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Thursday, August 25, 2016

The Latter Days of a Better Nation, Part IV

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Good news this morning for those who depend on EpiPens.

Well, not good news good news, but better news than yesterday anyway.

Mylan, the pharmaceutical company which manufactures the EpiPen epinephrine autoinjector, announced today that they are (not really) lowering the prices of the medical device. Mylan is also expanding its voucher program for low income/uninsured patients to provide access to the devices more or less free of charge.

The prices are still significantly higher than they were a year ago, but much better than they were last week.

This comes after weeks of public outcry over Mylan’s drastic price increases for the lifesaving device.

Over the last few years users of the Epipen saw their out-of-pocket costs increase by more than 500% in some cases, meaning that for many their costs increased from $120 per set of two EpiPens to anywhere between $400 and $700. Many severe allergy sufferers might need as many as six to eight Epipens per year depending.

It’s doesn’t take a Wall Street Pharma Bro to do that kind of math.

That’s one hell of a burden on one hell of a lot of people.

Naturally, predictably, rightfully, many Americans were outraged.

The price increases meant that for many, the EpiPen was no longer an option. And for a significant number of people, that meant a radical change in their lives. Some of the people I spoke to told me they simply couldn’t risk going outside until winter, because if they were stung by a bee they would die. They couldn’t risk letting their kids go to school because exposure to a single peanut might kill them without an EpiPen immediately available.

Now, for those who don’t suffer severe allergies, this kind of paranoia might seem overly dramatic.

It’s not.

People die.

Children die. Adults die. It happens. They always have, usually at young ages, you just never heard much about it. We chalked it up to poisoning or crib death or any of various maladies. But people have always died from severe allergic reactions. In the past many of those folks didn’t know they were allergic until they were choking to death. But now with increased awareness and education (much of it sponsored by Mylan and other Big Pharma), advancing medical technology and better diagnostic tools, many of these people are aware of their sensitivities and with devices such as the EpiPen readily available they can live normal lives.

For those not familiar, the EpiPen is a drug autoinjector – basically an automatic hypodermic needle anybody can use. You pop off the safety cap, press the tip against muscle tissue and push, a spring-loaded needle stabs into your flesh and a measured dose of a drug (in this case Epinephrine (adrenalin)) is forcefully injected directly into the muscle tissue. It sounds violent and painful and it is, it leaves a hell of a bruise (trust me on this), but you get to live which is always nice. Use of the EpiPen requires minimal training and can be used in seconds. And this matters because while epinephrine is used to treat a variety of conditions, in this case it’s being use to prevent anaphylaxis – i.e. a severe allergic reaction where breathing tissues – i.e. your throat! – can swell closed, which typically results in death via asphyxiation unless there’s somebody right there who knows how to perform a tracheotomy with a pocket knife and an ink pen. 

Having your windpipe close up is generally considered a pretty terrible way to go.

People with severe allergies, peanuts, bee stings, shellfish, etc, depend on the EpiPen for their very lives. Many carry the pen on their person at all times because should they suffer an allergic reaction there simply isn’t enough time to wait for medical personnel. Some severely affected people can literally suffocate in minutes. This is especially true in the case of children.

Overly dramatic? The ironic thing is that’s usually the opinion of the same people who think they have to have a gun immediately at the ready because it takes too long for the police to arrive.  I digress.

While there are other devices available, from other manufactures and including Mylan itself, the generic versions are cheaper but are more difficult to operate. And that difficulty is the problem. You see, the Epipen autoinjector is the standard – by design and intent.  It’s what first responders and emergency room personnel and patients themselves are all trained to use.

I myself have been taught to use the Epipen. I have trained many others. (No, I don’t suffer from allergies, more on that later). 

The generic devices work differently. And those differences can take minutes to figure out – when you don’t have minutes.

Moreover in many states, because these are medical devices, doctors have to write the prescriptions specifically for the generic version or the pharmacist can’t issue them and insurance won’t cover them (sometimes insurance won’t cover them even if the doctor does write a prescription specifically for the generic. The rules governing this are complex and difficult to understand even for medical professionals and it varies by state).

It’s complicated and frustrating and downright frightening for a lot of people who could find themselves choking to death while reading this essay.

 

A number of readers, those dependent on Mylan's Epipen either for themselves or for their loved ones, wrote asking why I hadn't posted anything on this subject either here or on my Facebook page.

 

I was waiting.

I was waiting for this, for Mylan to lower their prices.

As I said to those readers in private correspondence, I expected it to take about a week. And here we are.

Companies who depend on public approval for their stock returns don't do well when they come across to the public as greedy evil bastards willing to kill sick people for for a buck. Not unless they're defense contractors with billion dollar government contracts that is. Mylan isn’t that.  And I digress. Again.

Nor is Mylan run by a Wall Street pharma-bro like Martin Shkreli – not exactly anyway – though that comparison is so ubiquitous now I’ll be hard pressed to convince you otherwise.

But it’s true.

You see, Shkreli is an opportunistic douchebag perfectly willing to profit off the misery of sick people. He honestly doesn’t care if people die, so long as he turns a profit and he’s said so and grinned into the cameras while doing it. The man is purposely vile, he knows it and revels in his reputation. That’s nothing new for people like Martin Shkreli. He’s a hedge-fund manager, not a pharmacist, and he acts like one – absolutely no different than those greedy opportunistic Wall Street investment bankers who crashed the world economy for their own selfish ends.

The difference between Shkreli and Mylan is that his company, Turing, was by design a one-hit wonder.

Turing Pharmaceuticals owned the patent on a single critical drug, Daraprim, which is why Shkreli bought it. He knew what would happen when he jacked up the price and he didn't care – in fact public outrage was very likely his goal. Being hated made Shkreli famous. Being called the most hated man in America was the Holy Grail for Martin Shkreli.  Your hate meant everything to him because Shkreli wasn’t interested in running a drug company, he only wanted the money he could squeeze out of it before dumping it and moving on.  He wasn’t making money from those dying of AIDS/HIV, he was making money from hedging the investment. This is a well-greased Wall Street model, it's how business is done every day in America. It's just that most of the time you don't hear about it because it doesn't blatantly turn people dying of a hideous disease into Soylent Green.

Mylan is different.

Mylan is vast global pharmaceutical company registered in the Netherlands and headquartered out of Great Britain. Most of what they make is generic drugs – the less expensive formulas of name brands used by millions of low income and uninsured people all over the world.  That’s right. Without Mylan poor people would be paying a hell of a lot more for routine drugs.  

Mylan also holds the patents on certain specialty devices, such as the Epipen.

Now, Mylan has the a right to make a profit, just as Shkreli did.

Yes, I can hear you screaming. Go on and get it out your system.

But it’s true. The company has a right to make a profit. The morality of making a profit off sick people is a topic for another time and I’m not going to go into it here. It is how it is at the moment and it’s not going to change without a radical restructuring of our civilization. Deal with it.  

Unlike Shkreli, however, Mylan’s bottom-line very much depends on public opinion*. Once their stock started tanking, their response was perfectly predictable.

(*Note: The criminal case against Shkreli is still in progress, but it seems likely based on the charges and his track record that he was involved in a complex scam to manipulate the market in order to short his own investments -- basically betting against himself. If that was the case then the greater the outrage and the worse public opinion, the better his profits. It’s shady as hell and often illegal and depending on how his trial goes, maybe worth a long prison sentence. Welcome to Wall Street).

The primary difference between Mylan and Shkreli is that Mylan (like most pharmaceutical companies) has every reason to keep their customers alive, heathy*, and happy.  Dead people don’t buy Epipens.

Shkreli had no such interest.

(*Note: please don’t start in with the “Big Pharma wants you sick so they can sell drugs” nonsense.  That’s a ridiculous conspiracy theory, easily proven false as many times as you care to run the experiment. Big Pharma isn’t evil and without the drugs they produce every single day, many of you wouldn’t be here or would suffer a vastly worse quality of life. People get sick. They get injured. They have allergies. Diseases evolve, new ones emerge every day. Big Pharma profits far more from making you happy, healthy, and a satisfied customer than they ever would by keeping you sick. So just don’t**)

(**Note: Yes, I realize you will now brand me as a shill for Big Pharma and add me to the conspiracy to keep you sick. Go on. Feel free. Just do me a favor and keep it to yourself and out of my comments section. Thanks. Also, if you see my huge check from Big Pharma, please pass it along because I sure could use it)

 

All of that said, this is a damned good example of what's wrong with the American healthcare system.

 

Under this story on The Hill, commenters are waging a full out war with liberals on one side and conservatives on the other. Neither seems to have much understanding of the actual situation.

For example, commenter Scott declares:

"Regardless of who's paying (taking ACA out of the picture) they have jacked the price for pure and utter greed."

To which one Daniel Gray responded:

"THEY are the ones that invented the drug and the ability to dispense it, so THEY have the right to decide how much to charge for it. Using your logic, if you invented something that people found out later that they needed it I then suspect that you would be ok with the Government or someone else coming in and telling you that you had to sell them for $.03 each and eat the cost of developing the drug and the dispensing system that cost you close to a couple hundred million dollars, as well as the pay of all the employees and so on. These companies just cant win with people like you. If they make something you dont want them to be able to get their money back from what they spent on it, and if they do what you want and then have to lay off people because they dont have money to pay them, then you go after them for that. Stop buying into the left wing BS. Your invention, YOU set the price, not some cubical critter in DC."

Both commenters are wrong in varying degrees.

Shkreli jacked up his prices out of unvarnished greed. He gleefully admitted as much – it's why he bought the expired Daraprim patent in the first place and founded Turing Pharmaceuticals. Greed was his entire business model. But again, he’s a hedge fund manager, this is what they do. This is why Wall Street needs to be regulated – a topic we’ll come back to in a bit.

Mylan increased prices for profit, certainly, because they have to make a profit for their shareholders and they have every right to do so, but that wasn't the only reason. Scott says “taking the ACA out of the picture,” but the thing is you can’t take the ACA out of the picture. Complex economic factors and unexpected market pressures driven by implementation of the Affordable Care Act factor directly into the price increase – and that is entirely on Congress who has repeatedly and emphatically failed to act.  And to a certain extent on the President who has not made this flaw (and others) in his signature legislation a national issue and publicly demanded Congress stop screwing around and get on it.

This situation, and dozens more like it, could have been avoided, if Congress would do its goddamned job and start fixing the Affordable Healthcare Act – or even replace it with something better as Republicans have been promising for eight years now but have as yet failed to produce a single legislative improvement despite majorities in both houses. And without the ACA, the costs would be even higher and 20 million more people would be uninsured.

Congress could fix this.  

That’s their job.

No legislation is perfect, it can’t be. The world is simply too complex. Legislation is too complex. Social Security, Medicare, the National Highway Act, the Voting Rights Act, the Anti-Trust Act, every major piece of legislation was flawed in some fashion. There are always unforeseen side effects. That’s Congress’s job, to fix those things and to keep fixing them as new problems emerge.

But they won’t.

And they won’t because just like Martin Shkreli, they’re more interested in their own selfish satisfaction than they are in keeping the rest of us alive.

Congress has always fixed the problems with various laws, in fact that’s about 80% of what they do. Right up until President Obama came along, when petulant childish obstructionism became more important than your life.

Congress would rather let you choke to death than give one inch to President Obama.

Then there’s the other side of the argument:

“THEY are the ones that invented the drug and the ability to dispense it…”

Wrong.

Wrong on both counts.

Epinephrine is a compound produced by the adrenal gland. It was first isolated by a guy named Jokichi Takamine, a Japanese chemist who immigrated to the United States in the late 1800s. Takamine’s 1901 patent for “Process of Making Diastatic Enzyme,” US Patent #525,823, was the very first patent ever granted for a glandular hormone. Synthetic versions were later developed and patented. Most of those patents have long expired.

Mylan didn’t “invent” epinephrine.

And they don’t own it. Nobody does.

The amount of epinephrine per typical dose is at most a few cents. Combined with other compounds to increase the effectiveness of the drug and decrease side effects (variations of which are how you make generics), each injection costs around $1.00US.

But what Mylan does own is the patent on the EpiPen autoinjector – the device that allows somebody going into anaphylactic shock to self-inject themselves with epinephrine. Or allows a bystander, any bystander trained or not, to do the same.

That’s what they’re charging you for.

But see, here’s the funny part: they didn’t invent that either.

The EpiPen was developed by Merck Pharmaceuticals from the Mark I NAAK ComboPen,

Remember I told you I was trained in the use of the autoinjector? It was the Mark I.

NAAK stands for “Nerve Agent Antidote Kit” in case you were wondering. 

Military folks, particularly those who serve on the front lines, are intimately familiar with this beast or the newer version called the ATNAA (Antidote Treatment Nerve Agent Auto-Injector).  It was designed by the US government during the Cold War specifically to help military people survive a nerve agent attack. The drugs injected are not epinephrine (atropine sulfate and pralidoxime chloride and anybody who took my class better still be able to spell pralidoxime chloride in their sleep), but the device and method of use are almost exactly the same as the EpiPen.

Mylan acquired the various patents for the EpiPen and other autoinjectors from Merck when the company bought Merck’s generic drug division in 2007.

Now, pay attention: Merck never did much with the EpiPen. It was around, people could buy it, those with allergies knew about it and bought the device or one of the various other models available, but it wasn’t common. It was fairly cheap, but a lot of people who could have benefitted from wider availability didn’t have access to it. There were several versions on the market, there was no standard, and it was hit or miss which type you might come across.

Mylan’s CEO, Heather Bresch, the woman people are right now comparing to Martin Shkreli, set about making the-easy-to-use EpiPen available to everybody.

Her plan was to make the EpiPen ubiquitous. Simple, easy to use, and available everywhere. She undertook a program to increase awareness of the dangers of anaphylaxis and severe food allergies – which is why so many people actually know about them today. She successfully lobbied the FDA to approve the EpiPen for use in treating those conditions. And she successfully lobbied Congress for legislation and funding that makes EpiPens available the same way defibrillators are – and in fact she hired the same people who designed defibrillator legislation to design the EpiPen legislation. She started programs to help uninsured and underinsured people get access to the EpiPen. She got EpiPens into ambulances and first aid kits and schools and restaurants.

These efforts have directly and provably saved many lives.

So, what am I saying here? Bresch is some kind of hero? That Bresch did all of this out of the goodness of her heart. That she isn’t out to make a profit? No, of course not. Don’t be stupid. Bresch saw an opportunity, she saw how an obscure device could be used to seize the majority of the market-share in the area of emergency allergy first aid. And she took it and pushed that idea all the way. As a result, her vison and leadership increased profits for Mylan in this one area from about $200M in 2007 to over $1.5B in 2015.

Of course she did it for profit. Of course she did. But she saved a lot of lives along the way.

That, that right there, is what a good CEO does.

Heather Bresch is no Martin Shkreli and Mylan isn’t Turing.

 

Yes, I hear you there in the back, screaming in outrage. Yes, I know. Mylan is a tax inverter. Bresch took advantage of corporate tax loopholes to cut Mylan’s tax burden and increase profits (though their shareholders are likely to get a hefty capital gains whammy this year).  Yep. And it was all perfectly legal. And frankly if I was the CEO of Mylan, I’d have done the same thing. If I could save my company millions and increase stockholder returns, I’d be negligent in my duties not to do so. That’s what they pay CEOs for. Bear with me for a bit, we’ll come back to this.

 

Now, a side effect of this increase in availability, combined with unforeseen side effects with the ACA, resulted in massive price increases for the EpiPen. Some of which was deliberate on the part of Mylan, but not all.

And so here we are caught between the rock of capitalism and the hard spot of our obligation to those in need.

And it’s not as simple as greed.

And it’s not as simple as need.

“… if you invented something that people found out later that they needed it I then suspect that you would be ok with the Government or someone else coming in and telling you that you had to sell them for $.03 each and eat the cost of developing the drug and the dispensing system that cost you close to a couple hundred million dollars, as well as the pay of all the employees and so on. These companies just cant win with people like you. If they make something you dont want them to be able to get their money back from what they spent on it, and if they do what you want and then have to lay off people because they dont have money to pay them, then you go after them for that. Stop buying into the left wing BS. Your invention, YOU set the price, not some cubical critter in DC."

None of that is true.

Mylan didn’t develop either the drug or the device.

They did have to pay for acquisition of it however. It cost them about $6.7 Billion in fact. They have to make that back – and hopefully a lot more, otherwise it was a bad deal by definition and it’ll be bad not only for Mylan, but for everybody else too.  

Now, leaving aside Mylan’s obligation to its shareholders, does the government have a right to decide what a company can charge for their product?

Should the government have that power?

What happens when government sets the prices of goods? Anybody? There’s a name for that type of government, you know. And historically speaking, how does that typically work out? I’ll leave the answer as an exercise for the reader.

The commenter above doesn’t think government should be able to regulate prices – though one suspects he might have a different outlook if he had to buy EpiPens out his own pocket to keep his kid alive.

Then again, maybe not – and I’m digressing yet again.

But – but – here’s the thing the commenter is missing: The US taxpayer paid for the original design. 

That’s right.

The US government paid for the development and design and manufacture of the Mark I NAAK ComboPen.

Now, why shouldn’t the people who paid for that design have some say, via their government, in how that device is made available to the public?

We regulate prices for all kinds of products critical to the public good, either directly or through anti-trust laws.

Electricity is a good example here. We regulate utility prices specifically because in the modern world most people can’t do without electricity, and because electricity in many areas is a monopoly.  Without regulation that monopoly could raise prices to any level they wished and people would have to pay up or learn to do without.

Mylan – by deliberate design of their CEO – owns what is essentially a monopoly on the autoinjector market.

People die without it.

The same people who paid for its design through their tax dollars.

Tax dollars that Mylan has found a way not to pay.

So why shouldn’t those people have a say in how that the device is regulated and sold?

Look here: Mylan isn’t a villain. Mylan has a right to make a profit, as much as they can so long as its legal. Mylan has a right to take advantage of the tax loopholes, they’d be fools not to. Mylan’s CEO has every right to set her salary at whatever the shareholders will accept. And if we are to be truthful with ourselves, Mylan and companies like them do a lot of good – far more good than bad and our modern lives would be radically lesser without them and in fact if it wasn’t for people like Heather Bresch, we wouldn’t be having this argument because most of you would never even have heard of the EpiPen.

Without the incentive of capitalism, this situation wouldn’t even exist and hundreds, maybe thousands, of people would be dying every year of anaphylaxis.  

But Mylan’s interests are not ours.

And you’re a fool if you expect altruism from corporations.

It is the government’s job to balance capitalism against the needs of the citizenry via regulation.

And that responsibility rests squarely on Congress.

Congress has traded away your health and safety – and your tax dollars – in their mad vendetta against the President.

They are all, each and every one, responsible. And any death that results is squarely upon those sorry sons of bitches.

Congress could fix this. They could rewrite the tax laws to eliminate the loopholes, they could set fair regulation of critical medical devices including the EpiPen – regulations that are fair both to industry and fair to the citizens who need them – and they could use the resulting increase in federal money to subsidize in various degree EpiPens and other healthcare for all citizens exactly as the president intended eight years ago. They could do all of this today, right now. But they will not.

Mylan and the EpiPen is but one of a thousand similar problems that directly affect the quality of life for people all over the world. Every. Single. Day.

Those problems could be solved if the people responsible would only do the job they were elected and paid to do.

But they will not.

They will not.

 

Look, let’s get something straight here: I have no intention of being an apologist for the pharmaceutical industry. Or for capitalism itself.  But this is the world we live in and if you’re expecting altruism from Wall Street at the shareholders’ expense you are a fool. It’s not going to happen, ever – even if the company’s motto is “Do No Evil” because evil, like ethics and altruism, is subjective.

The only way to make this better for all of us is via the mechanism put in place by our Founders.

In the end, you hold the power.

Come this November, remember this betrayal. Remember this petulant, childish eight year long tantrum. These lousy sons of bitches would let your child choke to death before they cooperate with each other or the president and there’s absolutely no reason whatsoever to believe they will change in the future.

Remember that when you go to the polls to elect a new congress and a new president.

If you want a better nation, be better citizens.

If you want a better nation, you have to elect a better government.

236 comments:

  1. Salk refused to patent his Polio vaccine, for the greater good. He could have become a billionaire.
    Mylan bought the rights to a product and raised its price hundreds-fold, for their own good at dire cost to those not able to afford it.
    Now Mylan hopes to get a 'pass' by covering some of the insurance co-pays for users, leaving the full price charged to insurance policies.
    Sorry, Mylan, continuing to rape the insurers and driving their rates up is NOT acceptable!

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    1. You need to reread Jim's blog.

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    2. You've missed just about all of Jim's points.

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    3. I'm curious. Did you read this essay?

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    4. I think he did read the essay. Isn't he saying the same thing, that regulation is needed to prevent a corporate entity from doing things like gouging the insurance companies? And isn't he also saying that Mylan bought the rights to a product and raised its price for their own benefit? What is Steve saying that contradicts that? I ask you Kat, Symons, and Lee I.

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    5. I'd add to Steve's comments:

      1. If Mylan needs to raise the price 400% because they need to make a profit on their purchase of EpiPen, they clearly are lousy business people who stupidly overpaid for the product. That should be their problem, not the problem of a three year old child who is choking to death.

      2.Mylan is not only raping insurers. It is raping taxpayers whose taxes pay for Medicare and Medicaid to insured patients, and in fact to anyone covered by medical insurance and whose insurance rates will consequently rise.

      3. Where is it written in the United States Constitution that business people are entitled to a profit, regardless of the consequences of their business activities? That's socialism for corporations and capitalism for the rest of us.

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    6. The thing is, it's the job of CONGRESS to regulate this. Corporations do what they do, they have to be reined in like racehorses, guided to do the correct thing.

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    7. Thank you. This is not the first corporation pushing the profit motive over the line.
      The first in America was the East India Trading Company. EITC.
      Their tax free import of tea to America led to the Coercive Acts, which led directly to the American Revolution.
      The Bill of Rights and the Constitution were specifically written to give control of corporate activities to Congress.
      The Founders mistrusted corporations and wanted them well-regulated..
      We should, too.

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  2. Thank you for this. I was one of the outraged masses who was ready to brandish a pitchfork at Mylan. I'm still ticked off, but now I know more accurately who to be pissed off at. Well, more pissed off at.

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    1. For once "Mission Accomoplished" seems perfectly appropriate.

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    2. Don't be so close minded. Get TWO pitchforks and go after both of them.

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    3. Anonymous wins. So who owns the patent on pitchforks?

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  3. It's so good to see that it's possible to have a strong opinion together with such a balance! Thanks Jim!

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  4. Jim, the "be better citizens" argument is running squarely into the brick wall of gerrymandering of voting districts that benefits republican candidates to the point where, in 2012, republicans won seats despite garnering fewer of the popular votes. We MUST do something about this gerrymandering of voting districts, or there is precious little we can do to walk the consequences of their dereliction of duty to them.

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    Replies
    1. I am squarely in Mary's camp! I can be the best citizen in the country, and if i live in a solid red state, or have been gerrymandered into irrelevancy, i'm still screwed. All i have left is my voice of anger and frustration....

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    2. I feel you, Mary. At last census, I got gerrymandered out of WI-4 and into WI-5, which boasts one of the most conservative congressmen in Congress. You should see the map (http://sensenbrenner.house.gov/district/map.htm)! It's all straight lines until it gets into my stomping grounds. That was designed specifically to take out non-Republican voters. We have been made silent, no matter how faithfully we vote. The WI State legislature isn't even coy about it; various state politicians have said the new districting maps were designed specifically to ensure that Republicans stay in power.

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    3. I agree with Mary and Tess as far as they go. We also need to get Citizens United overturned and get corporate money out of election campaigns and out of politics as much as we can. Then gerrymandering is easier to minimize.

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    4. Mary, Gerrymandering has gone both directions. Admittedly, it seems that the Republicans were better at it overall than the Democrats, but both parties have been aggressively engaged in the practice for over the past 25 years. This has, in part, contributed to the gridlock in national politics, since in the House, so many have no concern about being re-elected. This allows them to take more extreme views on that national stage, with little exposure of 'their job'.

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    5. In red states, where your liberal vote simply doesn't count, you can still do something. Find and support a moderate Republican who actually wants to govern. And help him or her win in the primary by donating, voting, or even canvassing. In the general election, vote however you wish.

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  5. It's worth noting that in the UK, the same device is on sale for $60 at the current exchange rate...

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    1. Parts of the UK. NHS scotland doesnt charge for prescriptions.

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    2. You're comparing apples and oranges. The UK uses negotiated pricing, government supplements, and other cost control methods to control all health care costs.

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    3. NHS Wales doesn't charge for prescriptions either.

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    4. It's not apples and oranges. Jim's point was specifically that the US congress is doing nothing. If they wanted, they could institute negotiated pricing, government supplements, and other cost control methods to control health care costs.

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    5. That's because their government is regulating it, unlike ours. That's the whole point!

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    6. As always,Jim is the voice of considered reason. Here, in Australia, we have universal healthcare and a central pharmaceutical purchasing agency. Medication is subsidized by the Pharmaceutical Benefit Scheme, which has undertaken not to pass on the price rise onto the consumer. That being said, we pay as little as $7 for Epipens to about $100, depending on if you have certain concession cards. And, generic brands are offered as a more cost effective equivalent.Yes it's taxpayer funded, but no one misses out on life saving medication for lack of insurance, or money. Where there is the will, and politicians actually do what they are paid, and elected for, universal healthcare works. It is equitable and furthermore is affordable.

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  6. As someone who needs an Epipen to survive a bee sting, I applaud and wholly approve, love and endorse this insightful essay. Thank you for seeing the bigger picture. Thank you.

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  7. Thank you, thank you and thank you.

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  8. I consider it a good sign, that a section of writing has been carefully researched, thoughtfully stated, and covers sufficiently-large sections of a complex topic, that people with an axe to grind will be able to find something to support their prejudices, no matter which (of many) sides of that topic they may be on.

    You, sir, are a master. I've been aware of most of these concepts individually (apart from, perhaps, the intimate details of the relationship between the Epipen mechanism and the NAAK). I highly doubt, though, that I would be able to bring everything together in this manner so effectively.

    Get out and vote this November. More-importantly, get out and vote for people who have ideas, not slogans. People who know how to compromise (like all ADULTS have to), and to cooperate, and to communicate. People who base their decisions on facts, not dogma.

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  9. When does the patent expire? That creeping deadline probably has everything to do with the price of cheese.

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    1. Epipens were marketed in 1977, so any patents have expired by 1994 (patents lasted for 17 years back then, now 20 years). The original epipen is totally free of patent protection. The author also misunderstands the generic drug market - generic drugs are identical to the original patented drugs (within a small manufacturing variation).

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    2. Jim never claimed it was an issue with the drug. And because of upgrades and changes in various parts Mylan had been able to file additional patent applications, the last one in 2005.

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    3. I believe Jim does understand the generic drug market and explained it just as you have. The difference here is that it's not the drug but the device that is different than the generic versions.

      Delete
    4. Actually, that's not true. Generic drugs only have to have the same _active_ ingredients as the original. Inactive ingredients can vary substantially. Of course, you might think that doesn't matter, because inactive ingredients are, by definition, inactive. But it can matter a lot. Things the inactive ingredients can control are speed of uptake in the body, how far the drug gets along the digestive process before being released, or whether you have an allergic reaction to it. The FDA has recently started comparing generics using a "bioequivalence" standard, which helps a lot, but there are still entire classes of drugs (Seizure medications, ADHD medication, Thyroid hormones) where you cannot safely switch to a generic.

      Delete
    5. I cannot use generic ibuprofen unless it has that hard candy coating on it - most of it does not, so I buy Advil. The weird slimy coating that the generics have on them makes me nauseous, which is not helpful to trying to ease pain. Generics are definitely not identical.

      Delete
    6. Bryan is absolutely right!
      I can no longer take Armor Thyroid (previously it was Wonderful). Forest Labs sold to Actaivs, and the filler used to stabilize the product changed with the new owners,--and so did the price, from $25/month to over $70 within a year. My TSH kept dropping, I felt awful, and my Dr was confused as hell. I did my own research and found out the new filler in the pill took up some of the hormone supposed to be delivered to your body. Thanks, Dr, for knowing all about this easily found out info(snark). So I'm now on NatureThroid, for under $25/month and TSH getting to good levels.
      And years ago I used Retin-A. My derm told me not to use a generic form of this, as it didn't include the buffering agent in the non-generic and would burn the skin of sensitive folks, like me. Gotta be careful, and be your own advocate(your doctor just wants to get you out of her face and get paid).

      Delete
    7. Not all doctors are like that. Mine isn't, and if yours is, find another one. Seriously. I've nearly lost family members due to their being loyal to a doctor that was half assed. I don't like telling people what to do, but in this case, you're putting up with something you don't have to and rewarding this doctor's bad behavior. You deserve better.

      Delete
    8. Anonymous - so you expect providers to know all the details about every medication? And think we are all in it just to get paid? How very enlightened you are! It's patients like you that make practicing medicine the nightmare it has become.

      Delete
  10. I vote and I do my best to be a better citizen. I fear the practice of gerrymandering in so many congressional districts across this nation have made it next to impossible to vote in responsible and intelligent candidates who also want to be better citizens and reverse the damage Congress has done over the last eight years.

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  11. I have a vested interest in Epi-pens, they have the potential to save my Mom and my son's lives. Thankfully I live in Canada, and have never had to face paying a price that high to ensure their safety.

    What bothers me about this price hike is this- the company was holding people's lives in the balance, literally holding lives. I am all for free market and profit, who isn't?
    I am against making something so expensive that the average joe can't afford it. I have watched many American friends scrambling trying to find a way to afford the new price, some straight out said they would never be able to, that it was too much on top of everything else.

    Yes we have drugs that are massively expensive up here and it is wrong to force a person to choose their health over bills or vice versa, I am against people have to make that choice- ever.

    I am glad they came back down on the price and are doing more "free" ones, there is a cynical side to me that says it is being done to try and redeem themselves in the eyes of the public, but if people who need them get them it's worth the window dressing at this point.

    I hope that someone down there finds a way to ensure that medical equipment like this and so many others are kept at a decent price point for all concerned.

    PS- For all who come behind me saying - I don't want to pay for some (inset insult here) why don't they do it for themselves....yadda yadda yadda, please remember once upon a time we all helped each other, no matter what we helped our neighbours because it was good for the community as a whole.

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  12. 40 years ago I reacted to a bee sting and a doctor told me I was allergic to bees. I had to get an annual prescription so I could buy an EpiPen to carry with me in the event I would get stung while working daily in the timber for the forest service. Getting stung was a hassle that required me to leave the woods and seek medical aid. 15 years ago I found APIS MELL, look it up. The last four times I have been stung the Apis Mell has allowed me to continue what I was doing without delay. Perhaps I have a slight allergy and do not go into full shock but I know I can trust it to treat bee stings. http://www.elixirs.com/products.cfm?productcode=S111

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    1. Checking into this. Thanks for sharing. I have landed in the ER 4 times for bee stings. There is a definite pattern of the bigger the bees or the more times stung, the worse the reaction. The last was one sting from a small bee, but I used my pen. The ER doc said I should wait and see how bad the reaction is. I don't get throat closure, so in some instances, the effects of the epi could be worse than the reaction. It's true. Lifesaving drugs are often dangerous, as they cause physiological drama. My 22yo daughter had a heart attack during sinus surgery when epi used to control bleeding was improperly injected and when straight to her heart. As a society, we often get caught up in the established norms and forget to question. We've bought into a lot over the years, i.e., enriched foods (not GMOs) that gave us a false sense of nutritional security. Eating right is simple, but we've mucked it all up. Maybe we're doing the same in other respects.

      Delete
    2. Sorry, go peddle your magic woo-woo water somewhere else.

      Delete
    3. That's enough of that, Chan Kobun. I decide who does and does not comment here.

      You address the commenter without being a dick. Please do so. Or just walk on by.

      Delete
    4. You want people to spam your blog with links to stuff that does nothing? Bully for you. Don';t you dare talk down to me, though, BOY, when I tell these people the truth, just because you want o feel big. Apologize, NOW.

      Delete
    5. I repeat: YOU APOLOGIZE, BOY. You don't talk to me that way, ever.

      Delete
    6. I hope you enjoyed that, Chan.

      Bye.

      Delete
    7. Jim, your patience with fuckwit extraordinaire "Chan Kobun" borders on saintlike. You gave him three strikes - is that your standard, or is Florida living requiring medication? Just curious

      Delete
    8. Normally homeopathy products are utterly worthless. However there are some worth checking out.
      Specifically Zinc for colds and this that I know about. That is due to some products that are labeled homeopathic but actually are not the infinitesimal dilutions of most homeopathic products.
      This is 30% crushed honey bees. I can see where that might possibly work but as it is not a patentable drug so no one has an incentive to test effectiveness.

      Delete
    9. Ignore my comment, the crush bees have been diluted so much the molecules are undetectable.

      Delete
    10. Dickish, sure. But that stuff is just water. I wouldn't bet my life on it.

      Delete
  13. There is seldom absolutes in black or white in life. Most things are composed of varying shades of gray.
    I appreciate your ability, Jim Wright, to be able to view the world and it's issues outside of black and white perimeters.
    Very articulate and introspective article. Your words are much needed and much appreciated.

    Kali

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  14. Spot on as usual, Jim. Agree agree agree.

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  15. Mylan's CEO "acknowledged that high retail prices of EpiPens in the United States effectively subsidize the cost of the devices when they are sold in Europe, at just $100 or $150. Many of the countries there have government-run health-care systems that limit drug prices charged by manufacturers, unlike the U.S." As it is , OUR Congress bars OUR government from even negotiating lower prices for OUR medicaid/Medicare programs... friggin' vote in November people http://www.cnbc.com/2016/08/25/mylan-expands-epipen-cost-cutting-programs-after-charges-of-price-gouging.html

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    1. Correct, because medicare/medicade prices are set by the government. Not pharma, but hospital/physician prices are set by the government at what they believe is a proper price for your area. Issue was after the ACA, those prices were lowered. Pre-ACA, hospitals and doctors were paid on average 80% of what it cost to provide the service (cost of medicine, personal time, use of equipment and location, not profit). ACA lowered the compensation rate even further, the riders that kept it to 60%, expired in Jan. On average they now pay 20%, of cost, as dictated by the government.
      Someone has to eat that cost, it's why commercial insurance gets charged 120-180% off cost, or they can't keep things going. It is why we see things like this coming from pharma but mostly service side of medicine meaning increases. Government says they will only pay us x, it costs y to provide - someone has to pay it, it's not all profits.
      Why we have seen the rise of concierge physicians people pay a retainer for or they close up shop.
      You want to say doctors make a ton of money, the only fancy cars belong to surgeons if you ask around.

      Delete
  16. Thank you. Thank you so much for this. You hit all the right points. You are, indeed, my god in this regard.

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  17. Thank you for a lot of background most of the media is leaving out. Very informative.

    I'm quite pissed off about prices of insulin going up. Apparently there are large gaps between the new higher prices and Medicare/Medicaid coverage. This isn't a once in a while emergency need- this is a daily requirement for every type 1 diabetic.

    I'm Canadian and I don't understand how you guys do it. I would have thought the corporations, the bureaucrats and the politicians would be running from pitchforks by now.

    BTW, my sister in law is a pharmacist in Nova Scotia and she tells me that the price of epipens has been stable at about $100 for the past few years and I'm not sure why they're not gouging us the same way as they are the US market- whether it's legislation, provincial pharmacare coverage (which covers seniors, disabled and those on social assistance) or private insurance that covers prescriptions (usually part of employee benefit packages).

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    1. I know in BC seniors pay about $40, I think low income folks as well. My son pays about $110 or so for his (no benefit package).

      Delete
    2. Up here in Canada we can thank our government for regulation of the kind Jim is talking about and their Congress is not passing. Our drugs overall are cheaper. There are actually advertised bus tours to Canada from the US specifically to fill prescriptions.
      Even though our system is controlled provincially not federally, federal trade laws like NAFTA also play a part.
      In Ontario right now the Wynne government is playing with those subsidies and diabetic testing strips are no longer going to be covered so even here it comes down to the same bottom line, responsible citizens who question their government, speak out and demand performance of a certain standard and voting out governments that don't maintain our chosen social values is the key. Up here our citizens have different values and standards and look to the government for solutions more readily and we get what we vote for.

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    3. CBC.ca has a good article online that explains our drug review board and why Canadian prices have remained stable for epipens.

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    4. The medication I take for my chronic illness is old (off patent) for decades before I started taking it, here $30 for 2 months, some states $60 a month. It's nuts and it's playing roulette with peoples lives.

      Delete
  18. If I was Bresch, and I wanted to raise the price on a product, I'd raise it so high everyone screamed bloody murder. Then, after a week or so of the outrage machine cranking in overdrive, I'd drop the price back down - to the new set point I wanted in the first place. So that people would accept the price hike as being "better than the alternative."

    Thank you for the reminder about the real culprits here.

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    1. Exactly what I thought too :/

      Delete
    2. Exactly what I was just thinking, they got a price increase and praise for being considerate and reducing the price and expanding free/low cost programs. So in several ways, they have earned good will they wouldn't have gotten otherwise.

      Agree with Jim tho, the real problem is Congress and its endless pointless votes to repeal the ACA and the rest of its do-nothing stupidity.

      Delete
  19. Thank you for an excellent article. Add usual, the only lasts seem to be the American public.

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  20. This was the research I needed to see. Like many others I was infuriated by the increase. The MBA scandal of their politically connected CEO didn't help matters any. But what you presented here & how it was presented gave me more understanding of the situation than I've read anywhere else. And, I agree, even though this is still upsetting my outrage needs to directed towards the political shenanigans

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  21. PS...I'm going to post it so others can be better informed also

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  22. We need to reign in the worst excesses of capitalism, but without removing the carrot of making money for corporations and their shareholders. It's a balancing act, and our congresscritters are being useless at it; in fact, too many of them don't appreciate that it IS one of their jobs.

    Also, I don't have a problem with shareholders making money. Lots of people directly or indirectly (through 401(K) or IRA accounts, for example) invest in the stock market. My parents managed to extend their Social Security income into a frugal but comfortable life through thoughtful investing during their working years, and they're not alone. It isn't a moral flaw to be an investor, and investors need protection, too.

    It's a balancing act, only all the actors have left the stage.

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  23. I feel sorry for somebody who'd need an EpiPen to read this essay. Because that would mean they're allergic to truth & common sense.

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  24. As someone who works with the Pharmaceutical industry, I particularly appreciated your comments regarding the "Big Pharma" conspiracies so poplular. I think people forget the several thousands and thousands of people involved in that industry who have their own health and the health of their family and friends and co-workers and neighbors to be concerned about. Thousands of people trying to keep secrets about potential cures or harms that not only would effect the public but their own loved ones? It's an utterly ridiculous notion!

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  25. Mylan didn't actually lower the price. They are issuing discount cards to people who usually pay full price, and are raising the income cutoffs for their assistance programs. The discounted price won't be available to insurance companies, so won't affect our copays, and won't help lower prices of drug or medical insurance plans. The media has been sloppy in their reporting.

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    1. Actually, my son and I both carry Epi's and we received email to apply for a waived co-pay. I don't have a copay, but my 20 year old son does... And no, he didn't fill his prescription this year. He will now.

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  26. Thanks, Jim, I was wrong about several things. Looks like I need to do some correctin' on the Facebooks.

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  27. Mylan has every right to make a profit, of course. And especially the right to cover their investment. But, with the amount of time that the EpiPen has been available, have they not already had their return on investment? Why the sudden, drastic increase? It does seem as if it's a "just because we can" scenario.

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  28. I don't think Big Pharma's out to keep us sick for profit. I think they just don't care when an anti-depression medication can cause worse depression.

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    1. In my experience, that's true - but it's also not true. People and their conditions can vary a great deal so what works like a charm for one person leaves another worse off and doesn't affect a third at all. It can be hard to tell what's going to happen beforehand. It's also why it's important to have these drugs medically supervised. In theory that means that a drug that works can be substituted for one that doesn't.

      Delete
  29. Thank you for the detailed break down.

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  30. Excellent piece.

    The sentence that reads:
    "Naturally, predictable, rightfully, many Americans were outraged."
    Should that 2nd word be predictably?

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    Replies
    1. It should. And now it does. Thanks for the assist!

      Delete
  31. Unfortunately, this is just the tip of the iceberg if TPP passes. http://www.citizen.org/tpp-public-health

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  32. There is one WONDERFUL typo, in the paragraph where you note that your students can still spell Pralidoximine Chloride, you spell it 2 different ways. :-)

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    1. Doh!

      That's hilarious. I've fixed it, but I was sore tempted to leave it just for the irony. I'll never hear the end of it from my students.

      Delete
  33. For starters, I suggest an anti-trust investigation. I would also consider nationalizing the company in the public interest (reimbursing shareholders at the pre-profiteering stock price), an agency to monitor and if necessary regulate medical prices, a criminal law against medical profiteering. I would review the law on patent protection, possibly to shorten protection and possibly to just toss out patents altogether; let innovators make money from innovation, not from rent-seeking. Medicine is technology, and technology prices should go down over time, not up; if one company can't make a profit by providing the public what they need, another company can be found to meet the need.

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    1. Nationalizing the company?

      We don't live in that kind of country, Alex.

      Delete
    2. Well, not for the most part, since 1920 or so... or maybe 1971. :-)

      https://en.wikipedia.org/wiki/United_States_Railroad_Administration
      https://en.wikipedia.org/wiki/Amtrak

      Just poking a little, I understand, you're probably pointing out that they'll be selling snow-cones and ice skates in Hell long before an actual profitable company like Mylan gets nationalized.

      Delete
    3. Wasn't airport security nationalized? Also, countries can change; just because we don't live it that kind now doesn't mean it can't be altered.

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    4. Airport security?

      Um, that's a cost center, not a profit center.

      Just like the passenger trains into Amtrak, for the most part, I'll bet that the organizations (likely the local airport authorities) were overjoyed (initially) to get rid of the responsibility of handling airport security.

      Delete
    5. Airport security wasn't exactly nationalized but I'm not inclined to argue the point.

      Be that as it may, do you really think the government suddenly taking over a company or an entire industry just because its CEO did something that was perfectly legal and literally upending our entire political and economic model is a better solution than, you know, passing some basic regulations? Really?

      I have not response to that. Carry on.

      Delete
    6. https://en.wikipedia.org/wiki/List_of_nationalizations_by_country#United_States

      "literally upending our entire political and economic model"
      Our model already includes some nationalization.

      https://en.wikipedia.org/wiki/Category:Government-owned_companies_of_the_United_States

      https://en.wikipedia.org/wiki/Eminent_domain

      "...is a better solution than, you know, passing some basic regulations? Really?"

      I did not say, and am not saying, anything about value measurements (better, worse). The only two things I did were:
      A: point out the flaw in your claim "We don't live in that kind of country"
      B: point out that "that's not the way things are right now" types of comments are insufficient to negate someone's discussion about things that could be done going forward.

      Delete
    7. Actually my first thought in response to the nationalization comment was "Fannie Mae/Freddie Mac". Though truthfully that's more nationalize/privatize/nationalize. And yes, it was done in response to s situation that was portrayed as dangerous to the stability of the entire economy. But that also hinges on one's view of whether the banks should have been allowed to fail or not.

      Delete
  34. Thanks, Jim. I knew all of the facts you laid out in your article, having researched it myself. (My 3 year-old grandson depends on the EpiPen, and my daughter and her family will have to pay the price increases.) One note: Everyone pays when these price increases occur, because of the relationships between insurance and big pharma. Increased costs are passed on through premiums. Not sure if there's a good solution without total reform of the way the US provides healthcare, and that's unlikely to happen any time soon. But I've written to my reps in DC about my concerns, and I'll vote with those in mind.

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  35. I carry an Epi-Pen with me due to severe allergies to certain items. I'm fortunate enough to have insurance that covers it but this is the first year that I opted for the generic. I also run clinical trials for experimental oncology drugs. Yes, I work for the Dark Side. But I can tell you that you have nit the nail on the head with regards to Mylan and the rest of the pharmaceutical industry. The US taxpayer has funded the basic science research and development of most of the drugs and devices on the market. There is very little out there that is the result of a one person having a "Eureka!" moment. I would, however, ask you to turn your attention to the Dole-Bayh Act of 1980 - here is the wiki entry: https://en.wikipedia.org/wiki/Bayh–Dole_Act, as well as a 2008 NY Times article: http://www.nytimes.com/2008/09/07/technology/07unbox.html?_r=0. In my opinion, this is where the trouble began and how pharma became Big. American taxpayers are being cheated - and disgarded as if we were nothing.

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    1. Where's that damned "like" button...? ;-)

      Delete
  36. Fixing the gerrymandering problem also begins with getting more people to vote. The Republicans have been very good at getting a higher percentage of eligible voters to show up.

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  37. Fixing the gerrymandering problem also begins with getting more people to vote. The Republicans have been very good at getting a higher percentage of eligible voters to show up.

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  38. As someone who worked on an ACA project (Vermont Health Connect) and is very familiar with how it works, Jimis spot on. Well said Jim, well said.

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  39. people have been trying to place the blame on anyone they can find. Blame the guy making a profit. Yeah, that guy! Until this, I have not heard one person say maybe we need a more functional Congress in order to regulate these industries. Thanks.

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  40. Sure Congress is A culprit here. A, not THE. And yes, Mylan has a right to make a profit. As you pointed out, the contents of the device cost about a buck to manufacture. The device itself probably doesn't cost much more than that to make. Add in a few more bucks for S&H, and you've got about a $10 item, before the pharmacy get;s their mark up. Sure, there are other costs to be amortized, but there is no compelling reason to take Mylan's word for their magnitude.

    There's a difference between making a profit and extorting people whose lives are on the line. One would have to dig deep into Mylan's financial records to determine what sales price would give them, for example, a 20% profit, which would be pretty hefty for any manufactured item.

    Mylan would have to give convincing evidence that they were selling EpiPens at a loss 5 years ago to justify the price hikes since.

    Sure, this CEO isn't Shkreli. But it's not out of bounds to speculate that quite a bit of his style of financial reasoning has influenced her decisions.

    So - I'm in partial agreement with you, but not so eager to let Mylan off the hook.

    Cheers!

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    1. I'm not letting Mylan off the hook. I don't work for these people and it's not my job to be an apologist for the pharmaceutical industry.

      However, they aren't doing anything illegal. If you're expecting ethical behavior from any company, you need to first remember that ethics are subjective. It would be unethical for Mylan not to make the greatest profit they can from their point of view -- I'm not engaging in hyperbole here, that's the CEO's responsibility to the shareholders. In fact, the shareholders can take legal action against the CEO for not taking advantage of their monopoly. Is this right? Is it moral? Ethical? We can argue about that all day, it is what it is.

      Again, this situation exists because we allow it to exist. We allow it when we keep reelecting the very people who created the environment for it to thrive in the first place.

      Hell, half the citizens in this country want it to be like this. See the commenter quoted in the text. Are those people deluded? I don't know, but they vote Republican and they're serious about it.

      Delete
    2. Yeah. I took one law class on the long road to becoming overeducated, and the Prof hammered into us that the law definitely is not what is right, moral or ethical, and it's foolish to think otherwise.

      A different point - CEO's violate that fiduciary responsibility to profit maximization all the time, and giving themselves huge pay raises is one of those ways. I've seen a car company manufacturing VP run a third shift producing a vehicle that was not selling, forcing the company to rent large lots to store the vehicles. This went on for months. His bonus depended on production, not sales.

      So, in the real world, maximizing shareholder value is quite far down on the list of exec priorities. This whole EpiPen thing would not smell quite so bad if she hadn't given herself a mutli-million dollar raise. In fact, that event in itself rather powerfully undermines the whole fiduciary argument.

      Cheers!

      Delete
    3. While profits may be ethical in the pharmaceutical industry profiting off the sickness and misery of others is immoral. There can be no justification for the practice of medicine for profit. I'm not saying those who directly support the health outcomes are not entitled to a good living. I do question the payment of astronomical salaries who are tangential to actually providing and delivering necessary medical services. I understand it is the "system" we live under but it is deeply flawed and Americans appear helpless to take corrective action. I recommend emigration, preferably to a Scandinavian country where helping one another is part and parcel of the society's DNA.

      Delete
  41. The real culprit is not the ACA but Medicare Part D passed by the Republican Congress in 2005. A whistleblowers was fired for pointing out how expensive Med D was going to be. They needed to let Medicare negotiate prices like Canada does. Canadians do not pay prices anywhere near what we do. And unfortunately they did not fix this in the ACA. Government doesn't have to dictate prices but they can negotiate better deals. Martin S.and Mylan substituted the notion of actual demand for a product setting the price to using the value of the drug for those who need it. Decided the high value warranted a high price, consumer be damned. And Congress won't fix it because they are too busy dialing those companies for dollars. Please hold your congress men and women accountable. They are in league with the devil.

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    1. Yes, Citizen United.

      Delete
  42. Pharma has found the way to make enormous profits. But the taxpayer pay for research and developing new and improved life saving meds or medical devices. A benefit of this agreement was for the improvement of life with the intention of keeping cost down or corporate tax dollars to pay back the taxpayer. The tax loophole has nixed this understanding. So I think the taxpayes should get a direct return on this public investment right off the top from Wall Street.

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  43. You remind me of a very tough, very strict biology teacher I had at an English boarding school...former Royal Marine, as I recall. His classes could be quite horrible due to his enforcement, but, damn, I have remembered that man fondly for decades. "Always be precise in your terminology!" was one of his maxims, and I've kept host with me since. Your article here brings that yo mind...so many people are willfully imprecise, especially in argument, and certainly so when it's their ox being gored. Your precise focus on the details and accuracy is refreshing.

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  44. I read every word . . . Very Well Done! Made me think and rethink what I thought. Good job!

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  45. as a parent who has to co parent a kid with life threatening tree nut allergies.. thank you for writing this.. we bought before the price hike.. in addition the schools last year were strong arming us to buy the "talking" epi pen Auvi-Q... we could not not at 450.00 per pen... like an AED but with epinephrine.. great idea but I could not agree more with Jim.. this is for the greater good and should have a price regulation... just as there SHOULD be a public medical insurance option but as he mentioned congress was too busy trying to lynch our current president.. thank you Jim for the write up.. sobering..

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  46. Spot on! Thank you for the well reasoned research and exposition of this complex topic. Behooves us to remember we are a Republic, which means every one of us has to educate ourselves on the representatives we choose to make these decisions that can mean life or death for all of us. Vote! Better yet, vote as if your life depended on it.

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  47. I'm 65 and had my very first anaphylactic reaction a few months ago. Fortunately it wasn't bad enough to stop my breathing, but it was scary enough. And we still have not figured out what caused it. So if I encounter the same substance again I'm sure it will be worse. Knowing some greedhead has her hands on the process makes me sick.

    I wonder if epinephrine could be packaged in the pens now used to inject insulin? Those are designed to be easy to use, and the companies that are making a fortune off diabetics probably have the resources to offer it.

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    Replies
    1. Epinephrine can be administered in a variety of ways, it doesn't have to be injected via EpiPen. However unlike Insulin it's an intramuscular injection and not an intravenous one. Injecting epinephrine into a vein might very well kill you, it will certainly give you a heart attack. Which is why non-EpiPen injections should only be done by trained medical experts.

      You should talk to your doctor about the alternatives.

      Delete
    2. Insulin pens inject into the fat layer, not intravenously. The pen needle is only 4mm long on my injector, and you're supposed to use it on the inner thigh or lower abdomen.

      I think the problem is not only is that too short to hit the muscle, but the insulin pens also have to have the needle put on them and the dosage dialed in, which would slow down injection in an emergency situation. If the needle was already on and the dose primed, the device would have to be redesigned.

      I inject 2 meds via pen daily, so I'm intimately familiar with their use.

      Delete
    3. Almost anyone who cares to, can be trained to administer an IM injection into the thigh muscle. Pulling back on the needle to ensure you aren't in a vein isn't that hard. I know the average person is probably going to forget that step in the heat of the moment, but I don't think Epipens have any way of NOT doing the exact same thing. An Epipen just injects it kind of slow. You have to hold it there for 10 seconds. I've injected plenty of cardboard boxes with expired Epipens for training purposes. The reason they have you use the outer thigh is the odds of hitting a big vein are about none. Also if you hit a small vein and inject slowly the epi will do exactly what it is meant to do, constrict that vein to the point of being closed, no bolus 1:1000 epi to the heart. Respiratory arrest is not the only killer in anaphylaxis. Vasodilation dumps the patient's pressure to the point where they die from hypovolemic shock. The vasoconstriction is so strong that people who accidentally shoot themselves in the thumb with an Epipen (don't laugh, it happens because the safety cap you remove is on the end OPPOSITE from the end you stick against the thigh. Panicked people have popped the cap off, put that side against the thigh and pushed) risk having all of the vessels in their hand constrict to the point of losing blood flow in the affected extremity.

      There is in fact a pen much like the insulin pens for epi: http://www.epinephrineautoinject.com/index.php

      Delete
    4. Andy is correct to an extent. The problem is that people panic during a medical emergency and don't do the things they're supposed to do. I'm sure he's seen the same irrational reactions during emergencies that I encountered during my thirteen years as a firefighter. My wife is a professor of nursing at a local college, and is considering replacing her Epipen with a vial of Epinephrine and syringe when it expires.

      One of the other things people need to know is that the one-year expiration date doesn't mean that the clock stops ticking and the pen is now worthless. If the epinephrine hasn't changed color or developed a precipitate, it's still effective for a long time, only slowly dropping in efficacy. See, http://www.ncbi.nlm.nih.gov/pubmed/10808186 for a peer-reviewed study.

      Delete
    5. I should have made it clearer that I'm aware an insulin pen would have to be modified. It was just the concept that got me thinking.

      I've been injecting insulin (not with pens, though) for about 15 years. I wouldn't have a problem with a vial of epinephrine and a syringe, but I know a lot of people would.

      Delete
  48. Hi, sir. You've misspelled the CEO's name consistently. It's Bresch.

    ReplyDelete
    Replies
    1. Refresh your browser. I fixed it already. But I do appreciate your help. Thanks! // Jim

      Delete
    2. Jim, if you have not read it already, you should read the article on The Intercept. https://theintercept.com/2016/08/24/epipen-uproar-highlights-companys-family-ties-to-congress/

      Delete
    3. I've read it. I don't disagree.

      Again, this could be fixed. But you have to start with a better legislature.

      Delete
  49. It's the simple truth at the end all summed up. Another fantastic read Jim and just the kind of perspective we need in situations like these. In the end it really is just a shame that the power managed by so few can be cocked up so spectacularly. I'd say term limits would be great, and people are certainly throwing those terms around in the air as if the threat of occasional displacement will really route the political games in any one direction. Unfortunately even with such limits the occasional shuffle does not really prevent the 'new' people of congress from staying the course and representing the people they were apparently elected to speak on behalf of. The words are simple, the choice is at the polls. But I am starting to wonder if the timeline has simply progressed to where ambivalence to those charged with mandating law and order has become apathetic and almost extinct. Sure a few charged words get thrown up on the floor and demonstrations are held to make the appearance of empathy towards those who are affected by their decisions. This is of course a broad brush to paint these elected officials with but unfortunately the amount of sincere politicians is a haplessly small number. This is simply in its own way the way things are. But at least the words have been said, the rest is up to the future decisions and actions taken.

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  50. I already knew pretty much everything you've written here, as I've been following it since my fire department switched us to using plain old needles and vials for Epi after the pens increased to $150 each. But did I miss the part where you mention that her father is a Senator from W. VA(D)? Or that the price in Canada is still $100? Here's where I still hold Mylan out as greedy:

    They paid $6 Billion for the patent because they knew they could turn it into a cash cow. There were no R&D costs to recover. The company they bought the patent from, how much R&D did they have to do beyond the design that tax dollars paid for? How long ago was that paid off?

    I don't see where you explain the "unintended side effects" of ACA that caused the rise in price. I don't think you can really put this on the ACA, other than maybe the increase in demand was foreseen by the previous patent owner and that drove up the price.

    The people should own that patent or at least a share of it since tax dollars paid for the development, IMHO.

    Yes, ubiquitous Epipens saved lives, but risked others who could no longer afford it. Because they also develop other drugs we should give them a pass of "they are just doing their job" and blame Congress? I have to disagree.

    And I will fully admit that I have trouble staying dispassionate on this one and not banging my keyboard in rage as I read the above. I'm human, something I think Mylan's CEO is missing in some part. Sorry, but I think all of the public education and push to get Epipens everywhere that Mylan did was only done with dollar signs in mind. The good publicity initially? Just served to help them sell more people and institutions on getting Epipens into their people's hands until the government ORDERED all public schools to have them on hand.

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    1. They paid $6 Billion for the patent because they knew they could turn it into a cash cow.

      You say this like it's some horrible thing. Like it's unusual. Like Mylan did this and nobody ever has before.

      Yes, in a better world this company be tempered by altruism or some social ethic, but that is not the world we live in.

      Companies are in business to make a profit, they seek out opportunity to do so. The United States of America allows, ney encourages, companies like Mylan to make as much profit as they can and punishes them for not doing so. Is that right? Is it ethical or moral or just? Fuck no, of course not, not for you, not me, not for those who need the drug. But right, ethics, morals have nothing to do with it by design. This is what it is.

      You can blame Mylan, but they are symptom and not the disease and somebody in the medical profession ought to understand what I'm saying here without further metaphor.

      Delete
    2. And I know the argument is that they haven't broken the law. My problem is that with her father being a Senator, and the bill that was signed into law as mentioned above, smacks of conflict of insider action. I don't think it falls into conspiracy fantasy when so much of the interests are this incestuous.

      Delete
    3. Andy, I'm not arguing with you. I agree.

      But you're engaged in a non sequitur. Bresch's father is a senator, sure. But this same shit happens a hundred times a day with companies who aren't related to congress. Fuck, look at the defense industry sometime.

      Again, there is only one way to fix this and it starts at the ballot box and getting rid of Senators like Joe Manchin

      Delete
    4. I agree, but I don't think that's a non sequitur. Easier to show some sort of conflict of interest when the parties are that close. And I agree a change in Congress is the route to go.

      I'm not naive about this at all. But just because Mylan and Bresch have been in the game longer and are far better at it than Shkreli does not make them any better. I respectfully disagree on that point. I get that you don't approve of what they have done, and that you think it's unethical and immoral. I guess what threw me is that a lot of what you wrote above sounds too much like "just following orders" to me. Were they just following the orders of their shareholders to make them money? Does that make them less reprehensible than Shkreli?

      I'm not trying to put words in your mouth, just fully understand your point. Perhaps it is more of a "expecting a tiger to not be a tiger and refrain from eating you" situation? Sorry if I'm splitting hairs. I don't envy the avalanche of comments on the blog and FB!

      Delete
    5. No. That's it exactly. I expect a tiger to be a tiger. I'm okay with that. I think that if you expect the tiger to be anything other than a tiger you deserve to get eaten.

      That's why we keep tigers in cages.

      Delete
    6. Now you've got me day dreaming of CEOs locked in cages with tigers. I've always wanted to dump the Shark Tank guys into a tank with real sharks. Let's see you buy your way outta that great white's mouth Mark Cuban! LOL

      Delete
  51. I love the way you're reasonable and logical. Well written and I thank you for explaining the myriad of perspectives at play.

    Jason Carroll

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  52. I really enjoyed reading this article, but I don't believe all pharmaceutical companies want us happy and healthy. Happy, healthy people who have been healed of cancer or allergies or whatever any of us might have will no longer have to buy their epi pens or chemo drugs or whatever we need to either survive or have some quality of life.

    Western medicine isn't always good at treating the illness. They throw a pill at the symptom and move on. Our government allows the insurance companies to dictate what can and can't be considered an acceptable treatment, and they all go home with lots of money in their pockets. It's a huge problem, but it can be fixed. Vote.

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  53. 1. What triggered this price increase now?
    2. I do appreciate the deeper explanation of the history and the description of the delicate balance of capitalism. However, I am still not sure that this IS "capitalism", in the "free market" sense... The issue at stake is the patent/monopoly granted to drug companies for an initial set period of time for all products approved by the FDA that are "new". This enables the health care product companies to charge what they wish, not necessarily "what the market will bear", as there is no apples to apples competition during that time. The FDA controls approval and the approval process is expensive. Lives are at stake. Can one make the argument that no one would develop better medical technologies and drugs if the patent/monopoly period did not exist? Can one make the case that the FDA approval process is working (to protect from toxic side effects? to promote true innovations with superior effectiveness?) Should there even be insurance companies in the middle of all this any more, also trying to make profits for their shareholders? The role of insurance is to spread the costs of over a large number of users rover a long period of time, to reduce risk and cost, but I am not experiencing this any more due to higher and higher premiums, higher and higher co-pays and deductibles. To cover higher and higher prices for meds and care.
    3. Perhaps the lesson is that partially regulated industries, publicly traded corporations, and "public utility" type businesses are a bad mix.

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  54. I find it interesting at the end you blame this mostly on the Republicans, and the 8 years of obstruction, didn't the Democrats have a super majority. So they could have passed anything they wanted?? Much like they did with AMA.kind of gave the whole article a political slant,thereby losing alot of credibility.

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    1. Political slant? The fuck, Eric? I'm a political writer, try to keep up.

      As to blaming the republican, well buddy, if the shoe fits.

      On the other hand, I mentioned President Obama several times, or did you miss that? I said congress repeatedly, not republicans:

      And that responsibility rests squarely on Congress.

      Congress has traded away your health and safety – and your tax dollars – in their mad vendetta against the President.

      They are all, each and every one, responsible. And any death that results is squarely upon those sorry sons of bitches.


      Each and every one. Now, should you read "republican" into that, well, that's on you. And on the obstructionist sons of bitches who have openly declared their hatred for the president and their utter refusal to do the job they were elected to do.

      Buddy, it ain't the goddamned Democrats who are currently refusing to oh, say, do their duty on Supreme Court nominations, is it?

      You don't like the implication that your party is to blame? Tough. suck it up, Buttercup, these are your people. You own them. You fix it.

      Delete
    2. Eric, a Democratic Congress capable of voting down a filibuster lasted exactly FORTY DAYS. Republicans really have to take responsibility for their actions/lack of actions.

      Freckles

      Delete
    3. Living in the UK I am used to hearing "socialised medicine" as a criticism of our NHS.
      Apart from noting that the WHO ranks it as much more efficient and healthy than the US system, my key point is this:

      HUNDREDS of US citizens come over to the UK to live
      - one example of many saying the same thing, is @robdelaney (a few million followers on twitter)
      he says/they say, from a sudden change of experience, the NHS is WONDERFUL - "Don't ever go to the American system you guys, whatever is slightly wrong with your NHS, you MUST keep it"

      That's Americans saying this.
      Citizens raised on a system that, from our perspective, only appears to help the wealthy, and them none too well.
      The idea that you can be disqualified from insurance is enough to make us puke so change to social medicine, invest in your national resource - the people's health
      - just enough already.

      Delete
    4. As ghetto as the NHS is, it manages to get virtually identical outcomes as the American system for white males (the population I'm interested in, because I am one) despite spending 1/3rd the resources to do so. For example, the mortality rate from prostate cancer is identical for white males between the UK and the United States -- despite the fact that the U.S. screens for prostate cancer and performs prostate surgeries at a far higher rate. The NHS screens for prostate cancer if you're having trouble urinating and performs surgery only if a slow-growing tumor has become malignant, the US screens everybody and performs surgery routinely if any tumor is detected at all. Yet we in the US spend all that money on screening and surgery and people still die from prostate cancer just as often. What's with that? Other than putting money in the pockets of the medical establishment, I mean?

      That's just one example, but what it says is that given the amount of resources we're pouring into health care, we're doing a mediocre job here in the United States even for white people who have access to our health care system. I don't want to even think about mortality rates for blacks and Hispanics, who often don't.

      Delete
  55. Damnit Jim! Your FB post had me all set to be pissed off. Yet - once again - I find myself applauding another piece of cogent writing. Keep it up, my friend, keep it up.
    Larry Taylor

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  56. Here's the problem with logic that is predicated upon the axiom of "the government has no right to dictate the price of something": It is demonstrably false. Indeed, until the 1980's, many, many things in the United States had government price controls on them, from long distance railroad freight tariffs to gas pipeline transit fees.

    Now, on to the specific question, what do we call a government which imposes price controls on medications? Answer: The government of every other advanced economy on the planet. Every. Single. One of them. Except for the United States. Because we're special little snowflakes and refuse to see that our current system for pricing and distributing drugs here in the United States is broken. Utterly broken. People who need drugs aren't getting them. People who don't need drugs are watching television commercials telling them that drug X will solve all their problems and tell their doctor to prescribe drug X and, drug X also having paid the doctor for a seminar in the Bahamas where they extolled the virtues of drug X, the doctor promptly prescribes drug X, even though the patient doesn't need it.

    The system is broken. And every other advanced economy on the planet has seen that, and intervened in some way, whether it is via negotiating prices with drug manufacturers (Canada), operating their own drug company to churn out generics if no other drug company will (or can, because of patents) manufacture generics for an affordable price (India), or simply imposing price controls (France, though the prices are set by a committee that has representatives of all stakeholders, not by fiat by the Ministry of Health).

    Every.

    Single.

    One of them.

    Except the United States. Because we're special. Short bus special, perhaps.

    In the end, this particular situation is going to remedy itself, because while the current EpiPen is covered by patent laws, the patent on prior versions expired long ago. There has already been one attempt to bring a generic that operates exactly like the EpiPen onto the market, and there had been another competitor on the market that operated exactly like the EpiPen until they had some quality issues that forced them to be withdrawn from the market. This isn't a situation like Pharma Bro where he took anti-competitive steps to make sure that possible competitors could not snarf up enough of his drug in order to conduct a comparative analysis drug trial needed to prove to the FDA that their drug was equivalent. This is a medical device that administers a $1 dose of generic epinephrine and any drug company can snarf up a bunch of them from any drug distributor as needed to conduct the trial. Any price hike was always going to be short term because of the probability that it would pull competitors into the market -- which it has, though the competitor nearest to getting their product on the market won't be able to do so until next year.

    Which still doesn't change the fact that our system for pricing and distributing drugs here in the United States is fundamentally broken, and the most common remedies to that problem that have been implemented by every single other advanced economy on the planet are regarded here the same way that vampires regard garlic.

    - Badtux the Healthcare Penguin

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  57. "Congress could fix this. They could rewrite the tax laws to eliminate the loopholes, they could could set fair regulation of..."

    You have a duplicate 'could' you may want to remove.

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  58. Speaking of the pharmaceutical industry, i'll just leave this here: "Close to retirement at the time, Merck’s aggressive chief executive Henry Gadsden told Fortune magazine of his distress that the company’s potential markets had been limited to sick people. Suggesting he’d rather Merck to be more like chewing gum maker Wrigley’s, Gadsen said it had long been his dream to make drugs for healthy people. Because then, Merck would be able to 'sell to everyone.'”

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    Replies
    1. I believe the market you are thinking of is the soft drink industry. Companies make billions selling flavored sugar water at crazy markup. It's bizarre when you really think about how big and powerful companies like Coke have gotten. On sugar water. Thankfully I am not addicted to that particular drug.

      Delete
  59. Good god, man, could I love you any more?!? This is the most well-reasoned, clearly written explanation of this whole mishegoss I have yet read. Bravo! If only I could get more people to take the time to read it. Sigh. Thank you for this!

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  60. 1. I wonder who had all the Short Sell orders in on that stock? Their stock value just plummeted $3 billion in 5 days. Somebody cashed in. Count on it.

    2. The point of the outrage is this: the drug and the device itself were publicly-funded and developed with tax-payer dollars. Then Mylan acquired it, thus privatizing the profits and socializing the risk, then lobbied Congress to get their now private product into every school in America, and then jacked up the price to a now captive audience who'd alraedy paid for said product with their tax dollars because, as we all know, Mylan, a corporate "person," paid no taxes for it and will pay no fair share on taxes on their obscene profits.

    Oh - and the Senator's daughter with the inside track who is the CEO of Mylan is a major Clinton Foundation and Clinton Campaign donor.

    Companies have a duty to make a profit. They also have a duty to be good corporate citizens. Mylan is not merely a bad citizen - they are a morally insane one and that makes them a public menace and a threat to public health.

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  61. As someone going through so far successful chemotherapy treatments for metastatic cancer I so appreciate the perspective of the pharmaceutical companies not being completely evil. I can't tell you how many times already I've been told that chemo is a conspiracy to keep me sick and kill me while the doctors and drug companies line their pockets. People have no clue of the complexity of research and development. And drugs are used a lot if they are scientifically proven to be the most effective treatment. Thank you.

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    Replies
    1. As someone who has been in remission for 20 years from cancer ( Hodgkins Disease) due to chemo..I am living proof that they are not in this to keep me sick and kill me...it's irrational to think that the thousands of people who work on research and development are doing it to line the drug companies pockets. Especially my wonderful oncologist whose only interest is making people well.

      Congrats on your success and I hope it continues..

      Angelle

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  62. There are no angels, that is true, but you have nailed it, all of the so called greedy, bad actors have taken advantage of the lack of better controls, better laws and better leadership and guidance from the most dysfunctional sessions of Congress we have seen in a long time. And districts just keep sending more and more zealots to Congress!

    Even Adam Smith knew that Capitalism needed regulation and the idiots who claim that is always a bad thing will never admit the truth you have just plainly told!

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  63. The coupon is a joke. It will work for very few and not anyone on Medicaid because coupons don't work at all if you have that insurance. It puts the onus on the patient to go to a website to print it out which assumes everyone has access to a computer and a printer and reads enough news to know it exists. It was a way to make headlines by saying look, here's a $300 coupon!!! We're great!!! Insurance still pays the full bill if you have that kind of insurance which jacks up premiums. If they had dropped the price to $300, now that would have been effective for a lot more people and in a lot more ways. Jerks.

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  64. Like many people who carry an EpiPen, I am will shortly be carrying one that is outdated because I cannot afford to buy a new set.

    The funny thing is that I didn't need to carry one until recently. The thing I am allergic to (yes, fall down, stop breathing allergic to) is marijuana.

    I supported the legalization of marijuana both in the state I moved from (Montana) and in the state I now live in (Washington). It was that move that caused me to have to start carrying an EpiPen. In Washington, marijuana is legal. They stores that sell it. While most people who use marijuana follow the rules (not to use it in public), not all do and because of this, I now have to carry and EpiPen.

    We have good insurance and the cost of the EpiPens for me is significantly reduced (we won't go into what we pay for that insurance, though...). Even with the reduction, the cost of the EpiPens I carry has increased exponentially to the point where it is out of our price range unless we save for the purchase. Right now, that just isn't going to happen. For now, I will continue to carry the one I have even after it expires at the end of this month.

    I do not blame the Capitalistic vultures that have made American Health Care unaffordable for the average citizen, though it would be easy to do so. Having previously worked at an electronics firm that makes medical equipment, I know just how much graft there is in that industry. I have seen a lead for a medical device get marked up 1500% over the SAME EXACT lead used in a non medical application. Anyway, I digress...

    I DO blame the stuffed suits in Congress that want to prevent this system from ever changing so they can continue to get the millions of dollars from the industry lobbies. This, at least, is something that I CAN do something about.

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  65. When the prescription part of Medicare was instituted, the bozo's writing the rules set it up so that Medicare COULD NOT NEGOTIATE prices. So the pharma industry can charge Medicare anything it wants to for prescriptions that seniors are dependent on. Medicare passes the cost on to the seniors. A couple of my prescriptions increased 700% from last year - from $5/month to $35/month. Congress is responsible for this - even if they didn't write the original rules they have the power and responsibility to implement a fix. My "representatives" (all GOP) do not represent me and have not voted favorably for any legislation that could of helped me.

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  66. I disagree with Jim's assessment of Mylan. If Mylan did the right and ethical thing in their business they would recognize without legislation to set this at a fair and affordable price for anyone to purchase an auto injector. This is an old technology they did not develop and costs them pennis per injector. These injectors should be household items in EVERYONE'S first aid kits. Mylan just happens to be toxic with greed. And yes I can blame them. We wouldn't need our legislators to lift a darn finger if folks like Mylan behaved in an ethical manner. However, reality does mean that our legislators need to get off their asses and do something.

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    1. Anonymous, I would submit to you that any argument which begins with "If people would just..." is doomed to abject failure right from the start.

      Delete
  67. I know all the arguments for allowing the free market to set prices, but when reading about situations like this I keep wondering when the insurance companies are going to start their campaign to force price controls on drugs. Medicare Part D forced the cost of drugs onto the taxpayers, but insurance companies are getting clobbered by rising drug prices that they are forced to cover. I suspect that health insurance lobbyists have been pushing for such legislation for a while now, but with a Not Interested Congress still in control, I doubt much will happen soon. January should be an interesting time, particularly if the Senate changes hands and the Republican lead in the House is cut. The two parties might have to learn to play nice.

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    1. Why should the insurance companies complain? So far, they've continued to raise their rates, and so far, we continue to pay.

      https://www.heartland.org/news-opinion/news/washington-state-insurance-premiums-to-increase-by-13-percent

      I don't see too many insurance companies deciding to be nice and raise the rates by a smaller amount.

      One of the decisions that I tried to research the most, in our recent Primary, was who I was voting for as state insurance commissioner.

      Delete
  68. But, see, she raised the PRICE and gave herself and top officials in the company enormous raises. So it would seem raising the price, by orders of magnitude, had little to do with anything related to increased costs or making up for giving the devices for free to public places but to off-set the costs of giving everyone a higher salary.

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  69. A nuanced and intelligent piece, Jim. Health and Safety are two realms where government exists to protect us,the people. Republicans dote on the safety business and law and order yet have consistently backslid on the Health portion. For a wealthy country in an advanced society,where the Saudi princes come for Mayo Clinic attention, we can, we must find a way to give basic care and life saving care to all our people. Not just the well healed and oil rich. And the thing is we CAN do if it we WANT it enough. ACA was not a bad start, considering the way it dodged so many Republican missiles, and the likes of Tom Coburn and Ron Paul and Grassle and more...no compassion, only hate for that brown skinned upstart in the White House. Who abides and prevails as best as is possible so far.

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  70. Once again sir, you shine a spotlight on sides of the issue that most people don't have the time or energy to research. The local news channels are in Windsor Ontario tonight shopping prices at pharmacies and talking to the employees. None of the Canadians interviewed can wrap their minds around the staggering price differences and make it clear that they welcome all new business. The reporters offered no positive spin to the story, none of the fact based issues were raised; just the public outcry. May I post to a local media page with proper credit?

    Thank you for highlighting, once again, the need for Facebook to add a "stand up cheer" Like emoticon. And thank you for doing the work for those of us uninformed of the Epipen history. Always the highlight of the day to learn there is a new Stonekettle essay.

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  71. I might have missed it, but Mylan paid $$ for the entire catalog of Merck's generic division, not just the Epi.

    Pharma can charge whatever it likes for a drug in this country. In other countries, prices are negotiated by the government. So th US and developing countries are covering the cost of research for the countries who negotiate.

    Yes it is VERY expensive to bring a new drug to market. And a lot of potential drugs are lost in testing. And a good drug has to cover the cost of all the research that didn't pan out. But Mylan is not doing research. The whole point of generics is that you're using already tested and approved molecules. You're not discovering something new, you're redoing something already done. Not nearly so expensive to follow tested processes as to invent the thing in the first place.

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    1. Middle of the essay: Mylan acquired the various patents for the EpiPen and other autoinjectors from Merck when the company bought Merck’s generic drug division in 2007.

      Delete
  72. You are right. It is our responsibility to elect competent people to work for our government. Go vote, people.

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  73. Every time I read your blog I learn a little more about the world I've lived in for 55 years; it astonishes me, horrifies me, delights me and educates me. Thanks, JW, for this. The day I'm too old to learn is the day I'll dig my own grave.

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  74. The cost of Epi has not dropped. They are offering a coupon card. It's slightly different.

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    1. Furthermore, they've *been* offering a coupon card for quite some time. It's part of the standard marketing package nowadays -- hike the price of a drug, negotiate a lower price with insurance companies (but still higher than the original price), and offer a coupon card to pay the deductibles (if insured) or bring the price down to what the insurance companies pay (if not covered by insurance). The list or wholesale price has become somewhat of a fiction in today's drug industry, and the lack of price transparency makes the operation of normal market price signals problematic.

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  75. I checked the I hate you box for one reason, You are so much better then I am, at expressing yourself and making a well developed argument. I have made the same case in the past, much shorter though. Stop hiring vegetarians to run the sausage factory.

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  76. But the price wasn't reduced. If so, all consumers could benefit. I've heard it from reports on NPR, and here (edited) from Finance.Yahoo.com - "There is some fine print on Mylan's offer to consumers: The discount doesn't change the drug's list price ... What the discount does change is how much people with commercial insurance and say, a high deductible, pay.
    If you were at first on the hook for about $600 before, that will now be cut down to about $300.
    For people without insurance, however, the card won't apply. It also won't apply to people on government insurance programs, such as Medicare or Medicaid. So for those who are uninsured, they're still on the hook for the full price, which varies between locations and pharmacies but, according to GoodRx, is somewhere between $600 and $700." I greatly appreciate your research Jim, and your ability to analyze complex topics like this. I just think Mylan did take advantage of the Auvi-Q being taken off the market last fall and the 2 generic competitors on hold until next year by the FDA. Three price increases since last October by Mylan could be seen as predatory while they currently hold something like 87% of the market.

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  77. More typos - two instances of "personal" where I think you meant "personnel":

    "simply isn’t enough time to wait for medical personal. Some severely affected people can literally suffocate in minutes."

    and

    "It’s what first responders and emergency room personal and patients themselves are all trained to use."

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    1. Wow. That's not a mistake I normally make. Thanks for catching it. It's fixed. // Jim

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    2. Not to pile on the editorial train, but I noticed a duplicate instance of "could" in the following passage:

      Congress could fix this. They could rewrite the tax laws to eliminate the loopholes, they **could could** set fair regulation of critical medical devices

      Delete
    3. Got it. Thanks for the assist. // Jim

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  78. I don't necessarily disagree with anything, but I would add a point to it all. It is good to understand the subtlety of the situation (and in my case I've had to deal with the issues of insurance, copays, etc. for a very expensive different drug that left me only shaking my head) but I think we also need to remind ourselves that while we shouldn't expect altruism from corporations, we should expect some degree of common decency. Yes, Congress should have acted on this long ago and maybe this latest event will eventually push forward a public option with more controls over some drug prices. But that said, corporations like Mylan in this case seemed oblivious as to why people were so upset. Did you see the graphic they put out about how many other people were involved in profiting from the high prices? As in "We're not the only ones bleeding this, others are too!" The disconnect between corporations running based on short term investor profit motivations and the end results of their actions is part of the problem as well. No, we can't expect corporations to be altruistic. But we can point out shameful behavior when it causes increased human suffering all for an increase in already healthy profits. No, I don't begrudge them the benefit of their business model. It's how far they push it that defines them. In this case even Mylan's "price drop" is really just a drop for the under insured and will result in only massively large profits instead of massively huge profits all while the costs of insurance will rise to cover it.

    Shame on social media is a powerful tool. The same shame *should* be put on Congress, no question about it. But Mylan has acted with depraved indifference in part because Congress has allowed it through their inaction. It doesn't excuse Congress. But it also doesn't excuse Mylan. So who is worse, the one who acts with shameful indifference to suffering or the one who allows it? Both are culpable. And both should be ashamed of themselves.

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  79. Thank you, Jim, for elucidating the points I always feel I have to make when discussing 'Big Pharma' with others. Also, I have an interesting, and tragic, account of using pralidoxime many years ago, if you'd like to hear about it.

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  80. BRILLIANT and BRAVO, sir! I followed your link from Facebook (not friended; I'm just a follower, though I'd like to be on your 'cool' list someday). This explains and clears up a lot for me. Thank you for this much-needed dose of common sense.

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  81. Many thanks for your time, energy and intelligence, Jim. It's very hard to maintain focus on these types of issues and I appreciate your efforts. I haven't been following your blog for very long and I was curious if you could refer me to any of your works that deal with gerrymandering, the Citizens United decision or the Electoral College. Your research is top-notch and I will be playing catch up for a long time if you remain this prolific (not that I want you to change anything, just saying). I get the feeling one gets when in a restaurant and sees their food coming whenever a new post from you appears on Facebook. Keep up the great work. I share your posts often, since your views resemble mine, especially after I read your recently re-posted essay titled "Everybody's So Different, I Haven't Changed." *applauds*

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  82. The concept of the invisible hand of the market is such a central tenet of conservative thought and philosophy that it borders on religion. Complimentary to that is the notion that government is incapable of innovation and hopelessly mired in bureaucracy. Besides those in political position to Obama obstructing to obstruct there are the true believers in the magic of the market. Against all evidence they will always see the market as the best option and sincerely believe it.
    As Jim points out the source of this innovation was that supposedly hidebound government. And the interests of profit while providing initial brilliance in adaptive innovation, predictably proved to be incompatible to the needs of the many.
    I was particularly interested to see a comparison the utility monopolies. As this story was unfolding today I wondered if laws on common carriers applied. Of course the argument would be that there are alternatives to the EpiPen but considering the relative ease of use and effectiveness that would be akin to saying that when the government regulated rail service as a common carrier people had the alternative of horses.

    Thoughtful and thought provoking. One of my favorites
    Thank you

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  83. "Mylan increased prices for profit, certainly, because they have to make a profit for their shareholders and they have every right to do so"

    The idea that a corporation has a "fiduciary responsibility" to make a profit and related idea are false. It's propaganda to justify greed. Look it up. There's plenty of excellent articles from law professors ans such debunking this convenient lie.

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    1. Couple of questions:

      1. If not for a profit, companies are in business for what reason then? Altruism? The satisfaction of honest labor freed from the burden of having to make a living? Fun? What?

      2. What exactly would then motivate anyone to invest in such an enterprise -- the one where you put your money in and the company just sort of grins and says well, you know, we're not really into profit per se. In other words, what do the shareholders get out of it? Is it like that scene out of Caddyshack where Bill Murray describes how he gets eternal peace on his deathbed instead of a tip?

      Apologies for the sarcastic tone of my response, but "look it up" tends to do that to me. How about you explain this fascinating concept of how companies shouldn't make a profit in more detail yourself? // Jim

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    2. Actually, I think there is a name for an entity that's in it not for profit, it's called a charity.

      That's not really a very good business model though :-/

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    3. @Jim: You have to separate compensation necessary to function in society from profit. Profit is that which is over and above the cost of doing business. Many people happily perform work for entities that gain no profit. A company cannot have motivation. Only people can have motivation. People go to work to earn a living and often because the work is interesting and sometimes enjoyable. People feel a sense of self-worth through work. Many people would (and do) work with no renumeration at all. All government agencies work (and many work well) with no profit motive at all.

      As far as investing in a corporation goes, yes, without profit it seems pretty pointless, but many corporations don't need stock investors in order to gain the funds they need to operate. Most businesses start with little amounts of money from a principal or a friend or relative. Good businesses will make some little profit and reinvest that. If a business is relatively successful, it will be able to borrow money to meet its needs. Certainly money from an investor may help a corporation grow faster, but except in the case of banks, which legally require a significant amount of capital to operate. I think you put things backward here. Most companies don't require investors. The investors are hoping for a profit, so the directors of companies oblige and set prices accordingly. Those in charge of such companies also tend to compensate themselves handsomely. One could eliminate stock altogether and the would would continue, and that has nothing to do with government control of industry, other than government rules sanction what a corporation looks like.

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  84. Superb as usual, Jim.

    Since I quite nearly died from anaphylaxis a year ago, I'd like to limit my comments to these:

    Allergies can come on quite suddenly. The fact that you weren't allergic to something yesterday does NOT mean that you cannot die from it today. I speak from experience.

    There are several conditions that can indicate anaphylaxis including itching, chest pain, numbness, tingling and others. There is no way to determine which occurs first or how many indicators there will be. Since my wife is deathly allergic to vespid venom, we have always had EpiPens around the hacienda.

    The day I almost checked out, my symptoms began with itchy hands then chest pain. Soon after, nausea occurred. I ran for the bathroom. By the time I got there, tingling and numbness quickly set in followed closely by closing of the throat. I was now too far gone to get either an EpiPen or reach my cell phone. Thankfully, my daughter and a friend had seen me. They asked what was wrong, I responded as best I could. Daughter grabbed an EpiPen and shoved it into my thigh then called 911. By this time I am collapsing onto the floor. Just before I lost the ability to speak, in runs a cop, I mutter "Allergy" and then in come the EMTs. Long story short- a bad day at Hysteria Hall but I lived to tell about it. The EpiPen almost certainly helped. BTW, the EpiPen didn't hurt a bit. Maybe I was just doubly lucky that day.

    I am now allergic, deathly so, to red meat. The reason for sharing my story is so that someone else might recognize the symptoms of anaphylaxis sooner than I did. If in doubt, call 911 right away and let 'em know if you've used an EpiPen (You might be unable to talk or unconscious when the EMTs get there. Don't make their job harder by having to guess what you've taken.)

    Allergies are nothing to sneeze at. (Sorry. Couldn't help myself).

    Thanks again Jim.

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  85. Small niggle: "The criminal case against Shkreli is still in progress, but it is seems likely based on the charges and his track record" (is or seems, but not both).

    Mad props: I can't express in a few words how much I learned and how much I now have to think about from this brief and powerful essay. Thank you so much.

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  86. This was a great essay. So many don't understand either the role of government or the role of a citizen in that government. They also don't understand the danger of reducing government until it fits in bathtub or allowing to grow so large that it does every damn thing for you.

    It's a balancing act and we are meant to be the ones keeping it on the wire.

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  87. Excellent essay as always. I have a question, though--who's been saying that the reaction to EpiPen's price hike was "overly dramatic"? Hannity? The blonde bimbos at FOX? Or RWNJs in general?

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  88. Donald G. SwarbrickAugust 26, 2016 at 5:01 AM

    Outstanding. Absolutely outstanding!

    I've heard it said many times that "a mind is like a parachute... it only works if it's open."

    Reading your essays keeps mine fully deployed!

    Thanks again Jim!!

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  89. I have worked in health care for over thirty years. It has been difficult to watch more and more collections of people (like institutions and corporactions) make more decisions every day which cause more and more sick people to become impoverished and/or to die. My own pet peeve is "Anyone can change a bedpan". You're not just paying for the hands, you're paying for the trained eyes and other assessment tools to look into the bedpan and say, "Whoa, that ain't right."

    I have had to temper my rage (which has also relieved my friends and family) because no, most of it is not done with mustache-twirling EEVOL INTENT. Most of it is inevitable because you have no business expecting an entity designed primarily to make money, to choose ANYTHING else first. I have believed for years that health insurance is an inherently flawed concept, incompatible with the chronic nature of current health care. Insurance made money, historically, because policyholders were unlikely to need the large payoff more than once. That hasn't been true for a long time.

    I'm grateful to see articulated, some of the things I've been thinking for a long time about the futility of expecting corporations to put anybody besides themselves and their shareholders first.

    Also, thanks for the history lesson about the delivery system. Fascinating!

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  90. Great article. Here's a bit of helpful information. If you are insured and have a prescription for the Epipen - you can get it free, here.
    https://www.epipen.com/copay-offer/
    Eligibility Requirements: This SAVINGS card can be redeemed only by patients or patient guardians who are 18 years of age or older who are a resident of the United States and its territories. Not valid for uninsured patients. I just used it at Walgreens a few days ago.

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  91. The author almost grasps how markets work and then near the end goes tits-up-authoritarian about how Big Nanny in DC must be the one to decide the abilities of some to take stuff from and the needs of others to give stuff to.

    Whether or not Mylan is rent-seeking is a legit argument to have. Or that Government regs & redtape have made it prohibitively expensive for competitors to enter the market.

    But I am tired of the knee-jerk reaction to a problem with its roots in government interference is to demand MORE GOVERNMENT.

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    1. Somehow, Darleen, I think you missed the last sentence" "If you want a better nation, you have to elect a better government." WE, Darleen, are the goverment. That was the intent of our founders, by design. Jim is not advocating abdicating all responsibility to big brother, far from it. He IS advocating vigilance, and engagement on the part of citizens.

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  92. Thank you, Jim, for that explanation. I hate it, but there it is. This November, let's get busy fixing it.

    Jean Amann

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  93. Two thought, as hubs is a pharmacist. Couldn't read all the comments so apologies if it's been covered. 1., in the ER/hospital (your comment on training) at least here they use a syringe, less than $1 in drug, though lord knows what they charge you. 2., half the travesty of the price increase has been the refusal to sell one pen at a time (2 packs) and the bullshit expiration dates of less than one year. Individuals can't buy just one any more but they can ignore the date. Entities can't ignore the date. Hubs works for a major retail pharmacy and they are required to keep 4 in date pens in their vaccine kit. I'm actually pretty impressed with how the CEO lined them up for profitability. Runs very counter to the stereotypical female brought in to a dying behemoth for scapegoating purposes. I wouldn't want to cross her, she's playing several strokes ahead, but clearly one stroke too short in the end unless she just folds and retires. I almost said she was too much like me to cross her, had second thoughts on that point, but damn I did close shop and retire after the big lick. Guess I'll be doubly impressed if she knows when to leave the table. The fact it's impressive doesn't change that what allowed it to happen needs fixed.

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  94. But they did NOT drop the price, not really. Did you not read ? They just pulled a fast one.

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  95. Excellent article. Hits the nail on the head.

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  96. My understanding is not that they have actually halved the price, but they have made it possible for those who are uninsured, to pay half, if they know to apply for a $300 discount. According to Mylan, 80% of their prescriptive epi's are insured.
    THus, half of 20% is not impressive.
    Profit and profiteering are two different actions.

    Thank you for writing this.

    One of the issues with anaphylaxis is it's raw and horrible outcome. Thus, most of us intimately experienced with it tend to get a bit raw and sometimes horrible.

    Thus, Mylan literally profits on our terror.

    If there were no monopoly we would still be terrified, but perhaps less angry with great options.

    Thank you again for writing this.

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  97. One thing I'll take issue with is the continued buck-passing of responsibility. CEO's blame corporations, who blame regulators, who blame legislators, who blame lobbyists and constituents...

    But a corporation does not have a "right to make a profit" in the same way that a human being has rights. It either has an opportunity to make a profit, or it does not. When an opportunity would cause harm to others, it has lost legitimacy and the right to profit. Period.

    That's not setting the bar too high. There are non-profit companies that are quite successful, and for-profit corporations who pay attention to the Triple Bottom Line. On a smaller scale, we rightly recognize that we can't make money by selling people into slavery or harvesting organs.

    If your business model profits from internet games, or cars, or sports gear, your customers have the option to opt out. If your business revolves around life-sustaining goods and services (food, medical care, housing), you absolutely take on an ethical burden to do no harm, even if it makes your shareholders unhappy.

    When we point at "the system" or at shareholders, or "business needs," we set our conscience aside and agree to do something we know is wrong "because reasons." And that's what's truly wrong. If you're in a decision-making role, you absolutely must bring your conscience along and use it.

    At the end of the day, no matter how many excuses there are, harming someone for money is still harming someone for money.

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  98. FYI Mylan didn't lower the price. It only increased the value of a coupon that only some people can use.

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  99. Thank you, Jim. You dropped that flaming bag of dogshit precisely in front of the door where it belongs. Congress needs to get its feet dirty or it will light up the whole porch.

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  100. I disagree with the notion that companies have a right to make a profit. They're entitled to try to make a profit, but it's not a guaranteed right. That kind of thing is entirely too close to the "profit-taking" language in various of the trade agreements to which we're now all subject that allow corporations to sue your geopolitical entity for, say, passing an environmental law that cuts into some corporation's ability to foist its environmental externalities off on the taxpayer, thereby reducing its profit margin. Nope, forget it. Don't want to live in a world where corporations are guaranteed a profit no matter what they do.

    It used to be, even, that being a corporation (with the corporate veil and limited liability and stuff) was a privilege, even, but it's seeming even more like even that is now a right, and that's also not right. I'm personally in favour of the death penalty for corporations -- decharter the worst of the offenders.

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  101. More to say — Your remarks about corporations are dead on. We have given corporations rights and privs over and above those given to most flesh and blood U.S. citizens. Corporate "citizens," having no moral imperative except to return a profit, are sovereign citizens with no consideration for the rights of their fellows, or for their very humanity.

    You can't blame a tick for being a tick, but you ought to get rid of it none-the-less.

    Thanks again.

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  102. My wife has chronic myeloid leukemia, kept thoroughly under control by taking 400 mg of Gleevec every day. With no insurance or discounts, cost would be $10,000/month. Go ahead and look it up. Then, tell me about the costs of prescription drugs.

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  103. I was looking at Mylan's financials, and they don't pay dividends - at least, not since around the time they bought this division of Merck. I realize that's probably due to our amazingly low capital gains tax rates, but it begs the question of what they are doing with their profits. Oh, CEO pay. Never mind.

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