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The Problems With Generic Medications Go Deeper Than One Company | Slate Star Codex
The Problems With Generic Medications Go Deeper Than One Company | Slate Star Codex
I assume most pharmaceutical company CEOs are assholes who would line their own pockets with zillions of dollars by gouging AIDS patients if the opportunity presented itself. The interesting aspect of this case is that the CEO of Turing got the opportunity. In the United States, pharmaceutical companies that discover a new drug are granted a 20-year term of exclusivity to reward them for the public service of drug research. During this time, they can and do price-gouge as much as they want. After twenty years, the drug becomes public domain and anybody who wants can compete to produce it, usually leading to a precipitous fall in costs. But Daraprim is fifty years old; its patent is long-since expired. So Sarah Kliff from Vox asks the obvious question:? The New York Times estimates that between 8,000 and 12,000 prescriptions get filled annually. You could only fill about a quarter of a baseball stadium with the number of people who take the drug in a given year. So think about a generic drug manufacturer looking at the Daraprim situation. And this is, more generally, a problem with the markets for drugs that only a small number of patients use. It will keep all its patients — and my nascent drug company is likely going bankrupt. This is definitely part of the story. On the other hand, what about? Someone on a drugs forum hears about a cool experimental chemical that sounds fun to try. They get a couple dozen friends in on it and pay a lab in China a few hundred dollars to synthesize a big batch. I am not a chemist, but the Daraprim does not look very intimidating. This might not seem so bad, but it must be harder than it sounds. Nobody wanted to go big, so they all went home. In the absence of this barrier, it would be easy for small boutique companies with a couple of chemical engineers on hand to spend a few weeks manufacturing a few thousand doses of the drug whenever it was necessary to meet demand. Last week I prescribed some modafinil to one of my patients and got a call back from their insurance company saying it was denied because it cost too much. The insurance company said no, it cost way more than that. I was laboring under the misapprehension that the pharmaceutical market made sense. No tour of terrible generic medications policies would be complete without a stop for the. The FDA wanted to encourage people to study drugs that were already in the public domain and get them up to FDA standards. This is potentially a very noble plan. So the FDA was definitely responding to a real problem. Their solution, though, was to say that if anybody did a good enough study on a public domain drug, they could grab it out of the public domain and have it be their exclusive drug for the next while. This was a terrible terrible terrible idea. Colchicine is a very popular and very effective gout treatment extracted from the Colchicum plant. But the ancient Egyptians, being a primitive and barbaric people, had no FDA. And although many different groups had done studies proving colchicine effective, none of them had done so on the official FDA forms. In 2007 a company called URL Pharmaceuticals did an official FDA safety study, showed that yup, it was safe all right, and for this service were granted exclusive right to produce colchicine. After all other colchicine producers out of business and establishing a monopoly, they raised the price of colchicine by 5000%, costing gout patients thousands of dollars a year. According tosomething similar happened withalthough the FDA later changed its mind. Other times generic manufacturing proceeds smoothly. A drug is popular and many different pharmaceutical companies pass the bioequivalency tests, get in on the action, and compete with one another. Nobody snatches it out of the public domain at the last second and receives a new monopoly on it. The companies are able to sell it to the pharmacies for a reasonable cost. Now you get to have a completely different set of things go wrong. You can type in any Michigan ZIP code and any drug and find out how much it costs at all your local pharmacies. All the same stores that were trying to gouge me before. I am far from the only person to notice this. Why does this sort of thing happen? But for now you might want to try using something like GoodRx. The price increased by a factor of about 55, or by about 5500%. Where does the extra 1500% come from? The more easy and frictionless and liquid transactions are, and the more available information is about the products in question, and the more parties are involved in buying and selling the good in question, the closer it gets to the idealized example of the efficient market. You can find the same exact stainless steel multitool on Amazon for 10 dollars or 2. One of the reasons I think that is Cuba. They are poor and have low living standards but their healthcare is apparently top notch. That article is setting off alarm bells in my head. In the case of the Soviet Union, it became clear after the collapse that the economic statistics were largely bogus. In China during the Great Leap Forward, the statistics on grain production were about twice the actual output. That seems to have been not a case of the government fudging the numbers but of incentives for the local officials to vastly overstate them, with Mao at least initially believing the bogus numbers, exporting large quantities of grain while people were starving. Re: David Freidman above. That is exactly my point. The choices are trust what the Cuban govt presents, or the anecdotes that trickle out. Even taking the official reports at face value, the Cuban triumph consists of forcing a desperately poor nation to spend more than it can afford on health care. This is analogous to the example of the Soviet space program that someone brought up in comments to another recent post: a totalitarian government that decides to make a showcase of one particular area can generally succeed, but only at the cost of making the rest of its economy even more wretched than it already was. If I was living under a totalitarian regime, them making public healthcare a central focus would not factor highly on my list of grievances. Adams said in a puff of logic, taking this entire comment section with it. I now see that bringing Turing into it a rhetorical move that was probably too cute by half anyway only muddied my point. We should abolish health care and use the resources to provide the people with world-class food and shelter! I read a discussion a while back basically saying that a big part of health-provider pharma, hospital, etc. Am Australian, can confirm universal healthcare is best. The most you can pay here for a presciption is ~42 AUD ~30USDwith that price only being ~7 AUD for concession card holders. Since the pharmaceutical companies have to make deals with the governments the bargaining power is much better for buyers. We pay less per head of capita on healthcare last time I heard too. Also free overnight stays in hospitals is kind of nice. If the drug companies were losing money on the Australian market, they would just stay out of it. Companies try to make as much money as they can in each market. If the drug companies were losing money on the Australian market, they would just stay out of it. This demonstrates a very serious and fundamental misunderstanding of initial costs as compared to marginal costs. Besides which, if you are presenting the Australian system as a model for America, it is absolutely relevant that Australians are free-riding, and their low prices would not be possible if America were to try the same thing. Edward Scizorhands This demonstrates a very serious and fundamental misunderstanding of initial costs as compared to marginal costs. Development costs are distributed over the worldwide market. Drugs in the US are overpriced by 20 — 40% compared to European countries of similar per-capita wealth. Large pharmaceutical companies make profits in the order of 20%. I doubt that this profit margin was reduced from ~20% to ~18% it would discourage them from developing new drugs. RCF Sure I can. Nothing stops the Americans from bargaining collectively through their government like the Australians do, or even from teaming up with the Australian government and bargain as a single entity. Besides which, if you are presenting the Australian system as a model for America, it is absolutely relevant that Australians are free-riding, and their low prices would not be possible if America were to try the same thing. Almost everybody in the developed world does the same of Australia. The US has a far higher rate of death by murder and violence than Australia. This demonstrates a very serious and fundamental misunderstanding of initial costs as compared to marginal costs. Development costs are distributed over the worldwide market. Consider your previous statement: If the drug companies were losing money on the Australian market, they would just stay out of it. On its own, this market is unprofitable. Potential suppliers would do exactly what you said — stay out of the market. This market is profitable. Suppliers will spend the initial costs and enter the market. We could do an ex ante analysis. I hope you see how this hides the fact that entry to Market 1 is dependent upon Market 2 being suitably profitable. So, while Market 2 can reduce prices, Market 1 would need to allow prices to increase. All of this is obviously complicated by the fact that services have price elasticity. That argument must be justified with data that may not exist. Your system has trade-offs. Decades of politicians trying to come up with schemes to make healthcare better or cheaper with no obvious cost have really taken their toll. Many nations have excellent mostly-private healthcare systems like Switzerland. Many have perfectly good public systems, like the UK. You seem to be under the impression that the extra money Americans are spending on drugs is going to, like, yachts or something. No, most of what we spend subsidizes drug research for the rest of the world. Maybe it would be better to advance a bit slower and not leave people to die along the way. You seem to be under the impression that the extra money Americans are spending on drugs is going to, like, yachts or something. No, most of what we spend subsidizes drug research for the rest of the world. You are not the first one in this thread to make this claim, I wonder where it comes from. Large pharmaceutical companies have profit margins in the order of 20%. If Americans were paying prices comparable to European countries, that profit margin would be something like 18%. Therefore it seems that most of extra money Americans are paying goes indeed to yachts or something. In fact, about half of the largest pharmaceutical companies are based in European countries with universal health care and drug price controls. But there is a huge survivorship bias, because you are not looking at all the startups that failed. The possibility of those large profits encourage startups and investors to take risks. Maybe you are right and all that will happen still if we change the profits that the huge successes will get. Profit as a fraction of what? Defined how—what costs are included? Brn In my understanding, a pharmaceutical startup has two typical outcomes: either fail or sell to a big pharmaceutical corporation for a gazillion bucks. If the drug market was slightly less profitable, the outcomes would be: either fail or sell to a big pharmaceutical corporation for slightly less than a gazillion bucks. Right now there are people who die or live with a lower quality of life e. But you are willing to trade them off for the speculative lives saved or improved by some possible future drug that will be likely developed anyway. David Friedman I was referring to. Oh, Bayer, do you know that? Hey, Merck, apparently you are not the parent company of Merck Sharp and Dohme, after all! Please pardon me, dear Americans, for laughing at your outrage over the rest of the world leeching off your pharmaceutical research instead of getting outraged that apparently you are all regarded as geese to pluck by said companies. And what would you do without American-discovered drugs? How come a ticket costs more than that? Edward Scizorhands You seem to operate under the assumption that non-American health care feeds on the scraps that fall off the American table, while in reality some of the largest pharmaceutical companies are not American and most of health care spending occurs outside America. America is clearly dominant in things like military and computer stuff, but when it comes to health care, it has a system that performs sub-optimally for most people, compared to other first-world countries. Pull the other one; I own stock one of those huge not-American pharmas, I read their annual reports, and I know where their profits come from. Third math question: What price must a company sell compound X for in America to break even? Fifth math question: What fraction of the global spending on Compound X will occur outside of America? Sixth math question: What fraction of the gross profits from Compound X, potentially available for developing Compound Y, will come from sales to Americans? Seventh math question: Do the answers to any of these questions depend on whether the headquarters of the pharmaceutical company are in Boston, Geneva, or Mumbai? America is clearly dominant in things like military and computer stuff, Interesting that you should make the comparison with military dominance, because there are similarities and implications there that bear some serious consideration. It seems like the nationalist and libertarian arguments point in different directions on this one. Compliance with FDA rules gets you most of the way to drug approval in the rest of the world. And, for new drugs, you do need to do something like the testing the FDA requires. There may be ways to do it smarter, if the FDA were to change its rules or disappear in the Libertarian Revolutionbut almost certainly not orders of magnitude cheaper and not without some reduction in safety. As always, is the blogger to follow for this. But the rest of the world is unlikely to just sign on to the Brave New World of Drug Non-Approval just because American libertarians manage to arrange such a thing here. In that hypothetical, drug development probably gets cheaper but Americans still wind up paying for most of it because the rational pharma strategy is then to not even try to navigate the expensive drug-approval process in other countries but just sell the weakly-tested version to Americans at a suitable price. Meaning, expensive but less so than now. The rest of the world uses generic versions of existing drugs at prices their national health services will be quite pleased with. Actual manufacturing costs are estimated to be. This is why I think the US gov and companies should set a minimum sale price to foreign countries, maybe indexed to per capita GDP. It could apply to the US, too, so it seems less targeted against international countries. That way it can help force the rest of the world to pay something like what people in the US pay and limit the amount of freeloading currently done. So instead of defending the interests of the American people through collective bargaining and price ceilings, you are actually proposing that the US government sets a price floor for the benefit of corporations. Nice… Well, it would allow you to bargain down the price of US drugs while maintaining the same profit incentive to develop new drugs. Or, increase profits and encourage more development of new drugs. I would consider both in the interests of the American people. Did we just read the same article? The one extensively documenting the incentives artificial monopolies created by the FDA aka the government causing all sorts of weird market distortions price gouging life saving drugs. The most heavily regulated industries are always the most profitable. Naively, we would expect further regulation to cause further distortions from a well functioning market. Throwing more government FDA regulations at the problem is not the solution. Cars are regulated and must pass lots of tests defined by the government and insurers insist on even more tests, yet cars do not varying in price by factors of ten times nor suddenly go up in price by ten or fifty times when a new CEO takes over the factory or new shareholders buy big stakes in the company. All the GM factories have a new owner from the owner in 2008, yet they did not increase in price by even twice. The regulations impose fixed costs so high that they create a natural monopoly. They are qualitatively different. I think you mean oligopoly or cartel or something—there are a bunch of companies, but the barrier to entry is very high indeed. I think the difference here is that you can buy a car from any car company; drugs are way less substitutable than cars. If the price of, say, a Honda Civic went up by an order of magnitude, you might be cranky about it, but you could very easily just buy another, different, compact car, it would substitute reasonably well. Or buy a used one on the secondary market. So the government has mandated companies give health insurance, which creates distortions of its own. There is also no way for a free market to produce drugs. The government has to step in and pay companies to develop drugs. But instead of giving money directly, it creates a monopoly, allowing drug companies to recoup their investment at the cost of higher drug costs. Well, in places where there is no insurance market the market has managed to reduce prices massively and improve quality at the same time — see LASIK and breast implants. Can we stop bringing up LASIK and cosmetic surgery as if the only difference was no insurance market? They are also entirely optional. For the record, I think india political betting free market can do a lot to contain costs if the consumer had cost in mind, but bringing up those examples just tends to derail the discussion. Can we stop bringing up LASIK and cosmetic surgery as if the only difference was no insurance market? They are also entirely optional OK, shall we talk modern dentistry? In the same ballpark as LASIK and cosmetic surgery, as it turns out. For that matter, look outside the medical industry for a bit. And the resulting prices are almost always obscenely high, usually for poor service. At the same time, socialized healthcare seems to work decently in other countries, even better than the more market based system of the US. Most markets still end with people spending their own money to buy stuff they will personally use. Prescription drugs are usually prescribed by doctors, paid for by insurance companies, and consumed by patients, a decoupling that leaves nobody in a position to understand whether the deal is at all fair. Well, except maybe the seller. If the rare patient who pays cash for their own meds decides to not pay, say by buying mail order from an Indian pharmacy instead, who cares? EMH is about stock markets. It came from empirical evidence about stock market prices and aimed to explain that evidence. Might be thinking instead of the law of one price, which is important for other kinds of efficiency. If it were simply the existence of insurance, the same car should change wildly in costs based on where you buy it or who takes over to run the same company making the same cars because almost all cars get covered by car insurance that pays for fixing or replacing them. While I agree with that statement, Health insurance is a different problem than the regulatory barriers Scott is talking about. That is not what it says. It says that brand-name Provigil costs that much. Maybe the manufacturers discovered that they were alone and raised prices. Or maybe one of the reports is false. If only a few people have modafinil, they have an extra weapon against the demon. If everyone has modafinil, expectations and competition increase and so the demon becomes stronger. The same arguments which say that permitting modafinil would lead employers to expand the size of the week to 60 hours would imply that employers would already expand the size of the week to 60 hours at least, whenever they are legally permitted to. If you reject that frankly ridiculous assumption, we could all be in a much better position if everyone took modafinil, working harder and better. Since people find the marginal value of such hours higher, employers have to pay them more to buy the hours—enough more that it costs the employer less to hire a second person rather than pay the first person for the extra hours. The employer would only be able to do this if either the employee is so valuable that even the heightened salary is worth it for the employer which covers cases such as highly-paid actors and CEOs having to work long hours or if the employee is so cheap that the cost of the employee is dominated by fixed per-employee costs instead of by salary which covers sweatshop workers. Presumably, people who take modafinil to gain extra hours of wakefulness will value the extra hours more than the existing hours, so modafinil will result in the same effect and will not expand the work week to 60 hours. This person understands me better than they do. As a result, they might work somewhat longer. But this is not necessarily so. If modafinil increased productivity while at work, the income effect of the resulting higher wages might encourage them to work less. None india political betting this changes your basic analysis, which is spot-on. It is the market reason for overtime pay. The less leisure you have, the more valuable it is. That is, obviously, completely false, and George Reisman has a good article,carefully explaining why. Jiro: We actually pretty much do see that with salaried employees working a massive amount of unpaid overtime in the US with hourly employees there is a legal barrier, its much cheaper to have 3 people with 40 hour shifts than two people with 40 hour shifts. Though I think that is an even stonger demonstration in favor of the stuff, we have the problem even without the pills. That was the whole point of the raises and promotions existing to begin with. It literally cannot be cheating. Starve in your twenties or come down with cancer in your fourties — what an economy. Even if they actually were harmless, not just not-yet-known-to-be-harmful. It seems wrong on a level beyond the possible side-effects. But at that impossible level, it would quite probably be the right choice overall. Sports often already have detrimental side effects Muhammad Ali! And while I am sympathetic to the concern that economic competition make us waste our lives just to keep up, and that we need some kind of laws to prevent that, nootropics seem like the wrong end to start. I guess the most popular illegal drugs are amphetamine and modafinil, which help you concentrate and feel awake. Work keeps me from many fun things, but being distracted and sleepy are not among them. One problem with this discussion is that it implicitly assumes that market competition means the second best producer gets nothing, that if I improve my ability a little you have to match it or lose your job. So I get to decide whether the extra 10% of income is or is not worth my estimate of any negative side effects from the drugs. Humans are the economy, and the economy is humans. David Friedman However, if one believes in a Malthusian-type view of the world, then raising productivity by 10% will increase the resources needed to survive by 10%. If there was a drug you could take which would remove your psychological need for leisure, you would be obliged under utilitarianism to take it so you could donate more money while still being psychologically healthy. Apparently, you are one of those people who consider employment to be a terminal value, rather than instrumental to the goal of acquiring resources. Number of jobs can be an indicator, but optimizing specifically for it is a stupid thing to do. Albeit a rather inefficient version. If you want to give people money, give them people money. Humans are the economy, and the economy is humans. Entirely correct, thank-you, but I have to ask — what then? If being part of a superfluid had a moral impact on electrons and I cared about electron welfare, I would talk about how the order parameter should exist for the electrons rather than the other way around. How many people go around bragging about being artificially enhanced? We already have a society-wide experiment running for decades concerning how cognitive enhancers change the dynamic of work expectations and labor market competition — called caffeine. So many in fact, that caffeine users generally set the baseline standards for aggregate performance in any field of employment. Well, you better hope you find an alternative or have some other compensatory factor genetics, more sleep than average to keep from operating at a handicap. Since workaholics are more likely to be successful and rise to the top of their professional hierarchies, they, having earned the moral badge of success, set the behavioral norms and ideals for everyone else. In an economy where the path to life-altering success feels more and more like an top-tier college admissions funnel, the pressure to adopt the behaviors of the most productive members of the workforce become prerequisite for effective competition. But doping, and at some point down the line, other forms of permanent augmentation, imbue benefits that significantly widen the capacity gap between those with and those without. Disparities in access and affordability create new channels of widening social inequality. I should note that the generics market works very well for relatively common conditions. The biggest problem is orphan drugs going back to the orphan drug act of 83treatments that work very well for very rare conditions. Then someone games the regulation, so the regulation changes. The obvious solution is to use some of the many, many unemployed biochem phds to produce them in a tax-payer funded non-profit lab instead of letting grifters skim rent off the regulations. I got a prescription for it and went to the local CVS to have it filled. The next month I was in Taiwan and bought a larger tube over the counter for about six bucks. What size of tube was that? Unless this was for a bucket full of the stuff, I have to say they saw you coming! Did my CVS just screw up? Tablets, by contrast, are indeed cheap. GoodRx appears to find prices in about the same range the best deals are cheaper, but still in the hundreds. But only for the ointment. That is nuts and I must be making a stupid mistake here. But it may be that there are big state-funded not-for-profit drug factories in e. If so, maybe we should try making them an offer to up production. If you want it here, you need to smuggle it over the border. Buying price-controlled drugs from other markets is basically equivalent to imposing price controls ourselves. You think price controlling generics i. Or only price controlling new drugs? Price controlling generics would just impact supply of those generics and their potential competitors. Which evidently is already sufficiently a problem in some cases that the government feels the need to subsidize orphan drugs by offering to restore monopoly pricing. If a government funded lab is a politically viable option for undercutting private industry private industry will figure out a way to drop prices far enough the lab never gets set up. The obvious solution is to use some of the many, many unemployed biochem phds to produce them in a tax-payer funded non-profit lab instead of letting grifters skim rent off the regulations. Yes, because the moment you call something a non-profit human selfishness promptly disappears and no grifter would ever dream of trying to defraud The Government. Honestly one of my biggest pet peeves with the economic understanding of the average blue-tribers is that they tend to significantly overestimate the cost of profit while wildly underestimating the cost of logrolling, graft, regulatory capture, and bureaucratic waste. I work in a nonprofit. Or are you under the impression that a government-run unregulated lab cannot go bankrupt, impossible to succesfully sue for bad products will be better run than private unregulated labs? Now we have an entire department dedicated to producing paperwork evaluating the costs and benefits of each regulation. David Nutt tried to be rational about this, but it got him fired. But hey, free markets always work, right? Too few people have the disease to make it worth the cost of production. The point of the orphan drug and rare disease laws and regulations is to encourage drug manufacturers by increasing patent exclusivity time and providing tax incentives. You make it more profitable so people actually produce these drugs which basically offloads the inflated costs on insurance companies. The problem, as I said above, is that there are obvious ways for companies to game such a system. Consider the case of scorpion anti-venom. The entire supply for Arizona was made for free by Marilyn Bloom, an Arizona State professor who retired in the late 90s. As a result, a few years later the entire state of Arizona had no scorpion antivenom. We can go the simple route, and directly manufacture the unprofitable drugs, or we can hammer on the market trying to make these drugs profitable. And then hammer on the market again when someone starts gaming the regulations, and then keep moving them around,etc. Too few people have the disease This seems like a somewhat self-contradictory statement when the argument is about a company charging loads of money for a drug. Profitable at what price? The only way the government should intervene is if a producer gets total monopoly power over a drug, in which case price controls pending a competitor appearing seem OK. Of course, the real question is how much of the cost of entry is really necessary, since most of it is imposed by the government regulators in the first place. I have no idea? What bloody industry do you think I work in? You could churn them out in an unregulated factory for nothing. The unregulated lab could then seek some kind of independent certification from a private lab that specializes in testing drug quality. The unregulated lab could also purchase some form of liability insurance made cheaper by the independent certification. Could we maybe just cut steps 1, 2 and 3 and just not have the regulation in the first place? If everybody is allowed to sell sugar pills calling them daraprim or modafinil, then the information asymmetry will kill the generics business by turning it into a. If customers are unsure that a generic medication was a properly manufactured drug or a sugar pill or worse, a dangerous badly manufactured drugthen only the poorest and most desperate ones will buy it if the price is sufficiently low. This reduces the profits for the sellers, putting out of business the honest and high quality manufacturers while still allowing a margin for the dishonest and shoddy ones that incur in lower costs. This in turn makes customers even less likely to buy generic medications, and thus puts even more proper manufacturer out of business, creating a feedback loop that eventually results in generic drugs being very cheap and very ineffective and unsafe crap. They may not have wanted the government lab unregulated, but in that case the cost will still be high. RE: Lemon Market — I am not actually in favor of a completely deregulated pharmaceutical industry — I have seen the sub-standard work people will do in unregulated factories. Why not just setup regular non-profit labs? It seems like most of these small-market drugs could be setup for manufacturing or distribution by a single non-profit for a relatively small and mostly one-time expense. Drugs being developed by government-run labs is communism, but a government-enforced monopoly is a market solution. That was part of the 19th c. When a 32 year old hedge-fundie with an annoying smirk and a tendency to justify himself using rap lyrics jacks up the price of a drug a few orders of magnitude, everybody loses their mind; when the FDA and some of the largest pharmaceutical companies in the world collaborate to do the same, it passes with barely a peep. Yes, there is something different in the coverage. I suspect that there is an important phenomenon pointing in exactly the opposite direction. Selling off the drug isolates the backlash from all the other drugs owned by the big company. Has anyone here tried both wellbutrin and modafinil? Also, has anyone here tried modafinilcat and can say if it worked out? Worst experience is having to confirm with a friendly banking robot that I am not being defrauded. They offer a sampler pack; I personally found that armodafinil has a lot fewer unwanted side effects i. Shipping seems to take about or less than a week, modacat provides excellent package tracking, and the entire ordering process is a breeze. Is this a real thing, and has Scott or possibly Gwern gone over it at some point? Gwern did a big cover here. It sounds like rashes occasionally happen but go away if you stop taking it. I have been on Wellbutrin since 2011. I have long-term depression, and have been on and off a number of medications for it over the last 25 years. I have been taking Nuvigil armodafinil for a couple years, not for its nootropic effects, but because, thanks to a sleep disorder and a completely bizarre work schedule, I had become narcoleptic. If I am not actively working on something, I can literally fall asleep, standing up, in a noisy room with 1,000 people in it. Modafinil is racemic; that is, it is a mixture of left and right-handed molecules with slightly different pharmacology. When the patent on Provigil was about to expire, Cephalon determined to the satisfaction of the FDA that the right-handed molecule was more effective, and separated it out as a new product, Nuvigil. Nuvigil is now the recommended treatment for narcolepsy and shift-work disorder, in place of Provigil modafinil. This is, I imagine, the reason that the drug companies can charge these ridiculous prices for their products — most of the consumers are not paying for them directly. Probably you are, via higher insurance premiums. A warning: Modafinil in moderately high doses gave me rather noticeable muscle spasms. The spasms went away once I stopped taking modafinil. After a bit of research, other countries seem to use price controls to deal with the price of prescription drugs. That makes me uneasy, but maybe in a case as extreme as this it is warranted? Everywhere, not just in the United States. How much drug development money already comes from the U. H and other grants to universities and other places? How about Roche and Bayer? They survive European regulation while still being pharmaceutical giants. IIRC Merina and Skylar were developed in Europe. As I understand it the big costs in drug development are not the actual lab work but the big clinical trials which check for rare side effects. It gives you 100 targets that a potential molecule might be able to cure the disease by interfacing with. Not perfect but not everything is hopeless. Also, if people can get funding for drugs with small effect sizes, it should be possible to get funding for something that works on 100% of cancers. Though it might take a while to move through the chain of gatekeepers. Another tactic would be selling life insurance policies to cancer patients, then giving them the drug. How much drug development money already comes from the U. H and other grants to universities and other places? To the first order, none. Government and academic labs develop drug targets; interesting bits of biochemistry where if a molecule were found to bind to X, it would theoretically have effect Y and interrupt the progress of disease Z. Then someone has to find the molecule that binds to X. Not the one that also turns the patient plaid, the other one. No the other other one. Then, and only then, actually verify the theory that says that binding to X cures Z. Nine times out of ten, one of these steps turns out to be absolutely impossible. The tenth time, you have to prove you did everything right, with hundred-megabuck clinical trials. Government labs could in principle do it, and have in the past — Penicillin, as a drug you could give humans rather than just a laboratory germicide, came out of a crash government program to give the U. Army a decent antibiotic going into World War II. But I am skeptical that scientific megaprojects run by the government are going to turn out cheaper than free-market solutions or even crony-capitalist solutions. Turing is only the most outrageous increase. This is pure profiteering and nothing to do with pharmaceutical research and development, and he should be smacked on the nose for it. This is pure profiteering and nothing to do with pharmaceutical research and development, and he should be smacked on the nose for it. We need something more specific. The pharmaceutical industry can afford more and better lawyers looking for convoluted paths to obscene unearned profits in that environment, than the government can afford to pre-emptively block all those paths. The decade or so ended before most of us were born. This reminds me of the argument for perpetual copyright, as if anyone is going to make a movie if they can have exclusivity for 100 years but not if it is only 75 years. Was CorePharm the company he bought the rights from about to discontinue the drug? If so, imagine somebody more attractive buying the rights. Maybe another way to ask my question is: Why was this opportunity even available? Why are we mad at Shkreli rather than at CorePharma aside from the fact that Shkreli acts like an ass? Well, okay, Derek Lowe does sort of seem mad at CorePharma and GlaxoSmithKline the original producertoo. Some guy comes along and notices that there is some money to be made resurrecting it, so he tracks down who owns the rights and buys them, selling this previously unavailable drug at Market Price i. If not, what exactly distinguishes him from Shkreli? I wonder if there is anybody like that? Selling the drug at hundreds of dollars only makes money because of government interference, namely, the requirement that competing versions are tested against your version which you refuse to sell to them. Someone who does not do this government-mandated and impossible testing cannot make money by competing. It requires the second company to procure drugs from the first company to conduct the bioequivlence study. But under the pretext of complying with recent FDA regulations to encourage drug companies to prevent diversion, the first company can tightly control distribution to try to prevent the second company from getting any to test with. Hedgie is try to do. Not technically legal but in small numbers unlikely to be seized by customs. Which in turn points out one good solution to this mess — reciprocity with other developed world regulators, at least for generics. A more comprehensive solution is to publicly fund a generic manufacturer of last resort. Given that so much of the cost of these stunts including related stunts with so-called orphan drugs falls on medicare and medicaid, it would probably save money. And no one could accuse the government of stiffing the production of new drugs since it would only manufacturer drugs in the public domain. The basic idea is that Walter White branches out from being a meth kingpin and eventually delivers higher-quality prescription drugs than you would get at a pharmacy at a lower price, such that, regular, otherwise law-abiding citizens whose primary goal was to get their medication would buy from him instead of from whatever had FDA approval. This testing for medicinal and, I suppose, nootropic drugs is heavily subsidized by profits from recreational drugs, which are sold in high quality with fact sheets containing information about side-effects and risk of dependency and stuff. Have you seen the Dallas Buyers Club? The movie is similar to your premise except that what they do is more of a legal grey zone than a black market. That sounds like a premise of Breaking Rational, a HPMOR-equivalent for Breaking Bad. Now we only need someone to write it. I think Scott should help with the parts describing effects of psychoactive substances on story characters. Universal love, transcendent joy… What is interesting to me is how this whole story ends up being an ideological Rorschach test. The issue becomes who gets the blame for the situation. Libertarian-leaning people seem to blame the entire situation on evil FDA regulations. The drug companies say that high prices are because of how expensive it is to market and research new drugs but a lot of this is already done with government money in one way or another. There is an implied threat that there will be no more new drugs if the U. But the only way to test this is for the U. My guess is that there would still be new drugs coming to market. The guy is only three years my junior and he mainly tweets about spending 5 figures on rare bottles of wines, helicopter rides, and other conspicuous consumption choices. The dude might be operating in the world of the perfectly legal if not morally defensible but his brazen consumption bragging could not have helped his case. And I am not opposed to spending money on quality product or the profit motive. Well should we institute the price controls based on your hunch and then 15 years later try to figure out how many life-saving blockbuster drugs were NOT developed because of artificial price controls imposed by the government? There seems to be an argument that the rest of the world can have a welfare state at the expense of the United States not having one. I am not sure that this is true. Capitalists being capitalists will find ways to develop products even in countries with strong price controls. Thalidomide and Acutane were both developed in Europe and both have horrible side-effects. FDA regulations stopped Tahlidomide from being approved for use in the United States and it seems to be credited to one pesky regulator who died recently. Accutane is available in generic form in the United States. I see no evidence to suggest that drug development would stop if the U. The truth is that it was the person, not the rules that blocked it. It is these lost opportunities, decisions to not investigate a drug where society loses. You would never find evidence of this after the fact either from your point of view. Artificial restraints on the market are rarely a good idea, but sometimes necessary. There is some evidence. There are more examples in Bad Pharma. Legally drug companies in the US have the freedom to pull this kind of stunt but we can see from the fact that the company which previously owned the rights not doing so, not every executive acts like a sociopath and charging as much or more than the market will bear. Many countries deal with these problems by making the action illegal in both cases above due to the impact on others. The weird thing is that in the US there seems to be this belief that things are by default morally OK if someone is doing it to make money or that we should expect no better of corporations than to be exactly as evil as the absolute legal limits imposed upon them. It both improves scale and makes it more likely that one of the more socialist systems will fund things if the total cost is too high. People like Shkreli are the reason why so much regulation exists in the first place. Their determination to screw other people over to the maximum possible extent imposes both short-term costs on whoever ends up paying, and long-term costs on the whole society. Well, it depends on whether your fantasy system relies on all human beings to be perfect, compassionate and altruistic at all times, forever, or whether you deal with the real world in any form. The former explains high prices well, but only the latter explains massive price variations within the US. What solution can deal with these things is tricky. European-style government-run healthcare seems to do better on both at the moment. In such a system, the government internalises the costs that result from its standards. Internal politics and inappropriate levels of screaming make the tradeoffs European health systems strike still excessively cautious possibly less excessively cautious? Price controls would probably do a little worse there than the fully government run system, because in the latter the government is at least on the hook for additional healthcare expenses incurred as a result of poorly treated diseases. So, this makes me think about the underlying roots of which direction I run on this and similar issues. I get this idea that regulation X causes problem A; one side wants to remove X, they other side wants to patch X with regulation Y. Definitely a bias I need to make myself aware of any time a discussion on this sort of topic is taking place. Big corporations tend to LOVE complex regulations, because only they have the army of lawyers necessary to game the regulations to maximum benefit. Which has obvious conflict of interest issues. My admittedly cynical-libertarian slant is that the more power you give the government, the more detailed and complex you make their purview, the more opportunity for abuse you have. But maybe never a better time to get a hefty dose of rage? This is standard Regulatory Capture 101. Too late, not going to change, anything that looks like a change will just be cleverly arranged to produce the same end result. The Longecity-type hack is a neat idea, and might be a way for clever and exceptionally well-informed people to deal with the problem. If it ever comes close to being a real solution for everyone, the FDA actually does have SWAT teams and they can get the records of your payment to the Chinese lab. Take a look at the supplement and cosmetics industry. If you want to buy resveratrol, for example, there are 500 different vendors to choose from, and many of them are highly trustworthy. And resveratrol, as a raw material in powder form, costs twice as much as pyrimethamine. It beats buying bulk powders from China, and it beats a drug black market. Onerous regulations may make things marginally safer — at huge, one might say disproportionate, social cost — but it certainly does not eliminate risk. Did troglitazone and rosiglitazone have any unexpected side effects? Or did they just have bad luck to get a few adverse events and were pulled from the market due to pure noise? The supplement industry is actually kind of terrifying: Also, Consumer Labs and some of the other big testing places charge to read their reports — I think the current burden in research, knowledge and money in order to try to make a good vitamin purchase is fairly non-ideal. Surely not as terrifying as ordering chemicals from underground chemists in China and taking them on faith? As far as that particular article is concerned, the testing methods that the NY attorney general used were wholly inappropriate. Erebus Well, I have some health conditions that make certain vitamins and supplements desirable for me to take. And it beats the Longecity model by a country mile, as well — both in terms of scope and in terms of risk. Yeah, this is a poor example. There are useful ingredients and useless ingredients. Educated consumers are healthy and safe consumers. Cheaper than paying for a single dose of some generic drugs, which cost pennies to actually manufacture. The cream will rise to the top, and the scum will sink to the bottom; there will be trustworthy and untrustworthy vendors. My argument is basically that if regulations were loosened to near-nothing — to late 19th century levels — things would be a lot better than they are today. So far they are not being super well treated by the supplement industry but it doesn't matter much because supplements have small effect. Extending the same lack of regulation of advertising and of quality to medicine in general seems likely to have a very negative impact on them. The world does not have an underlying design which would make things great and fair for everyone so long as everyone does What They Are Supposed To, so making things more fair for the educated and intelligent consumer can make things less fair to other people, and there isn't going to be an easy fix for that in the form of someone else who just needs to start doing What They Are Supposed To to sort it out. You have to make compromises, not just focus on one group and optimise for them and assume that it should be possible for other groups to deal with the results of that because if they couldn't it wouldn't be fair. I live in Hong Kong. Medicines are wholly unregulated here and pharmacists are held in the same regard as shop-keepers. Antibiotics and antivirals cost pennies. In fact, they are very well-served by this unregulated market, as they can actually afford to pay out of pocket for the drugs they need, when they need them. Hong Kong also has an extremely high life expectancy, which would seem to indicate that its laissez faire attitude towards pharmaceuticals leads to positive outcomes. My objection was to the case built around solely how a market built on reviews and consumers doing their own testing keeps an educated consumer healthy and safe without addressing what it does for the rest. If there was a cheap way to do almost as well then companies would use it to avoid advancing drugs which were going to fail into FDA trials and avoid ever having expensive failed trials, and while they do some of that they still have a huge failure rate in clinical trials. There are useful ingredients No, in fact, there are not. Unless you are a pregnant woman, a Zambian child, or afflicted by one of a handful of rare diseases, there is no medical need for you to take vitamins or supplements. And what happens if the second bottle but not the first is tainted? Hong Kong also has an extremely high life expectancy, which would seem to indicate that its laissez faire attitude towards pharmaceuticals leads to positive outcomes. Are you seriously drawing a causal inference from a single data point? All of the developed East Asian countries have high life expectancies regardless of how stringent their drug controls are Asian-Americans have a higher life expectancy still. The point is more that huge sums of money are wasted on vitamins and supplements with a small risk of grave harm and no upshot. Earthly Knight I rather like CoQ10 and experimenting with nootropics, and lots of folks obviously feel the same way. And I feel that this problem is simply that there is no free market for generics. There are lots of things which some well informed people believe might be good for you which nobody can be certain are good for you. Strikes me as a sensible gamble. You are failing to factor in the amount of money which will be squandered on nostrums and patent medicines in an unregulated market. There are lots of things which some well informed people believe might be good for you which nobody can be certain are good for you. Certainty is an unreasonably high bar— what we really want is a reasonable degree of confidence that the supplement or vitamin in question will significantly increase your lifespan or improve your quality of life without also carrying an undue risk of harm. As far as I know, no supplements or vitamins exist at present which can make this claim, and indeed if there were any they could in due course secure FDA approval and sell like gangbusters. The product you mention has a batch of endorsements by high-flyers cf. And what exactly is being repaired in the body? And is the outcome the same for everyone? Good luck trying to sue them through a Chinese court from your hospital bed in America! Well, either this supplier is reputable or they are not. If they are currently reputable, they will no longer be and they will lose customers. If they are not currently reputable, then buying their stuff was a bad idea to start with. Now you may point out quite rightly that if the reputable producer poisons their pills, that will cause a lot of suffering before their reputation is updated. But then again, if a company with FDA approval to sell their drug starts cutting it with fertilizer, that will also cause a lot of suffering before their approval is revoked. Also, the problem today is that the very thing that makes a producer able to satisfy your demand for a cheap drug is what makes them able to deliver a bad product with no legal consequences. If medicine was deregulated, it is likely that there would be many US manufacturers to choose from who you could sue if they start delivering fertilizer instead of modafinil. But then again, if a company with FDA approval to sell their drug starts cutting it with fertilizer, that will also cause a lot of suffering before their approval is revoked. CLEARLY IT WILL MAKE ME LIVE FOREVER! Patent medicines often contained heroin or cocaine no surprise about their appeal there and ionizing radiation sterilizes things. Rich people in our day believe stuff just as stupid. But the 19th century was also about The Triumph Of Science. So much industrial and technological progress was being made, people were living richer, easier lives than in the past, new products and labour-saving devices were coming out all the time sound familiar? Now you can get better from a disease that previously would have been a sure death sentence — why, this same drug will surely knock that cold on the head in no time flat! And look at the unexpected side-effects when you start testing drugs — Viagra started off as a candidate for treating angina and hypertension before the other benefits turned up. Cue a whole new market when finally a working aphrodisiac had been discovered! Yes, that is an over the top and snarky summation. Do you agree or disagree with the following statement: The more the truth of claims about benefits and harms of a product are not readily apparent to the consumer, the more important it is that a third party which is hard to coerce or bribe be responsible for validating the product in some manner. Hard to coerce but possible to bribe, and, in the regulatory context, it has a monopoly position. I agree with this statement. Since basically all government bureaucracies are easy to bribe on an industrial scale, it is particularly important that government bureaucracies be kept out of the product-validation business. Nobody has yet found a way to make a government bureaucracy immune or even highly resistant to industrial-scale bribery, aka regulatory capture. Yes, that is an over the top and snarky summation. What about strict campaign finance laws? These seem like they have the potential to thwart regulatory capture, even if they are objectionable for independent reasons. Campaign finance laws would do very little to thwart regulatory capture. At least in the First World, most of it comes out of lobbying and information and staffing asymmetries, not favor-trading. Information asymmetries are not trivial, but there is generally a pool of academics to draw on and consumer or environmental groups happy to suggest candidates. But I can offer an even tidier fix for this problem. Sorry, if I was incorrectly ascribing views to your avatar. I mean, the completely independent bond rating agencies seem to have had a far worse problem in terms of corruption and capture. And the more arcane the instrument, the worse it was. I contend, this is just inherent tension in these types of systems. The best way to minimize it is via cultural mores. People like to piss and moan about building codes, but those seem to work pretty well. What about strict campaign finance laws? These seem like they have the potential to thwart regulatory capture, even if they are objectionable for independent reasons. Regulatory capture works primarily at the level of unelected bureaucrats, because it is the bureaucrats who write and implement the regulations. Even if an issue rises to the level where a congressman introduces a bill saying that e. Those pages of text will be written by unelected bureaucrats, and it will be unelected bureaucrats who explain to the congressmen that yes, these pages of legalese do in fact close all the loopholes. For reasons that I think have been explained here repeatedly, those bureaucrats will be very nearly de facto employees of the pharmaceutical industry. Even the ones that are specifically hired by individual congressmen to give them sound advice on pharma legislation. And if you still think strict campaign finance laws will be any use at all, those also will have to be complex tomes of legalese to close all the obvious loopholes, and will be written by, oh, you know the rest. And most regulatory issues never rise to that level in the first place. This is a complicated problem, deeply rooted in the structure of a civil service more than two centuries old, and lots of smart people have spent a lot of time trying to solve it. They are hired by people who are hired by people who… are elected politicians. There are literally hundreds of thousands of doctors, biochemists, and pharmacists who have nothing good to say about the pharmaceutical industry. There is little need to advert to institutional causes when there are actual flesh-and-blood legislators who will cheerfully tell you what a great idea it is to have Pfizer reps draw up bills for them. If memory serves, the solution I proposed has been tried before, but it was voided by unelected bureaucrats appointed by presidents beholden to mammoth corporations. So… case in point? Here is the fountainhead of regulatory capture: It publishes model legislation and has enjoyed great success in prompting chiefly Republican legislators to introduce bills on its behalf. The Cato Institute is a member. Dollars to doughnuts that the Pauls, pere et fils, have also collaborated in the past. Pardon for not being polite with the threading, but I really like this anecdote. Even more so, the discovery of vitamins! That terrible disease which cursed the mightiest navies in the world? That mysterious skin disease that cursed poor farmers for so long, maybe due to bad air or something insect-carried? Within a period of a few decades, diseases which had plagued us for centuries or longer vanished with the application of tiny quantities of nigh-magical substances, to the point where scurvy, rickets, and pellagra sound like weird, old-timey words to us now. People do take vitamins in useless ways just like they try to do for antibiotics. Probably most vitamins taken in the US are taken for such useless reasons. You could add some currently illegal drugs to this too. But not all because a lot of them would make very effective weapons to use on people, e. If I were the god of all drugs laws, I would try 10 other solutions before providing heroin. Solution number 3 would be setting up special areas very remote where addicts to the worst drugs could be sent, instead of prisons. Ideally these would be OK places to be, sort of gated communities for junkies. It would need to be funded but you would probably save money overall because of fewer prisons. These places would have the drugs freely available. Most people who were there would volunteer to go because of the free and easy availability of the drugs, they would be free to leave if and only if they agreed to have an implant fitted that prevented the drug from working on them. Having the option to exit society and spend the rest of your life doing heroin in a gated community, with the government footing the bill, seems pretty appealing! Sort of like a monastery, but for sin instead of prayer. Social engineering has a bad history. Drug addicts volunteer to be sent there because the drugs are free and clean eliminates incentive to evade the police 3. Drug addicts can lead lives there, have sex with the opposite gender! You are probably not making it much easier to take these drugs for most people because you would have to make a commitment to go to the drug monastery. It would not be a spontaneous decision you make at a party at 3am. Your opiate camp proposal sounds like it would have some potential negatives. Given that, so far as we can tell, prescription heroin already reduces criminality in addict populations, having the treatment centre in the place where people india political betting live, where their friends and family are thus keeping them in touch with the social connections that I understand is a big help in overcoming addictionsrather than sending them miles away to a place where everyone is already a problematic opiate user, would still seem like a more sensible option. Does that actually happen often enough to be a serious strike against the benefits of ending the War on Drugs generally? Winter Shaker: you make some good points. Would spiking someone even be illegal? Drug addicts have extremely inelastic demand curves!!! Having them injected under supervision, for free, at a government recreational drug centre would be better. Both options have the potential downside of increasing demand. With a drug centre in the community, people would go there in their lunch break because they thought they had the willpower to kick the habit… until they actually tried to. Alphaceph: Would spiking someone even be illegal? I remain skeptical that there is a significant of would-be heroin spikers just waiting for heroin to be legal to possess, who are not already happy to spike with alcohol. Again, do you have any instances of this actually happening, or any good evidence that it would be so much of a problem as to outweigh the enormous social gains that stand to be made by making heroin safer by regulating purity and dosage, and taking almost all the profits of the heroin trade out of the hands of violent criminals? Drug prohibition costs after all. Your premise seems to assume that even one dose is typically enough to create physical and psychological dependency, which seems pretty implausible to me. Taxing drugs would only work if the untaxed alternative basically had the same effect. Drug addicts have extremely inelastic demand curves!!! You also need to factor in the — the idea that the more you enforce a law against possessing a drug, the more you drive the market towards more concentrated and thus more dangerous but also more easy to smuggle for any given quantity of active ingredient versions of the drug — lots of users do not necessarily want the strongest possible version of a drug see, e. If the heroin is available on prescription, that would pull the rug out from under the street dealers, and to the extent that the users themselves would otherwise become low-level dealers to fund their own habit, that would further prevent more people from being drawn in. The word from is that their heroin-assisted treatment model has seen a decline in the number of new users, so it seems to be working out for them. No need to send people off to gulags far from their friends, family, employment opportunities and other support network type things that can be vital in helping you overcome addiction unless you can demonstrate that keeping them in situ would be disastrous. But what you are proposing is definitely better. But that would also mean treating adults like… adults. When eventually the drug turns out to in fact not work you lose your revenue stream, but can promptly start over with a new drug. Creating exceptions to rules can go awry as easily as the rules themselves can, after all. Not only is the amount of perverse incentive one is willing to tolerate to avoid being cruel and Orwellian variable between people, the size of this incentive and extent to which it is a problem is unclear to me. I just thought it was worth describing the major reason I know of for opposition since it was mentioned as not being understood. In the limit as the effect size tends to zero, drugs just become different brands of placebo. I suppose you could argue that they crowd out drugs that actually do work, but would people stick with a fancy placebo if someone came along with a real drug that actually works? For everything else, the revenue stream from right-to-try would be much smaller than getting a drug through the FDA and for regular sale — and the drug company is losing potential patent years since the 20-year patent timer starts ticking while the drug is still going through clinical trials. Without an actual approved, useful drug, most pharmaceutical companies would go under, right-to-try sales or not. It would only slow down their folding a little. Delay to capitalize on right-to-try seems like a losing strategy. And it might not be a clear cut case of spiking. They might get someone drunk, then persuade or overpower them and inhect heroin. They might use peer pressure to force someone young, vulnerable or frightened into taking it. How many times do you need to take heroin before you are physically addicted? Also, the existence of easily available heroin is a severe test of human rationality. Rationally, there is absolutely no reason anyone would want to take it unless they were terminally ill. Adults are adults … but drugs with severe physical addiction potential are like landmines. The problem is that most of them end up relapsing at some point, because the underlying psychological reason for the addiction is still present. Not to mention that the term assumes a non-existent distinction between neurochemistry and mental state. As the old joke goes: Quitting smoking is easy! BTW I read a few tragic stories about people adults being peer pressured into starting either a heroin or crack habit and within a week being full-on addicts with addiction and physical dependence and having their lives ruined. We have laws about food purity and adulteration because dairies and bakeries used to put everything from chalk to lead into their products. Medicines and drugs are dangerous. There was a case recently in the news here of a woman who died from an accidental overdose of paracetamol she had been self-medicating. The modafinil you get from sketchy Internet sites works pretty well and I have heard of zero recorded cases of serious side effects. The nootropics sold by the nootropics communtiy tend to be pure and safe effectiveness possibly limited by the science itself but not by the manufacturing process. There were a few cases where some people got bad batches of nootropics, sent them off for analysis, found they were indeed bad, posted about it, everyone heard, those companies went out of business, and the companies that the clued-in people buy from now are pretty legit. You pays your money and you takes your chance, I suppose! Did they take them and have mild side effects? Here is this nice imported bottle of Chinese mineral water. Now, it may be from a legit manufacturing source that really does operate to the highest levels and draws its water from a 1,000 year old well that is monitored for trace contaminants, bacterial and viral levels, and mineral contents. But to answer your question, as somebody who lived in a developing country without safety regulations for almost a decade, I can definitely say that you can find safe things. Sure, it means you need to do a bit more research though for common items such as bottled water you do your research once instead of grabbing just anything off the shelf, but you can definitely find trustworthy manufacturers. You can keep all the internal machinery exactly the same, the same inspections and personell, etc. The only difference is what you do with the output. If your regulatory body finds that the water is made from raw sewage, that has to be written on the front of the bottle, in big red writing, with the actual name that the manufacturer chose in small font, and the package has to be plain apart from the manufacturer name, ingredients and FDA warning. And furthermore, for the most egregiously unsafe products such as heroin or crack, I think they should still be banned because of their potential as a weapon to use against somebody. EDIT: and because it seems to me that physically addictive substances deserve special treatment in regulation BTW I am in the odd position of arguing the libertarian side in one thread and the nanny state side in another thread……!! Another thing to point out is that the dude got caught because he raised the price significantly in one swoop. I suspect his style is what attracted the lightning. Had he been more conservative in his style, he probably would have not been targeted in such a hideous manner. Step 1: Buy the rights to the drug. Step 2: Short stocks in a variety of drug companies. Step 3: Raise the price of the drug enormously and make sure the fact becomes public knowledge, resulting in lots of outraged commentary, proposals for drug price regulation and the like. Step 4: Wait until step 3 has pushed down the stock prices of drug companies and close out your short sales at a large profit. Potentially much more money to be made than from the drug itself, and it does seem to fit the background of the gentleman in question. I think that there might be legal bases for going after someone engaging in such behavior, such as tortious interference. Combining two legal actions need not produce a legal action. There are many things covered by your last paragraph that are illegal Market Manipulation. I think this example would easily count in Britain, but is more ambiguous in America. There are three or four manufacturers of the pill, contract labs, basically, and all of them signed exclusivity agreements with the other companies which held the Daraprim brand. Then Turing acquired the brand plus those contracts, becoming the new sole maker. They just paid off contract labs to become their sole customer for it. Although processes could be streamlined and costs reduced, bioequivalency testing itself is extremely important and currently not always stringent ~enough~ When a generic is introduced, oftentimes insurance will cover only the generic. If there are multiple generics, oftentimes the patient will receive a different generic every month depending what the pharmacy has that day. So, does anyone want to explain the price difference for the generic cancer drug in different pharmacies? Of course, from a capitalist perspective, this is the market working as intended. The dumb losers here are the Costco CEO and small pharmacies, who apparently did not get the memo that cancer patients are desperate to live. Pharmacies do not have identical business models. They also offer different services. They have direct billing to almost every major PBM in the country, not to mention the Medicaid clients. I thought it was pretty clear the Turing CEO was trying to create political outrage against big pharma, driving down biotech share prices so he could sell their stock short. Given how biotech stock prices dropped after his performance, he would have made way more in a few days that way than by selling a low-demand pharmaceutical for years. That seems plausible at first glance — he is primarily a finance guy, after all. A rational munchkining genius who will soon be smiling at us from the top of a giant heap of utility! If true, that would be amazing. This assumes, of course, that he was not exposed to nonpublic info in any such stock trades by virtue of being a biotech CEO. For instance, knowing unpublished third-party analyst predictions can under certain circumstances be insider trading. Anyway, do you think he really could have predicted this backlash? A These price increases are not actually that unusual. B Negative press attention for one tiny company is FAR from guaranteed to torpedo the whole biotech index. This is part of my point about capitalism i. Come back to me when you have a free market. What you say about the pharmacies charging various prices rings true to me, not just about nationwide chains of chemists and not just in America: My family, like everyone else in Ireland, was a customer of our national telecoms provider for years mainly because it was a monopoly until competitors finally entered the market in the 90s and we never got any offers on the pricing structure. You want a landline and this was before mobiles became commonyou pay our charges and put up with our crappy service. And it does sound like the court system in the US should have some guidance about cases where big companies sue pre-emptively on out-of-patent drugs or ones that have been in the public domain for decades in order to ward off potential competitors. The only good thing about Turing which apparently bought the rights from a company that bought the rights from a company that bought the American rights from GSK, the original manufacturers is that up to now, Daraprim had too small a market and was cheap as dirt so nobody was interested in coming up with an alternative. So some real competition might ensue. In Lovely Theory Land, Bill is now in a dominant position as the customer with a greater choice, supply is outstripping demand and there is a glut of salsa, so prices must come down. In the real world? And so you get firms article source Turing being founded which took no risks, invested no money, did no work, and are merely creaming off the profit from the work of others. So possibly an answer is to licence small firms to make these kind of low-volume drugs for the big companies which created them and put a limit on the amount of price-hiking that can be done. Or loosen up the law so generics can compete fairly. I trust Capitalism to deliver me a wide variety of consumer products. But I think certain goods like health care are human and social goods, not consumer goods. Are consumers now inhuman or antisocial? The people that keep going on about how great the free market is are precisely the people that complain the loudest about companies abusing the legal system to create monopolies. Can you imagine if the US government just one day banned interest rates? Banning interest rates The experiment has been done, although not in the U. Other ingenious people, at least in Judaism and probably the other two as well, devise rules intended to prevent such evasions. The first set of ingenious people …. It raises transaction costs and adds unnecessary uncertainty, since one way of not paying interest is a loan where the expected value of the amount paid back is larger than the amount lent but it takes a form, such as lending in one currency and repaying in another, where the actual value is uncertain, so no promise of interest. I read that bit in the post as Scott expecting health insurance companies would be writing to the drug companies and pharmacies demanding lower prices, not Scott writing to the health insurance companies. Is switching your health insurance easy enough for this to work? It was pretty hush-hush, even though billions of dollars were on the line. Speaking as someone who is much more fond of regulation than most folks around here, this is my largest issue with regulated markets. The FDA has special problems. It is not at all obvious to me that abolishing patents will have good outcomes. In any event, it certainly has nothing to do with gated regulatory markets, which are made monopolies not because of intellectual property but at least in theory to ensure that all providers in a sector meet certain legal requirements in their provision of services. That is to say, gated markets are supposed to address externalities. Entities entrenched within the system sue newcomers as a matter of course in order to increase the cost of establishing a new service and in the hopes of knocking out new competitors before they even exist. I think the first should always happen, and the second should happen sometimes. Gated communities without patents tend to be much weaker. With patents one or a small number of producers get years of information, experience and brand building as well as regulatory connections which add to the barriers that potential competitors face when the patent expires. The primary way to alliviate the current problems with gated communities is to lower the cost of entry for quality particicpants. The best way, IMO if we are keeping a regulatory structure is to allow any company that thinks it is competant to enter the marketplace. You could ask for a large bond that would cover damages if they were found to be of low quality but that would be returned to the company after they had cleared the outcome hurdles. For people interested in a book arguing for the abolition of intellectual property, both patents and copyrights, I recommend Against Intellectual Monopoly by Boldrin and Levine. True to their principals, the authors have a version webbed where you can read it for free. One of the things I discovered teaching IP theory a few years back was that whether IP was a good or bad idea was a live issue well into the 19th century, with serious people on both sides. And is it not possible in the US to order generic Daraprim from other countries, e. If not, would it be legal to go to Europe, buy a large stash and return home to US? You might have trouble getting a large stash past customs, though. Buy your drugs from Canada online. About ten years ago, generic manufacturers in Canada got together and formed a cartel related to the production of tricyclics. One would make amitriptyline under the ancient brand name of Elavil, one would get imipramine and so on. They would not cross-compete and all raised prices about ten times. All because tricyclics in small doses made a big comeback for altering sleep architecture in chronic pain and there was an opportunity to profit. To be honest, I hate out generic companies far more than the brand name companies, especially since production has gone overseas and frequently large batches of staple drugs have to be condemned for safety reasons. It would make sense tome to give the original inventors good patent protection and the right to recoup their development investment, but at the end for there to be a government generic plant that would sell the drugs at cost price to the provinces. The company control lab tested the mixture for flavor, appearance, and fragrance and found it satisfactory. Immediately, the company compounded a quantity of the elixir and sent shipments—633 of them—all over the country. The new formulation had not been tested for toxicity. At the time the food and drugs law did not require that safety studies be done on new drugs. Because no pharmacological studies had been done on the new sulfanilamide preparation, Watkins failed to note one characteristic of the solution. Diethylene glycol, a chemical normally used as an antifreeze, is a deadly poison. Hence, the real question seems: is there a cheaper way of ensuring the same safety? Oh I agree, the current system in the US appears to be a mix of good sense combined with political interests and corruption. This I think is the problem with the large anti-regulatory camp here. Yes, sure, the regulations cause all sorts of deviations from ideal markets, and this allows rent-seeking monopolists to extort money from people and cause all sorts of inefficiencies. Regulatory capture means that this is worse than it in some sense needs to be, OTOH regulatory capture is pretty much inevitable so in another sense things are exactly as bad as they need to be. On the other hand, the regulations are necessary. Kicking the cruftball into the long grass and starting again with something completely different — even worse. Fell off the back of a lorry it did. Equivalency tests seem like a much higher bar. There are some drugs where bioequivalency is really important; for example, if you change your anticonvulsant dose even a little you might get a seizure. For everything except warfarin, we just take this in stride. I think if generics had weaker bioequivalency testing, we would just have to worry a lot about the dose when switching people from brand names to generics, or among generics. So all we need to do to know which drugs can be cleared via Purity tests rather than Equivalency tests is to figure out which drugs are potentially dangerous to some fraction of people if taken with some different set of excipients. Replicating the set of excipients seems like it would allay the concern. If that number is low enough, we could simply accept that as part of the risk of living in a world with cheap abundant medicine. We could also require disclosure. Do you have five more? Adulterated Quinine During the course of the war, 1,773 Americans were killed in action with an additional 13,271 dying from other causes. This high number of collateral casualties shocked the nation, and calls came from across America for an investigation. Although the high death rate had many contributing factors from compromised food provision and poor living conditions to infectious diseases, public outrage focused on the medical care given to soldiers. It was concluded that adulterated drugs supplied to the Army had caused the large numbers of deaths among soldiers. This enraged the public, and the outcry led Congress to pass the Drug Importation Act of 1848, the first federal drug law. Tetanus-infected diphtheria antitoxin in 1902, the Virus, Serum and Toxins Act Biologics Control Act was passed in response to tetanus-infected diphtheria antitoxin which was manufactured by a small laboratory in St. Ten school children died as a result of the tainted serum. No national standards were as yet in place for purity or potency. Also prior to the FDA common food addatives included Formaldahyde and Borax because private industry had basically zero incentive to find out if their addatives were toxic or deadly. Borax defeated, the poison squad moved on to test other common additives, including sulfuric acid, saltpeter and formaldehyde. One of their targets, copper sulfate, was especially disturbing: used by food producers to turn canned peas a bright shade of green, it also caused a host of health woes, including nausea, diarrhea, vomiting, liver damage, kidney damage, brain damage, and jaundice. If people died it was rare to be able to pin it on a batch of drugs even if it was straightforward poisoning. Hm, and what if there were uncensorable websites that sold any pharmaceutical one could want, sending them stealthily, paid with magic internet money, that could even easily coordinate the crowdfunding of batches of medicines on enough demand? This is precisely why some of us are Calling Up That Which Can Not Be Put Down. And about the quality control … Let me tell you the story of the Avengers. There was once a black market site that sold recreational drugs. The market was opaque and lots of products were of shitty quality. Doing that raised the quality of all the drugs on the market, basically overnight. But that crowd-managed quality control was better, even when gameable, than no control at all. It was easier to sell good drugs than to cheat the quality control system just to go on selling shitty ones. There might well be some way to set up incentives to do the same thing on larger scales. Like … if having the government run medicine was for some reason necessary or correct then surely for the same reason they ought to be handling the supply of bread? This one for example has 44 To get an idea of the amounts of money involved we can look up how large they are. Less than 10 million EUR net worth. They are handling the supply of bread. US does it less directly than Rome, but even here we have food stamps and farm subsidies. A right to food is not a bad idea. Aside police, one other example would be the third major emergency service: the fire brigade. And your subsidising of the poor is going to get absurdly expensive as a result of the high prices people pay due to the state of the market. Food is available from a whole bunch of different stores which all compete quite aggressively on price. Different markets work more or less effectively at settling the price at a stable minimum needed to motivate someone to do the job. The latter is a healthy, well-functioning market that works well. So we have the state take over the former but not the latter. Healthcare, it seems to me, sits closer to the fire example here. The above should be sufficient, but an additional reason is that government is also tampering with healthcare by setting safety standards and awarding patents. This creates some particular kinds of dysfunction like the situation discussed in the article, where costs are distributed to parties not responsible for making the decisions which generate them and in a very haphazard, sometimes extremely painful or quality of life degrading manner. Medicine — specifically prescription medication — is different than food, hygiene products, and most other necessities. Food is a relatively cheap business to get into and the regulations are far fewer and lighter than for pharmaceuticals. If you hate them all, you can buy flour and yeast and make your own at home. Or just not eat bread, and eat something else instead. Whether more government regulation or more free-market solutions would lead to better outcomes, prescription pharmaceuticals ARE a different and possibly unique case. Well I trust my government to run healthcare yes. The reason why I like it is because it means that whoever is pricing stuff has to bargain with the whole country. Individuals cannot always shop around so easily but governments can. In some circumstances a single company can decide to increase the price of medication by silly amounts. Medication works differently though. If it is an FDA approved drug in the public domain, yes. If it is a new drug then no, you need 300 million. Specifically Lymerix, the discontinued Lyme vaccine that is still approved by the FDA and is now off-patent. Recombinant proteins, like Lymerix, are in the middle. It also had some great points about how the media really works. BUT, somehow Uber gets people to get into a car with a stranger all the time, without some fancy government stamp of approval. What if you had a database that has user reviews of hundreds of labs around the world. A patient or doctor, or insurance company could put in a request for a particular drug, by a particular date, and when there are enough requests Groupon-like for the economies of scale to hit a certain point, then a batch is produced. This is the whole reason that brand names and trademarks were invented. Of course, Uber managed to get young and hip West Coasters and Washingtonians as customers, and therefore on its side, to help shield it from the regulator blowback, while all that this hypothetical high profile, lots of advertising, Canadian shipping pharmacy would have going for it are a bunch of sick people who are too poor to pay for drugs. The FDA puts really strict regulations on what you can and cannot advertise. Not so much with taxi regulations. Several of my friends used to work on the software backend for one of the biggest ones. And also that housing, education, and medical care are the three industries besides the financial industry in which the govmt is most heavily involved and also, by some strange coincidence, the industries where pricing is crazy and incomprehensible and getting more expensive all the time? In the 50s it cost something like 2x the median annual salary to buy a house. Average sq footage of new homes has gone way up as have the extras in a house air conditioning etc. Costs of homeownership include interest rates for most buyers insurance, taxes, repairs etc. The education system is so government controlled that no one even dares think of privatizing it. The closest we can get is charter schools. The are private k-12 schools, I went to two of them one secular, one parochial. I think in some ways the housing market is the worst. The are private k-12 schools, I went to two of them one secular, one parochial. They are not an alternative in terms of your budget, because you are still paying the taxes to fund public k-12 schools. All the people without school age children have to pay those taxes too. Parents of children in private school presumably share in whatever positive externalities justify publicly funded education to begin with. And also that housing, education, and medical care are the three industries besides the financial industry in which the govmt is most heavily involved and also, by some strange coincidence, the industries where pricing is crazy and incomprehensible and getting more expensive all the time? I agree with the broad sentiment here, but I would dispute the facts. I work in the pharmaceutical industry myself, so I can confirm it is heavily regulated. However, I have some acquaintances who work at a nuclear power plant, and based on their reports, I think that nuclear energy is definitely more interfered with than pharmaceuticals and almost certainly more so than housing. This is what effective altruism should be doing, right? Does it already exist? I think you have missed the point of the article. You sound like you are focusing on the recent headlines, where the problem is inadequate competition between drug companies. But the point of the article is that there are a lot of other ways in which generics are expensive. Why is generic modafinil so expensive? Is it the lack of competition between drug companies? Maybe, but large price differences between drug stores suggest that it is more complicated. And there are examples of much more extreme price differences between drug stores. But even the recent headlines about high prices on monopolies might be a poor choice for charity because the market is so small. Functioning markets are all alike, dysfunctional markets are all dysfunctional in their own way. Orphan diseases are essentially natural monopolies due to high fixed costs of regulatory approval. Varying prices for other generics are price discrimination behavior. Price discrimination and natural monopolies are two different concepts. Your electric company is a natural monopoly and your movie theater and grocery store engage in price discrimination. DIFFERENT POLICY RESPONSE REQUIRED. Of course, the answer can indeed be single-payer: the government can set prices for everything, including my groceries, the movie theater ticket, and the price of my electricity. Price discrimination certainly implies non-competitive markets, at least in the purest sense. How big of a deal you make of this? You buy the second best because it costs much less than the best, which is being sold at a high price to people to whom it is really important. And, unlike governmental solutions, you are increasing, not decreasing, the incentive to develop better drugs. And if the charity is rich enough, buy the first best. I analyzed the economics of this, and came to the conclusion that the deadweight loss from profit-maximizing pricing is at most half of the consumer surplus from pricing the drug at marginal cost. Beware Systemic Change notwithstanding, it might be even more productive to get the government to buy patents, although getting a fair process for determining purchase price might be problematic. It might be easier to get an initiative passed for a single state to buy a statewide license, rather than the national government buying a nationwide license. Given the legal and practical limits on restricting trade between the states, how do you enforce a license that covers a single state? The price descrepancies between pharmacies can usually be explained fairly easily. Costco will have low prices because their clientel have already demonstrated that they are willing to put in the effort and expense to find lower prices and also have cars and can afford modest up front costs. For an extreme example take a 24 hour pharmacy. Normal hours are in the neighborhood of 8am-9pm so a 24 hour pharmacy has to pay a pharmacist 13 hours more pay at crappy night shift hour rate so they need higher prices to compensate. Those higher prices have to be a lot higher because you will sacrifice some of your daytime business due to higher prices, and 3 am script refills are a low volume business. But does it typically result in a 4000% increase in prices? Also, the highest price for Letrozole was at a Target pharmacy. Do they tend to work longer hours? Convience is frequently a big one and is why people are willing to pay a buck or two more for basic goods at a 7-11 than they would at the grocery store 2 miles away. But how come people who buy drugs during the daytime will still go to the pharmacies with the higher prices? It can be convenience. Maybe the 24-hour chemist is the only one in your area. Maybe the pharmacist knows you and gives you good advice about your medication, or is willing to help you find a cheaper generic. Maybe you take the hit on higher prices to support it because for the one time in a blue moon when you need an open-all-hours chemist because you or one of the kids woke up and started vomitting at 3 a. Convenience and laziness are in the same bucket, except for moral posturing. Costco does home delivery for your pharmacy needs. Why would Walmart be more capable of charging more for convenience that Rite-Aid? As for the costs of staying up late explain why a store would need to charge more, that is quite different from why they can. The last time I was prescribed a medication was at least twenty years ago. I think the majority of drug sales are repeat business- people with chronic conditions or terrible lifestyles that leave them open to illness. Convience is probably really big factor. A few years ago I spent a month working two bakery jobs, my schdule was bascally midnight to 7 at one and 8 to 2 at the 2nd. If I had to pick up a perscription during that time frame I would hapily pay a few bucks to be able to get it prior to my first shift rather than after my 2nd. Now as a stay at home dad if there was a pharmacy next door to my pediatricians office or directly on my way home I would happily pay a modest premium not to have to drive an extra 10-20 mins with a sick kid or two in the car. Costco, by contrast, often takes a week to fill a prescription, if I fill there I have to deal with my own insurance reimbursement. Which really means besides maybe NASA and the military. Retail pharmacy is srs bsns. But the people getting the convenience are not the people paying the bill. My copay is a percentage of the overall cost with, I think, upper and lower limits. So it would tend to vary with those, and be different at Walgreens and Rite-Aid if the amount they charge is. It used to be a fixed amount, but that changed on our plan some years back. My copay is higher than the cost of the drugs being discussed in this article- I would be paying the full amount for a good number of generic drugs if I needed them. On the subject of Modafinil … what the post recommends doing is absolutely breaking the law, correct? I was curious so I went to that site and immediately saw how they promised to scrub my payment information and suggested I used bitcoin instead. Seems like a pretty important piece of information to just skip over. What which post recommends doing? Acquiring bitcoins is a giant pain in the ass, though. And this seems, based on scotts name drop, reviews, and etc- to be super safe. Can ModafinilCat legally sell modafinil in the US? Scott can choose to ignore bad regulations by the FDA because he is a doctor and knows what he is doing. A normal patient however, cannot make an informed choice. The rule is this- Lets say I make a drug that treats acne. If they want to use this drug to treat baldness, they can. The caveat being that they can get nailed for malpractice and off label use leading to serious injury or death would probably be a big issue. It also gives me some cover- if they go off-label to treat nicotine addiction, and the patient has a super rare reaction, I might well be off the hook as far as reporting responsibilities go reporting serious complaints resulting from the use of your product is also a Big Furry Deal. Basically, these sort of things allow the doctors to have leeway and the company to be covered. Your acne drug example may or may not be pertinent, given the allegation that a acne drugs increases or causes suicidality in teenagers. I suppose that they typical ModafinilCat customer is considerably wealthier and has a higher social status than your typical patient. It never ceases to amaze me how laws are selectively enforced based essentially on class in such a blatant way. So how shady is modafinilcat? Seems like something with a small but real chance of getting in trouble for using. What would be the drawbacks of the FDA establishing reciprocity with other countries? As an aside on the topic of pricing vs. Riddle me that one. Sigivald, Drug pricing is…. There are still some obvious problems, but one company monopolizing the drug and raising the price 10000% is probably not one of them. Any standard formulation would only need to specify: -Dosage per capsule or tablet. Am I missing anything? Anyway, if generics conform to the specifications of the standard, there should be absolutely no need to prove bio-equivalence in a clinical setting, and thus no need for any company to buy drugs india political betting its competitors in order to perform bio-equivalence studies. Am I missing anything? And neither does anyone else. There are still surprises waiting to be discovered in the field of drug-human interactions, and if you want the highest possible level of confidence in safety and efficiency even for a nominally identical drug, nothing but a clinical trial will do. But the FDA already has regulations for chemical and pharmaceutical purity which extend to this case — and, interestingly, also extend even to cosmetics and nutritional supplements. At what point is cringing regulatory caution taken too far? In some FDA applications, it represented these as much larger exhibit batches and presented the data as proof. And then there was the ultimate shortcut: using brand-name drugs as stand-ins for its own in bioequivalence studies. The first is probably some combination of the placebo effect with increased drug tolerance. The second is human nature — for a recent example, see Volkswagen. Would more regulation stop these issues? Would we be better off with more regulation? Would we be better off with laxer regulations than the ones currently on the books? After twenty years, the drug becomes public domain and anybody who wants can compete to produce it, usually leading to a precipitous fall in costs. I think I read somewhere it costs approx. Nobody makes that investment for a disease that affects 10K people. Drugs fail clinical trials. Drugs prove to be ineffective after looking promising. Bad side effects or drug interactions are discovered. Guess how much the public pays for these drugs? Exactly zero or all of it depending on your point of view. They just send the drug to a chemistry lab and have it analyzed. Their relative cost is about zero. This is about the clearest case of wanting your cake and eating it too. All we need is a fairy to whisper us the chemical formulations during our sleep and then ask China to whip us up a batch. Possibly they are all Chinese robbers? For the record, I am no fan of the pharmaceutical industry, and there is a lot to fix here. And not trivial research and development, either. Right, I see your point. A better target I think is when pharmaceutical companies slightly revise a drug formula to get a new patent extended release… and then market this as a major advance. Observation The CEO of Turing is condemned for acting like a market-efficient corporation, not as a sympathetic human being. Tradition Human beings who act like assholes are ostracized from their communities … the stability and health of the community requires this. Implication Corporations who act like assholes should be ostracized from their communities … the stability and health of the community requires this. Legislation Be it enacted, that directors of any corporation can be replaced with public appointees, by plebiscite of the electorate, upon grounds of incivility. I mean, the Swiss really are going after! Given many of the drugs are low volume, that would not seem to be a problem. Of course, you the doctor would assume liability for the effectiveness and any harms from the prescription. Also, is melatonin a drug? On the other hand- there are limits. The most unregulated this are GRAS- generally recognized as safe. These can be used in just about anything without any regulation. On the other hand, some companies have gotten Warning Letters this is very, very, very Bad in the regulatory world for using it in drinks and such. You well, maybe not you in particular regularly read articles in fashion magazines etc. The point here is that the manufacturer can stuff as much of the ingredient into the product up to the point where it would actually become effective, which then makes it a drug and invokes regulation. So the very fine print is that alpha-hydroxyl or melatonin? Deiseach: is the key phrase. So- I work in regulatory affairs, and interact with both FDA and European regulatory bodies on a regular basis- any interest in a write up from my perspective on these things? But this is kinda like work, and thus my brain treats it differently. Unless what you have to say contradicts my views on the matter, in which case keep it to yourself. We have a different farm and corporate culture in the US than in many places in Europe. My understanding citation needed is that most European chicken farms are actually very clean and the chickens have plenty of room. Actually, that should be all treated as hearsay. Livestock antibiotics have very little to do with disease and thus very little to do with crowding. The main reason for giving antibiotics to livestock is that they grow faster with less food. No one know why, but presumably it is due to changes in gut flora. And since you mention Perdue, they apparently have been cutting down on antibiotic use. They ended the use of antibiotics used for humans there are some used only for animals for growth promotion in chickens entirely in 2018, and they say only about 5% of their chickens receive human antibiotics for disease treatment. So, even giant corporations will do the india political betting thing if customers are willing to pay for it. We have a different farm and corporate culture in the US than in many places in Europe. My understanding citation needed is that most European chicken farms are actually very clean and the chickens have plenty of room. A more likely option — the people raising livestock are just as smart as you and have as large of hearts with regards to animal suffering, they just have much more experience in the field than any animal activist. You being smarter than me can work out what percentiles fall where on the bars. So I suppose I might take it that you are trying to say tactfully: a stupid er people are crueller to animals and other people? Deiseach: Lunch is responding to a comment that farmers are likely smarter than I am. An argument that has some merit, but seems poorly worded and framed. Unfortunately, not one that I made. An argument that has some merit, but seems poorly worded and framed. Please feel free to expand on this. This leaves you vulnerable to misinterpretation. My guess is that this blog has a much higher percentage of 2 and 3 SD above average IQ than farmers in general. This seems fairly incontrovertible. The average blog commenter here knows far less about farming and the specific challenges this entails than even a very run of the mill farmer. Much like a mechanic, what really matters is applied, practical knowledge, not theoretical. I think point 4 is actually a quite strong point. HBC — Thanks for the reasonable response. If my reply fails to match in polite charity, please to forgive. For the purposes of general debate, though, I would question the assumed? History is full of people outside of buggywhip making who make buggy whips immaterial. Or inventing vegan-compatible, parasite-invisible, non-plant harming humans, which would be the logical outgrowth of a need to have vat-grown protien. If we claim that the virtue of SSC, et al, its its capability of out-side-the-box theorizing, then we should outside the box theorize. You do have an unspoken assumption there that the people here are the only ones trying to solve the issue. I think that the strong desire for citation and the interest in novel, published approaches to thorny problems cuts against that though. Not saying that is in evidence here, but EAs interested in animal suffering not not opposed to eating meat should produce something like that at some point, and I imagine people here would be very interested in that. The basic idea is that humans rarely engineer solutions from scratch, they tweak something that already works. As such, this leaves us very vulnerable to missing the forest for the trees. What it means is that the average farmer on their farm is not the most likely candidate to re-think the entire system. Broiler meat birds are kept tighter than layer hens, but layers are more flighty and fight more, and live in the same barn for a year or more, in contrast to the 55-65 days of meat birds. So the rules allow for a farmer to keep the animals inside when necessary, and in general to allow them access to the outdoors as the animal chooses, instead of forcing them out. Also putting feed and water outside attracts pests like rats who eat the chickens and wild birds that carry diseases. So the feed and water is kept inside. In particular, young birds have to be kept in very strict temperature to keep from dying. So they are older before being exposed to the outside. Some people prefer the injuries and damage and poop on the eggs and workers in hand labor gathering eggs, and extra cost to the enclosed cages. The differences between the USA organic rules and those for most countries in the EU are even more interesting, but I am likely already tedious. Drug prices are also crazy on Medicare — I just ran modafinil through the medicare. Now, for reasons relating to the ridiculous way the drug benefit was set up, patients do need to be aware of the full costs of their drugs, and so the estimator will show that too. Is there a startup opportunity here? Would anyone use it to cure themselves? OT: I saw your post on the alleged deaths of people struck off disability benefit. You might be interested in thea pet project of David Cameron, set up to encourage social change by the use of behavioural economics it says on the tin and since sold off, as it was so successful, as a company or at least partially private, with the Cabinet Office holding shares in it. People have been keen from the start to use this as an example of market failure. A free market is an almost perfectly contestable market, which has three main traits… no barriers to entry; no sunk costs; and universal access to the same technology for new firms as well as existing firms. The pharmaceutical industry is actually a perfect example of the exact opposite of a contestable market. This whole Daraprim issue is a good argument for drug approval reciprocity at least with other first world nations. Remember that GlaxoSmithKline sells Pyrimethamine generic Daraprim in the UK for 60 cents a pill. But on the political market, individual actors—voters, politicians, lobbyists, judges, policemen— almost never bear much of the cost of their actions or receive much of the benefit. Hence market failure, the exception on the private market, is the rule on the political market. It could also mean the established price is too low. If they did, the competition would surely lower the price. The only question is, would the end result of the competition be a price lower than the one Turing Pharma has now voluntarily lowered it to? For instance, better availability in the event something happens to their main supplier. Remember that GlaxoSmithKline sells Pyrimethamine generic Daraprim in the UK for 60 cents a pill And this is the crux of the matter; I think we all got side-tracked by arguing about generics, regulatory bodies yea or nay and so on. Each company bumped up the price of Daraprim as it acquired it, but none were as blatant as Turing. Manufacturers of generic drugs that legally obtain a market monopoly are free to unilaterally raise the prices of their products. The Federal Trade Commission will not intervene without evidence of a conspiracy among competitors or other anticompetitive actions that sustain the increased price. So what if this inconveniences patients and the hospitals? The blessed rights of private property including intellectual property have been preserved! For inpatient procurement, institutions can no longer order from their general wholesaler. Instead, they must set up an account with the Daraprim Direct program. Once enrolled, orders may be placed with the company until 6 pm Monday through Friday and will be delivered the next business weekday, because there is no weekend delivery at this time. For outpatient procurement, patients can no longer obtain the medication from their community pharmacy. All prescriptions must be transmitted to a single dispensing pharmacy: Walgreens Specialty Pharmacy. This is not primarily a drugs regulatory testing problem. If laws against profiteering can be made during wartime, surely laws about profiteering can be made about health? So what if this inconveniences patients and the hospitals?