care Excellence), which does the cost-benefit analysis for all medicines prescribed, nationally. It frequently decides medicines aren't worth the money. If you, as a private citizen, want that particular medicine, you can waste your own money on it. NHS England does not have a moral hazard problem.
The NHS also spends money trying to convince people to exercise, eat well, lose weight, not smoke, look for early signs of cancer, etc., because they find that relatively tiny amounts of money on these campaigns results in massive, massive savings from not having to treat so much preventable disease later in life.
i think healthcare is one market where capitalism just doesn't work well at all. for those areas, it actually makes sense to introduce hard or soft price ceilings.
> Contrary to the USA where it's a much more responsible market,
This is satire? I can’t tell anymore.
I mean the USA is the only country where someone can allegedly murder a healthcare executive for denying treatment and popular culture is engaged in drooling about how well the alleged killer fills out a tailored shirt.
The US is a GDP ponzi scheme disguised as an economy. The silly prices exist to shuffle money between pharmaceutical companies, PBMs, insurers, pharmacies, hospitals, and who knows what other intermediaries. Everyone takes a cut and can put large revenues on their balance sheet.
The US today is structurally dependent on this sort of cash migration. If all Americans suddenly began to save 10%+ of their income every month (also structurally impossible for most), GDP would dramatically contract.
Then the drug companies come in and offer a "savings card" which you apply at the pharmacy like another layer of insurance. I searched and Miebo has one too: https://miebo.blsavingscard.com/ You'd have to read all the fine print, but it reveals that the actual cash-pay price is $225 (still high, obviously) and they have a co-pay assistance program that reduces your copay to $0 to incentivize you to get your insurance billed for this drug. So a lot of people who take this drug in the US actually pay $0 because they sign up for this card.
The FDA is partially to blame for this situation: They required a complete New Drug Application before they would let anyone bring it to market, even though it's over the counter in other countries.
The cost of performing a New Drug Application starts in the mid hundreds of millions of dollars range and can extend into the billions for some drugs.
So nobody could feasibly introduce it to the market here without investing $500 million or more up front. At that price, your only viable option is to stick a big price tag on it and try to milk that money back from insurers.
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