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.

But it is absolutely revolutionary if you have dry eyes. Quotes include "I feel like my eye is actually too wet now"

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.

[1] - https://fourthievesvinegar.org/

[2] - https://www.youtube.com/watch?v=5rQklSmI_F0 [video][1hr16m][DEFCON 32]

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

() Biden's inflation act gave Medicare permission to start negotiating drug prices in 2026. Who know what the current US Administration will do though.

</sarcasm>

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.

It’s totally fucked.

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

https://en.wikipedia.org/wiki/The_St._Regis_Mohawk_Tribe_and...

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.

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.

These things aren't broken. They are by design.