Relevant and even prescient commentary on news, politics and the economy.

A Look at Drug Pricing 2020, Costs, and Why – “Redux”

I had written on the high cost of pharmaceuticals late 2019, “Another Look at Drug Pricing, Costs, and Why” citing from the World Health Organization, the ICER, JAMA Network, Health Affairs, and my own posts (links below and in text). You will find the some of the same articles cited in new commentary of increased drug costs in the Washington Post, Kaiser Health News, and Medpage Today. It appears the three of them have caught up with Angry Bear’s coverage on the rising costs of pharmaceuticals except we go deeper into this issue. A footnote would have been nice as my information has been out for ~ 1 year now.

The Cost Table (below) lists the most common prescriptions from 2012 through 2017 as detailed in the May 2019 JAMA Network Open’s article “Trends in Prices of Popular Brand-Name Prescription Drugs in the United States” shows  median total costs and percent change in price for 49 high volume brand name drugs over six years. If you care to read it, this JAMA Network Open article is open to anyone.

A Bit of A Summary

This particular table can also be found in another post I wrote; Does Trump Read JAMA Network Open? which reviewed the latest JAMA findings (Trends in Prices of Popular Brand-Name Prescription Drugs in the United States) on pharmaceutical price increases from 2012 to 2017. It is another in a series of articles (by me) which has looked at the rising prices of pharmaceuticals. The World Health Organization (2018) findings cited here reflect on R & D costs for cancer drugs and the amount of time needed to recoup those costs (median of 3 years for $750 million) with an average return of $14. 50 for every $1 invested in R & D for cancer drugs.  For the maximum estimated risk-adjusted cost of R&D (US$2.827 BN), the time to cost recovery was 5 years (range: 2 years; 10 years, n=56).

Click on the JAMA Table: Median Total Cost of Top-Selling Brand-Name Drugs 2012 – 2017 to enlarge and again to magnify if needed.

Harry and Louise Now Support Sanders’ Medicare-for-All Plan. With Good Reason.

In the Comments thread today to my post yesterday titled “Clinton Announces When She Will Disclose Her Healthcare Insurance Improvement Plan: She’ll announce it just as soon as the Republican presidential candidates tell us theirs,” reader Urban Legend wrote, as part of a several-paragraph comment:

While a single payer plan is superior in theory — and has been proven in practice — thought should be given to the extreme political danger of offering a program at this time that can and will be painted by Republicans as one that will destroy half a million jobs in many different states. There was more than spite in Joe Lieberman’s objection to the public option. Think Hartford, Connecticut, insurance capital of the country. We would see “Harry and Louise” in spades. (Look it up if you’re too young to remember, and see what happened to Congress in the following election in 1994.)

I responded:

Guys, I’ve pretty much given up on trying to convince Dem baby boomers and silent generationers that it’s no longer the ’80s and ’90s and that the Bernie-is-a-SOCIALIST thing would mean a George McGovern-like trouncing and a Repub sweep in congressional elections. Finally, that argument is no longer being made by the punditry; instead it’s now the reverse: Can Clinton beat Trump, given the public’s now-obvious anti-Koch-brothers-Republican-platform mood.

But I do want to respond to Amateur Socialist’s concerns about Harry and Louise, whom I remember quite well.

The reason for the success of the insurance industry’s anti-Hillarycare ad featuring the young couple Harry and Louise was that the essence of Hillarycare was that it would all-but-force people who had choose-any-doctors-and-hospitals-you-want insurance into HMOs or PPOs that limit the choice of doctors and hospitals to those in a network, sometimes a small network, especially back then, and that sometimes required a referral by a primary care doctor for access to a specialist.

Most people back then had employer-provided insurance that did not have those limitations.  Their insurance was like Medicare—usually like Medicare with a supplemental plan is now.  The problem back then was that there still were tens of millions of people who had no access to insurance, many of them because of preexisting medical conditions, and also that premiums had been skyrocketing. And suddenly many employers were no longer paying the entire premiums.

But of course now, very few employers provide insurance that does not involve healthcare networks.  And very few now pay the full premiums.  And most policies have much larger copayments and much larger deductibles.

These are the really big problems with the ACA’s marketplace plans, too.

And these are the problems that Sanders’ Medicare-for-all proposal would eliminate.  No provider networks, no large copayments, no large deductibles, and affordable premiums.

In other words, Harry and Louise would support the Sanders plan now.

Enough said on that, I would think.

The two paragraphs in Urban Legend’s comment that precede the one I quoted read:

I agree that the Thorpe alleged take-down of Sanders’ single payer proposal is ridiculous. As you say, you can’t expect a candidate to dot every i and cross every t in a broad campaign proposal. The experience of other countries indicates almost certainty that in the long run, everyone would come out ahead with a “Medicare for All” system.


I disagree completely that Clinton has no proposals for healthcare. She has quite specific proposals, including tax credits up to $5000 to reduce co-pays and deductibles (which she says are excessive), efforts to reach 16 million people who are eligible for Medicaid (a single payer plan) but haven’t signed up, and revival of the public option, the primary purpose of which was to make a genuine non-profit, efficient insurance offering available and force insurance costs further downward through direct competition. Whether they are adequate or not is a matter of opinion, but it should not be said that she has no proposals. They are there for everyone with a finger and two seconds to see.

The first of those paragraphs refers to the main point of my post: the sheer silliness of Emory University healthcare economist Kenneth Thorpe’s most recent attempt at a takedown of the Sanders proposal. The second of the paragraphs—well, it’s meaning needs no background.

But it does raise this question: Why has there been no study by mainstream progressive economists about the costs of these proposals of Clintons’, and an explanation of why this would be better than a plan that would, among other things, significantly reduce what are now the very high premiums that employers now pay to private insurers and that employees themselves pay in contributions to the premiums costs and also in copayments and deductibles?

Paul Krugman, maybe?  Nah.

Sighhhh. [Addendum added.]

Sarah Kliff has a very helpful account of Vermont’s attempt to create a state-level single-payer health care system, and why it failed. It’s a bit like the old joke about the farmer, asked for directions, who says “Well, I wouldn’t start from here.”

The point is not that single-payer is a bad idea. It is that given where the U.S. is now, achieving the kind of low costs we see in other countries would involve imposing large losses on many stakeholders, including people with generous policies, health care providers, and more — which is the point I’ve been making. The gains would almost surely be bigger than the losses, but that’s not going to make the very hard politics go away.

— Paul Krugman, Lessons From Vermont, today

I don’t have time right now to read Kliff’s piece, so I don’t know whether she, like Krugman, says that Sanders’ single-payer plan precludes the purchase by employers for their employees, or by individuals, of separate, private-insurer, supplemental policies?

Medicare-for-all means Medicare for all.  Or something close enough to it to allow separate, private-insurer, supplemental policies.  Just like real Medicare does!

As an aside, I do wish Krugman would address the candidate he champions’ campaign tactics, especially regarding healthcare insurance but also about … well … things.

Gotta run.


ADDENDUM: By Noni Mausa in the Comments thread:

Noni Mausa / January 20, 2016 6:59 pm

Canada here. I had a good professional job for 20 years, which included a generous supplemental health policy. Having been retired for 15 years (!) that means that for at least 35 years public and private coverage have rolled along smoothly side by side here.

Still haven’t read the Kliff piece.  But, for the life of me, I don’t understand the basis of this claim that Sanders’ single-payer proposal precludes the availability of supplemental healthcare policies. Or precludes employers from providing them as benefits.  Or whatever these folks are saying.

It sounds like a classic canard, to me.


The little problem with Clinton’s message that Krugman doesn’t mention in his critique of Clinton and Sanders today: Her incessant claim that only taxes bears negatively against “incomes”. [Edited and typo-corrected. 1/20 at 11:34 a.m. Addendum added 1/20 at 11:50 a.m.]

[T]there are serious questions about how we’re going to pay for what we want to see our country do. And, I’m the only candidate standing here tonight who has said I will not raise taxes on the middle class. I want to raise incomes, not taxes, and I’m going to do everything I can to make sure that the wealthy pay for debt free tuition, for child care, for paid family leave. To help us bring down student debt we’re going to refinance that student debt, saving kids thousands of dollars.

Yeah, and that will also come out of the — some of the pockets of people in the financial services industry…

— Hillary Clinton, during Sunday night’s debate

Yep.  She wants to raise incomes, not taxes.  Because all that matters to the financial bottom line of ordinary folk is taxes.  Or so ordinary folk think, cuz they can’t do simple math computations and don’t own calculators that do that.

Or so wealthy Democrats like Clinton, her army of campaign consultants, and Paul Krugman think.

In a blog post this morning critiquing Clinton politically strategically and Sanders substantively, Paul Krugman diagnoses Clinton’s main political problem as against Sanders this way:

[Clinton’s] biggest vice, from my point of view, is listening too much to consultants who want to make cheap shots, like the claim that the Sanders plan would kill Medicaid, when her real strength comes when she lets her inner wonk and fundamental toughness shine through.

Krugman hits Sanders as dishonest for making claims of massive savings in healthcare expenditures in his single-payer plan.  Fair enough—and I dearly wish Sanders would read this post of mine from this morning on healthcare expenditure issues.  (Yes.  My post on this subject.  It’s a good post.  Really.  It mentions Uwe Reinhart!  Who now will post something somewhere on the Supreme Court, in retaliation.*)

But does he think Clinton will actually be able to pay for what she proposes by taxing only the wealthy?  Just wonderin’.

Far more important, though, does he actually think it’s a terrific idea for Clinton to use as a campaign mantra that raising incomes for the non-wealthy and raising taxes on the non-wealthy are mutually exclusive, thus defining “incomes” in a remarkably crimped way?

Why does he think Clinton should claim that, say, healthcare premiums and out-of-pocket healthcare expenditures don’t effect “income” in any but the narrowest sense if those payments are made not to the federal government (horrors!) but instead to UnitedHealthcare, Anthem Blue Cross, hospitals, medical labs, and physicians?

Depends on what the meaning of “incomes” is.  Y’know?

Krugman is exactly right that Clinton is listening too much to consultants who want to make cheap shots, like the claim that the Sanders plan would kill Medicaid.  Actually, though, she should stop listening to political consultants at all.  It doesn’t instill confidence in her abilities as a candidate or officeholder that she mouths imbecilic and easily-verifiably false soundbites proposed by these political consultants.

Or did she actually expect that voters would assume she was correct that Denmark is not a capitalist country and that it has low levels of innovation and a low standard of living?  And that Bernie Sanders wants to remove healthcare coverage from huge swaths of people—or from anyone, for that matter, because universal healthcare coverage means universal for almost no one.

Depends on what the meaning of “universal” is, I guess.  According to Clinton, her daughter, and her campaign, anyway.

It also depends on the meaning of weird. This falls comfortably within that definition.** But a campaign consultant said this was a terrific way to counteract Sanders.  Because …. um …. who knows? Reason enough for Clinton to run with it.

Same with the Republican-governors-could-kill-single-payer-so-I’m-supporting-Obamacare-whose-marketplaces-provision-works-vis-à-vis-the-states-exactly-like-the-2013-Sanders-bill-would.  Nothing—no issue, no matter—is too important for Clinton to profoundly mislead about it. She isn’t paying all those consultants those huge fees for nothin’, you know. She’s gonna get her money’s worth.

Live by the sleight-of-hand, die by the sleight-of-hand.  Or at least because of the sleight-of-hand: you’re own.  At least if your opponent is now, finally, getting real media attention and has a zillion followers.  Who use social media!

But Krugman makes another big mistake that Clinton and her campaign also make: He conflates Clinton’s toughness in defending herself against Republican attacks with toughness in deconstructing, for the public, Republican memes and specific legislative proposals.

Clinton, Professor Krugman, is not Elizabeth Warren.  Warren never conflates herself as an individual with her skill as a policymaker and as a communicator on policy, hers and theirs.  Clinton incessantly does.

Click Krugman’s link, above, to “fundamental toughness”, and up pops a picture of Clinton at … surprise! … the Benghazi hearing last October!  Seriously.


Sorry, Professor Krugman, but I-want-to-raise-incomes-not-taxes is the very antithesis of toughness against Republicans. It’s unnerving that Clinton doesn’t recognize that.

This matters. A lot.

What Krugman gets right in his post today is his reiteration—he’s said this before—that Sanders really, really needs to make clear that he recognizes the abiding importance of regulating the shadow finance industry.  He needs to retain a real expert in this to formulate a specific, detailed proposal to address this.

Please, Sen. Sanders.  Please do this.

But Clinton needs at least as much to ditch the I-want-to-raise-incomes-not-taxes slogan, and to recognize, belatedly, that the price of some cutesy soundbites can be high.

As an alternative, she can switch parties.  Or could if it weren’t too late.


ADDENDUM: Here in sum is the point: Clinton says that the only thing that matters to people’s bottom line is the amount of taxes they pay.

Which apparently is largely true for the wealthy, but is hardly true for the middle class and so-called working class–whose financial bottom line, financial security and standard of living is impacted tremendously by such things as healthcare insurance premiums, whether paid to the government or instead to a private company, and out-of-pocket payments to hospitals, medical labs and physicians.

That’s was so enrages me. Clinton claims by that soundbite of hers that all that matters is “income,” not income minus such things as private-healthcare-insurance premiums and out-of-pocket payments for health care. Added 1/20 at 11:50 a.m.


*For those who don’t read Angry Bear regularly, the Supreme Court is my area of expertise; healthcare economics is definitely not.  So that sentence was intended as a joke.

** Sentence rewritten to make sense. Paragraph corrected also to change “know” to “knows.” Post (obviously) written hurriedly yesterday (I had only a few minutes to write it) and posted in anger.  Rather than deleting it, since there are comments posted to it, I edited it somewhat.  The post’s sentiment remains intact. 1/20 at 11:34 a.m.

FOLLOW-UP TO: The critical point that Paul Waldman highlights, perhaps unwittingly, about the healthcare debate between Clinton and Sanders

FOLLOW-UP TO: The critical point that Paul Waldman highlights, perhaps unwittingly, about the healthcare debate between Clinton and Sanders

I exchanged the following comments with reader Lyle in the Comments thread to my post titled “The critical point that Paul Waldman highlights, perhaps unwittingly, about the healthcare debate between Clinton and Sanders”:

Lyle /January 18, 2016 6:31 pm

The question I would put to Sanders: Hospitals say that they lose money on medicare patients and make it up by charging those with insurance under 65 more. If they are being truthful how many hospitals would your plan drive out of business, or force major modifications to. How many physicians would retire if they could only get medicare reimbursement rates?

Now perhaps then you move to a model like the Japanese system, where once a year the providers and the government negotiate fees,


Beverly Mann / January 19, 2016 10:57 am

Lyle, quite a number of rural hospitals went under, with tragic results—they were the only hospitals within a range of, say, more than 100 miles—after the ACA kicked in, in states that refused to agree to the Medicaid expansion, because the Medicaid program as structured before the ACA had included substantial subsidies to hospital apart from the Medicaid benefit to individual recipients that paid ER bills and such.  The ACA switched that part, and only that part as I understand it, to the Medicaid expansion provision in the ACA, presumably as encouragement to states to adopt the Medicaid expansion.

In other words, it was the federal government that was keeping many hospitals afloat, and still is in states that accepted the Medicaid expansion.

Look, in every other modern-economy, Western-style democracy in the world, the government funds the country’s hospitals as part of the country’s healthcare system. The hospitals do just fine in countries—which is all of them, I believe—that have that system.

As for doctors, I have no idea how many would leave the profession if their incomes were cut.  But, without question, this country needs more medical schools and more residency positions; that’s been the real bottleneck in the medical field.  There are large numbers of people graduating from college with premed credentials who aren’t accepted to medical school because of the small number of medical schools and small class sizes.  And there are many more who would get the premed credentials if they thought they had a decent chance to get into med school—and would have a way to fund it.

Which brings me to this: Medical school should be tuition-free.  At public and private universities alike. This would be a really inexpensive way to eliminate one big reason that justifies the sometimes-exorbitant fees doctors charge.  The government should pay off young doctors’ current medical school loans, and, in my opinion, during the financial transition period should offer physicians stipends to compensate somewhat for lost income.

Many doctors, especially so-called primary physicians—internists, family practitioners, pediatricians—while they have comfortable incomes, don’t make huge amounts of money.  Specialists, especially surgical specialists, do, mostly, I believe.  I have the greatest respect for them and for all competent and dedicated physicians.  But maintaining the huge fees many of them charge just cannot justify the huge costs of healthcare in this country.

What strikes me as absolutely necessary—the Clinton administration’s failure to do so in 1993, and the Obama administration’s failure to do in 2009, were respectively fatal and deeply harmful to the effort—is to place one of the most accomplished healthcare economists at the helm of structuring the plan: Princeton’s Uwe Reinhardt.  There are a few, but only a very few, others who could play the role well.  That Bill Clinton put his wife, who had no background whatsoever in this, as head of his administration’s effort, and that Obama mostly just delegated the entire project to Congress, were foreseeably awful decisions.

There is no question, in my opinion, that physicians’ groups must be major players in this process.  But the issues you raise are not insurmountable obstacles, or should not be—any more than they were in any of the other many countries that have excellent universal healthcare whose costs are far lower than the costs of this country’s current system.

These are, obviously, critically important issues.

Why Do So Many Wealthy Democrats Think The Only Money That Matters To The Hoi Polloi Is The Money They Must Pay To The Government? [with update]

Second, single-payer would require a lot of additional tax revenue — and we would be talking about taxes on the middle class, not just the wealthy. It’s true that higher taxes would be offset by a sharp reduction or even elimination of private insurance premiums, but it would be difficult to make that case to the broad public, especially given the chorus of misinformation you know would dominate the airwaves.

Finally, and I suspect most important, switching to single-payer would impose a lot of disruption on tens of millions of families who currently have good coverage through their employers. You might say that they would end up just as well off, and it might well be true for most people — although not those with especially good policies. But getting voters to believe that would be a very steep climb.

Health Reform Realities, Paul Krugman arguing today in his New York Times column against attempts to enact single-payer, Medicare-for-all healthcare insurance

Good grace.  Where to begin.

Maybe by quoting myself with this excerpt from my post from yesterday, posted before the debate began:

Having no healthcare insurance is not the same as having healthcare insurance.  Unless of course the medical care you need is not covered by the insurance you have, because the deductibles and co-pays under your employer-provided insurance or under the policy you bought through a state marketplace under Obamacare for a premium low enough that your employer or you could afford it, means (unlike more comprehensive plans that others have but you do not) that you must pay those medical bills yourself.

Apparently, Chelsea Clinton doesn’t get out much these days.*

But then, neither, it appears, does her mother, who has claimed repeatedly, including in comments in defense of her daughter’s odd statements about Sanders’ single-payer concept, that the only expenses—the only money people pay—that actually matters to them is money paid to the government.

No other expenses count as money—as loss of income or as other expenditure that actually effects your and your family’s financial bottom line and therefore standard of living.  Money paid to UnitedHealthcare or Anthem Blue Cross in premiums, and to hospitals, physicians and medical labs in co-pays and deductibles, don’t count.  That’s not money paid to the government, see.  So it’s wayyy better to pay more for less-comprehensive coverage to private insurance companies, and still be financially insecure about medical expenses, than to pay less money in healthcare costs to the government and be financially secure about medical expenses.  Because, y’know … the government.

Which—I wish Sanders would point out—is exactly what Clinton says.  Again and again. Just like the Republicans do.

Hillary Clinton should get out more, too.

Sanders did almost exactly that in the debate last night.  But I hope, especially in light of Krugman’s column today, that he points out that the Democratic politicians and commentators who say the public thinks that the only money that matters to their financial bottom line, the only expenses that effect their standard of living, is taxes. Or that the math involved to understand that that is not so is too complicated for most folks to perform.

Calculators are cheap these days.  Even the hoi polloi can afford one.

Sanders got it right last night.  This is the Republican mantra.  And it’s no longer selling so well.

But Sanders also should question why it is that the Clintons and now Krugman, and surely other wealthy Democrats, think (or claim to think) that large and annually increasing healthcare premiums and co-pays and deductibles don’t matter to middle class and so-called working class folk because they’re paid to private insurance companies and private hospitals, physicians and medical labs. Sanders’ next ad should feature one of those folk saying that his or her family’s healthcare insurance premiums and the four-figure medical bills they are paying for a short hospital stay are actual money.  Honestly and truly.

Another ad should show a small-business owner discussing the amount the business pays in premiums for private insurance for its employees and that paying less to the government in additional taxes than the amount it is paying for private insurance could be paid instead in increased salaries and wages.

And there should be a third ad, maybe featuring that very same small-business owner, explaining that the business has a few employees who are seniors and receive, um, Medicare—and that the business pays for their excellent Medicare supplement insurance.  Not complicated.  And not very costly, given that Medicare is—yes, really—itself good insurance. So … voila! Hard feelings by those employees because they aren’t part of the awesome UnitedHealthcare plan that the younger-than-65 employees have and love.

Okay, look.  Only people who are, like the Clintons and Krugman, financially way-more-than-comfortable would actually think that people who aren’t don’t care how much they pay in healthcare premiums and out-of-pocket medical expenses because the checks are made out not to the federal government but instead to private entities and parties.  And that only the most sophisticated among the rest of us will understand that Medicare combined with platinum plated supplemental policies paid by their employer will give them the same awesome benefits that they receive now.  Maybe even better.  Even though it will cost the employer less money.  (Less real money.  Really!)

The Clinton claims and Krugman arguments are profoundly elitist.  They’re spades that should be called, by Sanders, what they are: spades.

Krugman, too, should get out more.

*Chelsea Clinton said last week that she doesn’t “want to live in a country that has an unequal health care system again.”  As I said in my post yesterday, she apparently wants to move to France.  Or Canada.  Or Scandinavia, or Germany, or Thailand.  Or one of the many other Western-style democracies that has an equal health care system.


UPDATE: Reader Lee Russ has posted this comment to the Comments thread:

Krugman’s assessment leaves out one extremely important reality and understates a second.

He left out the reality that his approach is a surrender to the power of the health insurance industry that, as he says, “played a major part in killing health reform in the early 1990s.” As he also says, Obamacare was specifically designed to rely on private insurance to keep those insurers from killing it. Now Krugman recommends walking away from a national healthcare system that even he acknowledges is both better and less expensive than Obamacare, again in deference to the insurance industry’s desires. Allowing the insurance industry to control our lives and our health is not practicality, it is an abandonment of our
rights in a democracy and it is a very big mistake.

Krugman also understates the problems that Obamacare is causing out here in “reality.” Expanding Medicaid has helped the poorest of us get some care, but that program’s low reimbursement rates mean that many doctors decline to treat Medicaid patients. The doctors who do take Medicaid are swamped by the newly Medicaid eligible, and may lose money treating them.

For many people who buy insurance policies through the exchange, massive deductibles must be paid before the insurer pays anything. Doctors across the country have noted the increase in the number of “insured” patients who are having serious problems figuring out how to both eat and pay their deductibles. Krugman wrongly says that “access to health insurance for all Americans” has been the goal. It’s access to health care—not to insurance—that matters. Obamacare too often fails to achieve it.