I met Joe (JB) the late spring night our University of Texas Longhorns won the College World Series; the big thing is they turn on the orange lights for the infamous campus tower to celebrate the national championship. Joe was a pre-med undergraduate while I was starting work on my first Master's degree (mathematics). Joe had the most advanced grade-related scheduling system I've ever seen. Grades were important to me, of course, and I've got a number of honor rolls, dean's lists, scholarships, a fellowship, a dissertation award, honorary societies, etc. to show for it, but I remember being determined to take metaphysics my freshman year, even though I was warned Sister Morkovsky (PhD) "doesn't give A's".
Joe knew the grade distributions for each professor for each course he was planning to take and registered for those class sections most likely to optimize his GPA. I'm sure med schools are very picky in selecting applicants and I don't blame him for maximizing his chances to realizing his career dream. [JB and I have lost contact since I earned my Master's, but based on Googling, I'm fairly sure he is an oncologist practicing in Texas, in the D/FW metroplex.]
I remember one amusing incident when I attended his and Yvonne's wedding. I introduced myself to Joe's mom as "Joe's friend" (as against the bride's friend; I knew Yvonne but only through dating Joe). His mom stared at me and promptly corrected me, "One of Joe's MANY friends." LMAO.
So what does this have to do with the Twitter kerfuffle? I don't even recall how the topic came up in one of our conversations I had relatives on both sides (not all) who had developed type II diabetes, and Joe immediately asserted that I would get it, too. I had no idea how he predicted that, but it bothered me he seemed so matter of fact about it.
On the other side of the picture was a good friend of mine I met as a fellow PhD student at UH. He and his wife invited me to dinner at their family home a handful of times. One day after dinner, we adults were conversing, and one of them made passing reference to their oldest child, a girl in her mid-teens, being recently diagnosed with diabetes. I was curious what led to the diagnosis, and they mentioned an abnormal string of short-spaced urination stops on trips.
Just a note of caution here: I'm not a medical doctor or a dietitian; do not take advice from someone you don't know and trust from the Internet. Do due diligence with local credentialed professionals. I'm not.providing medical advice here, but hopefully I'm providing a layman's overview.
Insulin is a hormone naturally produced from your pancreas and used to process dietary sugars into the energy your body needs. There are two major problems people have with insulin: (1) your body doesn't produce enough insulin (type I diabetes); (2) your insulin isn't processing sugars efficiently (type 2). The bottom line is the diabetic needs to monitor blood sugar to ensure your blood sugars are within a a certain range: if blood sugars are too high, you risk damage to your nerves and organs, including eyesight, plus possible coma; too low, and you risk other symptoms, including possible coma. Frequent urination can be a telling way for the body to flush excess blood sugar.
Diabetics are at disproportionate risks for high cost, tragic consequences for uncontrolled conditions like heart attacks, strokes, kidney failures, and amputations. Roughly 1 in 11 are diabetic; 4 to 5% of diabetics are Type I and of course require insulin supplementation, typically by injection; maybe 7-15% of Type II diabetics require insulin supplementation (in more advanced stages, patients may lose the ability to produce insulin). In many cases, Type 2 diabetics can control their blood sugars through oral inexpensive generics like metformin and of course diet and exercise. Typically one follows a lower-carb/low glycemic diet: at the risk of oversimplification, you want to avoid the "white foods", like sugar, white bread, potatoes and rice, not to mention sugary drinks or fruit juices. Look for more complex carbs and (soluble) fiber, like 100% whole grains.
Now let's get to an overview of the political kerfuffle on insulin in California and the recently passed Inflation Reduction Act. Before the 1980's diabetics made use of insulin sourced from pigs or cows. More recently we've seen human insulin and insulin analogs. Human insulin is produced by growing insulin proteins inside E. Coli bacteria. Insulin analogs are genetically altered to work more quickly. It seems tht insulin analogs work better to stabilize sugar swings with natural insulin-deficient diabetics. " For people with Type 1 diabetes, human insulins “are harder to live on, lead to worse control, make it harder to hold down a job, impact quality of life,” said James Elliott."
In high concentrations, human and animal insulin tends to clump when injected into the skin. This clumping can cause slow and sporadic absorption. In comparison, insulin analogs tend to clump less and are absorbed more predictably.Human insulin tends to take effect slower than insulin analogs...A group of insulin analogs called long-acting insulin analogs or basal insulins can act for up to 24 hours and require fewer injections than human insulin.
See here for more compare/contrast of human insulin vs. insulin analog. I've even seen some discussion that some animal insulin is tolerated better by some diabetics but domestic consumers can't find it in stock (but apparently is available in Canada.
OK, so human insulin itself is not what is leading to the horror stories of out-of-pocket costs. In fact, Walmart sells it <$25/vial with diabetics requiring 1-6 vials a month. That's not the $400-1000 out-of-pocket horror stories political demagogues have been citing to justify government intervention. So the real issue has to do with the often faster active, more convenient/reliable insulin analogs. Note that Walmart markets at least one budget insulin analog, ReliOn NovoLog, starting at about $73, up to 60-75% off branded insulin. Here's another good piece covering product price comparisons.
Part of the problem here deals with industry practices known as evergreening and pay-to-delay.Patent rights have a limited lifetime, implying possible opening to typically lower-costing generics, Evergreening basically refers to making product improvements to extend patent (exclusive marketing) rights. and pay-to-delay is an incentive to other vendors not to produce knockoffs of products coming off patent.
Part of the problem here is market concentration and the intrinsic complexity and high costs of mass producing biologics/biosimilars (a non-proprietary copy of a biologic) of human insulin/analogs, and there are relevant FDA approval complexities. Similar to the situation in the current infant formula market, the insulin market is dominated by z few vendors: Eli Lilly, Novo Nordisk, and Sanofi.
So what's not to like about Democrats pandering for diabetic support with capping co-pays and/or capping annual out-of-pocket costs? This is what sparked the tweet I wrote opposing Pelosi that triggered Twitter Mommy; Pelosi basically wrote a tweet I would loosely paraphrase: by voting against the (tax-and-spend) Inflation Reduction Act, Republicans voted against diabetics' health and lives. Now personally I don't care about partisan sniping: I'm not a Democrat or a Republican, although I generally oppose leftism and a growing general government, which the Democratic Party represents. The GOP tends to be better on fiscal responsibility, taxes and deregulation, although we had massive deficits and mutually destructive trade wars under Trump.
The problem that I have with the political whore Pelosi is that socializing diabetic expenses doesn't address the intrinsic issue here of suboptimal competition, never mind healthcare regulation is not a general government responsibility under our federalist system of government.
Just to give a simple, but telling example: the prices of similar insulin products are much cheaper across the borders. But the FDA limits the product an American tourist can bring home to a few weeks. That ceiling is artificially low and could easily be extended. The FDA could mutually recognize insulin approved by other OECD countries. We could streamline approvals for biologics/biosimilars, incentivize additional capacity, lower trade barriers and domestic barriers to entry. We could engage in patent reform.
Michael Cannon has written a good summary of what I would rephrase as "if government is a diabetic's friend, who needs enemies?" Let me summarize key points:
- overinsurance, incentivized by employment tax policy, insufficiently vests individuals in minimizing costs
- USG requires prescriptions, unlike other OECD nations like Canada, an added cost.
- the current insurance market provides little incentive for vendors to cut prices to gain market share
- extending the import allowance for American medical tourists could motivate domestic producers to compete for that business by cutting prices
- the high price of biologic/biosimilar plant/product regulation ultimately gets passed onto consumers
- the current healthcare insurance market is employer- vs. individual-oriented; given job mobility, this undercuts a more long-term approach to managing healthcare.
