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.
The individual mandate merely guaranteed a captive audience for health insurance companies. That doesn't do anything for cost. What drives cost is the ACA limiting profits based on the cost of care, thus more expensive care equals more profits. Can you see where this is going?
Five states plus DC still have an individual mandate (ugh), and yes health insurance premiums are spiking there too. A large part of that is due to the tax credits (generously labeled subsidies) expiring – even with an individual mandate health insurance is prohibitively expensive.
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.
Most (and the biggest) BCBS licensees are for-profit. Kaiser is not but is still eye wateringly expensive. For me, a silver plan will be about $700-800 next year. And then you take a look at what a bronze plan covers…
This is correct. BCBS is for profit and most others are. Kaiser Foundation Health Plan is one of the few not for profit insurances and only available in 8 states.
Yeah, some individual states do have not for profit, and it does help. These are the vast minority of states. That's why it should be available nationwide as a public option.
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).
That may be, but I'm speaking from experience in my country.
Almost 10 years of treatment for a health condition, and the only forms I've ever filled in were:
1. Legal risk document to say I understood the risks of treatment
2. Change of address form
3. Form to say I wouldn't impregnate people while on a certain medication
And honestly, that's it. I've genuinely been able to focus on my health without being bothered by forms.
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.
My mum was diagnosed with stage four lung cancer. Almost three years of radiation, chemotherapy, trail drugs, appointments etc. free transport and accommodation at the major city four hours away when required.
Insane prescription drugs that seriously raised the eyebrows of the pharmacist every month.
Never paid a cent, never had a single call or piece of paper for logistics or payment or any of that bs.
She was a teacher her whole life, middle class, no private insurance ever.
It can be, and is, phenomenal in countries that do it right.
All of that happens in the US, the big difference is that if you get care you stand a good choice of going bankrupt. The largest single reason for bankruptcy in the US is medical care and of that group the largest chunk is folks who previously had insurance but no longer do.
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).
Not limited to healthcare btw. This is also how I feel about my public transport card, unlimited data on my cellphone plan, and so on.
I'll take a queue over bankruptcy any day. And these queues people complain about are triaged - if you're dying you skip to the front. The complaints about waiting hours are from people with broken arms, and at least they get seen and their arms get fixed, for free or a nominal price.
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.
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.
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.)
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.
> 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.
I guess it depends on how you define “poor” and “uninsured”. Considering most of America offers Medicaid expansion or ACA plans, being uninsured is basically a choice.
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.
You do typically pay for insurance or otherwise have a reduced salary because your employer provides insurance, so saying you pay $0 isn’t really fair.
> 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.
> Nobody in the US actually pays $800 for the drug.
The lowest I can buy this drug for is $819.26.
Period.
> That's the "list price" for insurance companies to pay.
$819.26 - $893.72 is the actual price (range) I must pay if I want to purchase this med.
Period. The tales to the contrary fell apart the moment they were scrutinized.
> Then the drug companies come in and offer a "savings card" which you apply at the pharmacy like another layer of insurance.
No. They don't. They pretend to. It is a lie, as delivered.
The manufacturer (Miebo) has a discount program. Miebo promises my cost for the eye drops will be ...
..."as low as $0"
But below that we are told this deal only for Eligible Commercially Insured Patients.
The ones with insurance that pays for the med.
This American, on the other hand, will pay $819.26 - $893.72.
Despite endless hints that there are pharma industry cards all over the place for the millions of millions of us who pay 100% out-of-pocket, there aren't.
What there are: Tightly bounded programs, primarily for newly released and evergreened drugs. Generally the discounted cost is still more than the nearly identical drug they're trying to replace.
> The FDA is partially to blame for this situation:
Not in a meaningful way. Even Dodge vs Ford is a greater factor. Even the stinking DEA does more harm to out of pocket drug consumers (because it does that harm ceaselessly).
> The cost of [ ... parrots pharma's trivially debunked talking points about why US Drug Consumers Must Get Gouged... ] back from insurers.
What med do you plan to pay $650/mo for? Tirzepatide is $300-450/mo straight from Lilly[0] and semaglutide is similar from Novo[1]. (This is another price cut after Lilly dropped prices already in February[2].) It would not be shocking to see prices continue to fall in 2026 as semaglutide goes off-patent in Canada and maybe some of the in-pipeline drugs from other manufacturers come to market.
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.