It turns out that lots of wealthy people prefer to not pay for other people's health care, or their own.
They show poor judgement at times, in that manner.
The Republican party was pretty explicit in 2016 about wanting to keep more people uninsured so that the elderly could have less completion when it comes to getting a doctor. Which, apparently, was a winning strategy.
Pence-Ryan 2024: If everyone who needs it can get insulin, the value of hard work will be destroyed.
I truly do not understand why candidates are being sucked into bullshitting as if there are substantial differences between health care plans,
Because the peculiar institution of the "televised debate" broadcast on a commercial entertainment channel means that the policy debate has to be entertaining, and this means that there have to be disagreements and conflicts.
I agree with 5. It's also a fact that the candidates are in competition with each other, and if they all admit that basically the contours of what gets adopted in 2021 (if anything) don't depend much at all on which of them gets elected totally destroys their branding campaign.
Yang's necktie comment might have been one of the better moments of this round.
There's a class of journalist today complaining that they're not attacking Trump enough. Last night the attacked Trump a lot. I have no idea what these people think the debate is supposed to look like: who hates Trump the most? Who thinks kids in cages is really bad? If hey want it to be a discussion of how best to beat Trump, that's been there too: Booker's comment about energizing African-American women is directly on point. So was Warren's assertion, night before last, that we beat Trump with big ideas. (I think this is a misdiagnosis of 2016, but recognize that this is hotly disputed.)
There are substantial differences between the democratic candidates healthcare proposals. They are definitely all better than the status quo, but the proposals that allow for a major role by the insurance industry are worse and will cost more. In any event, arguing about policy is what we want the candidates to be doing.
Ideally, though, they'd be arguing about policy they control. The details of health care are in the hands of Congress -- the important differences between candidates are sort of limited to where they draw the line between "I'd sign that" and "I think that's worse than the status quo so I wouldn't sign that," rather than the precise implementation.
It's kind of down in the weeds, but I found an empirical description of how the US spends money on health care under our current system. All prenatal care combined is a small fraction, so is all ER care, for instance.
Figure 1 and figure 5 summarize pretty concisely. It's possible to spot the year that the oldest statins went off-patent.
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5551483/
Whoops-- "I found a description helpful" was what I meant to write
I'd like to see an open-book debate, where they can websearch and share documents and links around. Perhaps on a marginal issue unfamiliar to them.
The figures in 9 are great. WTF happened to diabetes medications 10 years ago?
Costs are borne in a way that correlates with wealth, in an acceptably progressive scale.
Doesn't that follow if costs are paid for out of general revenue? Wealthier people pay higher taxes. Even dedicated revenue (like Social Security or Medicare) could be made more progressive. Of course, "acceptably" is carrying a heavy political load here.
Sure. I'm totally fine with that. Sign me up.
Is anyone proposing making social security taxes progressive? Of the candidates.
12 I don't know the answer to that, but I do know that 10 years ago I was a year or two in to working on a whole lot of lawsuits involving Avandia, before changing jobs.
Something is broken with how generic competition works, because it's not reducing prices nearly as much anymore. My best guess is fewer investors are interested in generic manufacturing unless they can find niches where they're the only manufacturer, or special deals making them the only non-branded manufacturer, and existing companies that could make steady-but-low profits in low-price competition are pulling out for the same reason.
Obviously this isn't in all generics - Walmart and Target have their $4/month generics catalog where they pass on low prices from foreign manufacturing just as with clothing; and Walmart has one older type of insulin that works for a minority of people, for $25/vial. But this winnowing of the field has happened with insulin and many others, it seems. And when there are just two or three manufacturers, they don't necessarily start price-competing; maybe they collude, maybe they just tacitly let the high prices stand because they know they'll both do better without price-competing.
15: Warren has said to remove the payroll tax cap - that would result in a flat percentage, but it's still a lot more taxation primarily on rich people than the status quo. Sanders apparently wants a doughnut hole - no payroll tax between the current cap and $250k, regular 12.4% over $250k. I suspect several other candidates are in favor. (Obamacare eliminated the Medicare payroll tax cap, I believe.)
17: My suspicion is that it's broken antitrust enforcement but I don't know details.
18: Sanders seems to know what his voters earn?
17: this seemed plausible, from the HMS blog:
https://www.health.harvard.edu/blog/why-many-generic-drugs-are-becoming-so-expensive-201510228480
-- The market for some generic drugs is so small that it does not attract multiple producers, as with pyrimethamine (Daraprim), a very old drug used to treat a parasitic infection called toxoplasmosis. GlaxoSmithKline had long been the only producer of pyrimethamine, but priced it modestly. This August, however, Turing Pharmaceuticals acquired rights to the drug and exploited its monopoly, raising the price 5,000% (from $13.50 to $750 a pill).
-- In some cases, the number of producers of a generic drug decreases because of an ongoing wave of market consolidation within the pharmaceutical industry.
-- Unanticipated safety issues can limit the supply of a generic drug. Hikma Pharmaceuticals, for example, was forced to stop production of doxycycline in 2011 due to quality concerns at its New Jersey plant. The shortage resulted in a 6,000% increase in the price of the drug.
-- It can be difficult and expensive for a manufacturer to get a generic drug to market in the first place. The average time for the Food and Drug Administration (FDA) to process a generic drug application was 42 months in 2014, compared with an average of 8 months for a standard new drug application.
-- A generic manufacturer must demonstrate that its version of a drug is equivalent to an existing "reference" product already on the market. When only one company produces a drug and tightly controls its distribution, it can be extremely difficult for other companies to secure samples of this reference product.
So, of those, 1 and 5 translate as "industry being awful", 2 is I suppose "broken antitrust", 3 is just "shit happens" and 4 is "FDA taking ages for some reason, possibly connected with generic manufacturers not donating very much to politicians".
4 is really striking, because an application to approve a generic is shorter than an application to approve a completely new drug - the actual title of the form is "abbreviated new drug application" - so there isn't really an obvious reason for it to take five times as long to process.
8
Medicare for All is better than the other plans. And the very act of making it a central part of a campaign makes it more popular and more likely to be enacted.
It is true that one needs to get everybody in Congress on board but that just makes the more complicated and worse plans of certain candidates more frustrating to me. There is now lots of cover for individual democratic congressmen to fuck up bills to favor the insurance companies.
22: There's been recent improvement there. The backlog is way down. Also, an extra fee to avoid the line, because capitalism.
Why do you need consumer protection if there are no bills?
Yes, I should have mentioned consolidation. Free markets aren't free, you have to fight for them!
25: I'd think it becomes more about keeping doctors and other providers accountable. Are patients being discriminated against, for example.
19: There's probably collusion in the insulin market, and there are specific considerations with insulin that make getting generic insulin in the US difficult. (The insulin Novo Nordisk and Lilly make today is significantly better than that of thirty or forty years ago in a couple different ways, but obviously that means jack shit if you can't get it.)
I believe there have also been perfectly plausible accusations of price collusion between Novo Nordisk and Lilly.
25: there is definitely a role for patient protection in the sense of prosecuting malpractice, and looking out for discrimination as you say. It sounds funny talking about consumer protection in the context of the NHS but it does exist and is needed.
21. I don't know how much effect it has had overall, but many of generics are produced in India and FDA inspections have indicated poor quality control during manufacture in some factories, resulting in shutdowns. That leads to a smaller supply of those drugs, or none being available, which pushes prices up. NPR has had a fair amount of coverage of this.
Denials of care will always exist. Medicare has stricter standards for CPAP coverage than many private insurers. People who feel they've been harmed by that need a process for appealing the decision.
And you can't just cover whatever a doctor bills, because there are some who do an excessive number of procedures since they pay well - even if they are not in the interest of the patient.
You could capitate the billing and charge a penalty for everybody who dies based on years of life lost relative to expectancy based on only knowing age.
And take it out of the hides of anyone who serves poor or otherwise disadvantaged communities?
Re: diabetes drugs, I research this every time it comes up and arrive at the same conclusions. There's a growing number of regulatory failures at play. I will try to drop some links tomorrow when I have time. In short, it seems clear that there is collusion. The new insulins are marginally better but not that much better. The biggest problem is that while the insulins themselves are off parent, the companies are patenting things like slightly altered formulations or means of delivery to extend patent life.
Re: generics, it's a low margin area of pharma for old drugs. However, for new drugs, a lot of the original manufacturers also file for the first generic and sell it at a discount from the brand name, but not a deep discount. They have a huge advantage because they have all the data to file and manufacture materials off the same lines, sometimes identical, sometimes with cheaper inactive ingredients or coatings. Traditional wisdom is that only the first two companies to file make money, so it means it's a serious race to be the second entry.
Medicare has stricter standards
BernieCare is way different from Medicare. Coverage will be so comprehensive, no one will be able to imagine a supplemental policy.
35: They practically exploit themselves.
6: So was Warren's assertion, night before last, that we beat Trump with big ideas. (I think this is a misdiagnosis of 2016, but recognize that this is hotly disputed.)
I agree that this is a misdiagnosis, and I suspect it's an intentional one for the exact reason you propose: branding.
It's a shame heebie didn't tell us about this sooner. Maybe we could have gotten her qualified for one of the debates.
That is, I think lemmy is exactly right in 7 that the differences between one set of proposals and the other are truly substantial. I think he's also right in 25 that running and winning on M4A makes it more likely to be enacted. (I'd say marginally.) What hasn't been shown, and what the candidates advancing this approach are really going to need to show in the next few months, is that running on Revolution! isn't just going to run up the score in Brooklyn, Oakland, and maybe Missoula, but is going to win us Wisconsin, Michigan, and Pennsylvania. If Sanders or Warren can show real poll strength for this approach in the particular counties where this thing is going to be won or lost, by the end of the year, I'd say, they might just succeed in derailing Biden.
33: having doctors' income depend on taking commissions on every test they order is nuts, though. Capitation payments work much better.
35: intelligent doctors would simply encourage their patients to lie about their age, thus making the figures look good.
"Ah, good morning, Mrs Alvarez. And how is your little boy today? He's looking very well."
"Oh, he's fine. Just brought him in for his dip-tet immunisation."
"Very good. The nurse will be with you in a minute. Let me just get some details... how old is he?"
"...Eighty-seven."
"That's right, Mrs Alvarez. He is."
43: Well, yeah it's nuts. That's the US heslthcare system. We are moving in some parts of the country to value based payments - combined capitation and outcome based but it's not everywhere.
Sanders apparently wants a doughnut hole - no payroll tax between the current cap and $250k, regular 12.4% over $250k.
WTF?
36. No generic insulin, who is to blame?. STAT seems to be a good place to read about the ridiculous price gouging on insulin. It's relatively recent, it's pure predatory semi-monopoly pricing, and it sucks. NPR's "Shots" articles cover the insanity of our drug pricing periodically, as well.
(Written as someone who has totally fine blood sugar/A1c/etc. but is outraged by this kind of shit.)
46: The discreet charm of the bourgeois forbids certain things.
Please tell me that means no payroll tax for income above the cap. Even so, WTF coming from a socialist (why not just raise the "cap"?), but not quite as bad.
I assume so. Probably the marginal rate for regular income tax jumps at about the same point so it's too much of a double whammy.
47: That first guy quoted used to have an office near me.
47: this really should be a bigger issue. 30 million Americans have diabetes, another 85 million have prediabetes (turns into T2 diabetes in two years unless successfully treated) - that's a third of the population! Where's the National Insulin Association hammering politicians?
I assume so. Probably the marginal rate for regular income tax jumps at about the same point so it's too much of a double whammy.
Not that I can see, but I'm sure you guys are more familiar. Payroll tax is capped at $132k, federal income tax goes up 6 percentage points at $157.5k. Besides, we're talking about a 6.2% marginal rate (12.4% if you include employer contribution). If even Bernie's afraid of that sort of tax hike on people making over $130k, we're never going to get anything funded.
Yes. House payments are only like $1,000 or less, so someone with that kind of income has bunches of money.
There is a general tendency among the Justice Democrats and Berniecrats, including AOC, to go really HAM emphasizing that they only want to raise taxes on the super, super rich. I presume it's part of their notion of building as broad a movement as possible?
(To be fair to them, they do not do this with the taxes needed for Medicare for All - there they can make the persuasive case that the new taxes the middle class would pay would be far under what they currently pay in premiums.)
they do not do this with the taxes needed for Medicare for All - there they can make the persuasive case that the new taxes the middle class would pay would be far under what they currently pay in premiums.
According to CNN debate moderators, this argument doesn't count.
52: The employed middle class is largely insulated from this because of health insurance. The elderly slowly sliding from prediabetes to insulin dependence get government Medicare.
My other beloved uncle is now on in-home hospice care (which is why I've been absentee online - they're also in Texas so I keep driving over there for a day here and there). At any rate, he has stopped eating and drinking, but is "transitioning" and not yet unconscious. When I was there a few days ago, my aunt had reached out to hospice and said, "I think we're ready for crisis care", ie 24 hour nurse care. It was such a relief - he's not catheterized, not getting out of bed, and my aunt and cousins just aren't equipped to read his body language and why he's uncomfortable at any given moment, and if it's fixable or not. It had been really stressful. When I was there, it was clear that the nurse just had so much knowledge that we lacked - moistening the inside of his mouth instead of giving him water, practical methods for scooting him up in his bed when he's slipping, keeping him cool and comfortable in ways that hadn't occurred to us.
Now hospice is taking him off 24 hour care, saying he could be transitioning for days to weeks. I get that this is the industry standard, but the level of stress that my aunt is feeling for the burden of trying to keep him pain-free and comfortable makes the whole thing feel very inhumane.
58: This. The most politically powerful demographics don't personally experience it.
As an aside, I finally found a way to legally buy insulin for my cat at a reasonable cost. Works out to only about $30/month, instead of the previous $95/month. Very happy about this.
I'm sorry to hear about your uncle and my sympathies for your aunt. It's not an easy thing to go through even with help.
59: I'm so sorry. My uncle went through similar things; there's a stressful period where you know it's coming, you can't appreciate the time together, but it isn't coming quickly and there are occasional mini-emergencies.
Because of the tv choices in care settings, I still associate Steve Harvey with death.
Which may be what he's going for anyway.
I'll suggest to them that they put some Steve Harvey on in the background.
58: Even with insurance insulin co- pays can be high. Don't forget the deductibles.
They are bad at times, but there's also more success in the movements to cap that.
I wonder if there's also the issue that Type II diabetes is a disease people are seen as "at fault" for, making it harder for them to advocate and organize. Obviously they still have a level of organization, but it seems well below that of people with cancer.
American Diabetes Association-commissioned Insulin Affordability Survey, 2018, % of people saying past year cost of insulin has affected their purchase or use of insulin:
Uninsured: 50%
Individually purchased insurance: 37%
Employer insurance: 26%
Medicare/Medicaid: 26%
Tricare/VA: 5%
Maybe? But I thought injected insulin was more a Type I than a Type II thing -- don't most people with Type II manage without? I could be wrong about that.
There are several treatments for Type 2, but many need insulin.
Yeah, Type 1 is the childhood onset one where you definitely need insulin all the time. Type 2 (90% of cases) is adult onset - some people manage it with diet and exercise and so on, some need insulin occasionally, some need insulin a lot.
There's adult onset Type 1 and kids with Type 2.
My best wishes for your uncle, Heebie. (And your cat, dal.)
74. Indeed. The pancreas can be attacked by various infections that kill off the insulin producing cells. That's a common cause of Type I in adults.
So given the relative prevalence, the majority of people with diabetes who need insulin probably have Type II.
Since one part of my job is helping primary care practices improve their care delivery to diabetics, I know a bit about this.
If the A1c (glycated hemoglobin - a measure of blood sugar over the past 3 months) is high enough insulin is generally encouraged. (One of our goals 5 or 6 years was to work with our endocrinologists to help PCPs feel more comfortable initiating insulin).
There are newer injectables that are really great and can help with weight loss, but even they don't work if the sugars are high enough, and they are also expensive.
Type 1 diabetics if they gain a lot of weight can develop type 2 as well.
I'm sure A1c is a fine measure, but nothing beats the old-fashioned touch of a doctor who just tastes your urine.