I Write About America’s Absurd Health Care System. Then I Got Caught Up in It.

By Bram Sable-Smith, who covers the Midwest for Kaiser Health News. Originally published at Kaiser Health News.

I got a hurried voicemail from my pharmacist in Wisconsin the day before Thanksgiving letting me know my insurance was refusing to cover my insulin.

I had enough of the hormone that keeps me alive to last 17 days.

In my 10 years living with Type 1 diabetes, I’ve never really struggled to access insulin. But in my job reporting on the people left behind by our country’s absurdly complex health care system, I’ve written about how insulin’s steep cost leads to deadly rationing and about patients protesting to bring those prices down.

For the most part, though, I’ve been spared from the problems I cover. Maybe that’s why I waited over a week to call my new pharmacy in St. Louis, where I recently moved for this job with KHN.

I’d been waiting since September for an appointment with an endocrinologist in St. Louis; the doctor’s office couldn’t get me in until Dec. 23 and wouldn’t handle my prescriptions before then. When I finally called a pharmacy to sort this out, a pharmacist in St. Louis said my new employer-provided insurance wouldn’t cover insulin without something called a prior authorization. I’ve written about these, too. They’re essentially requirements that a physician get approval from an insurance company before prescribing a treatment.

Doctors hate them. The American Medical Association has a website outlining proposed changes to the practice, while the insurance industry defends it as protecting patient safety and saving money. It feels like a lot of paperwork to confirm something we already know: Without insulin, I will die.

I knew right away the prior authorization would be a problem. Since it was a Saturday when I learned about the need for the authorization, my best option was to call my old endocrinologist’s practice that Monday morning and beg his staffers to fill out forms for their now former patient.

I had enough insulin to last seven days.

But late that afternoon, I got an automated message from the pharmacy about an insurance issue.

After spending 45 minutes on hold the next morning, I finally got through to the pharmacist, who said my insurer was still waiting for a completed prior authorization form from my physician. I called the doctor’s office to give a nudge.

Four days’ worth of insulin left.

The price of my prescription without insurance was $339 per vial of insulin, and I use about two vials per month. Normally, I pay a $25 copay. Without the prior authorization, though, I’m exposed to the list price of insulin, as is anyone with diabetes who lacks insurance, even if they live in one of the states with copay caps intended to rein in costs.

I called the pharmacy again on Thursday at 7:30 p.m., figuring it’d be less busy. I got right through to the pharmacist, who told me my insurer was still waiting on the prior authorization form. Friday morning, the diabetes nurse at my doctor’s office said she’d check on it and call me back.

I’d be out of insulin the next day.

By this time, I was live-tweeting my attempt to refill my prescription and started to get the kind of messages that are familiar to anyone in what’s known as the “diabetes online community.” People in Missouri offered me their surplus insulin. Some suggested I go to Walmart for $25 insulin, an older type I have no idea how to safely use.

My new strategy was to use one of the programs that insulin manufacturers started recently to help people get cheaper insulin. The very same day, the U.S. House Committee on Oversight and Reform’s Democrats released a report deriding these types of assistance programs as “tools to garner positive public relations, increase sales, and raise revenue.”

But before I tried that option, I heard back from the nurse who had called the pharmacy (she had spent 25 minutes on hold) and learned that my new insurance wouldn’t cover the brand of insulin I was using. The pharmacist was checking on a different brand.

Soon the pharmacist called: My insurance would cover the other brand. But the pharmacy might not have enough to fill my order. She said I should call a different branch of the chain. The first location I called was also out but pointed me to another one that had it.

With 12 hours’ worth of insulin left, I walked out of that third store with my medicine in hand.

It took 17 days and 20 phone calls. But I know I’m lucky. My insurance really is exceptional, recent events aside. My boss insisted that being alive was part of my job as I spent hours on the phone during the workday. And my job is to be persistent as I puzzle through the labyrinth of U.S. health care.

The time wasted by me, the pharmacists, the nurses and probably some insurance functionaries is astounding and likely both a cause and a symptom of the high cost of medical care. The problem is also much bigger than that.

Insulin is the single most important resource in my life, and this is what I had to do to get it. But I know not everyone has my good fortune. I’ve interviewed the loved ones of people with Type 1 diabetes who could not get insulin, and it’s not hard to imagine how my story could have ended just as tragically.

On Dec. 23, I finally saw my new doctor, who sent in a new prescription. That night, I got a message that my insurer was waiting on a prior authorization.

I had 17 days’ worth of insulin left.

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About Lambert Strether

Readers, I have had a correspondent characterize my views as realistic cynical. Let me briefly explain them. I believe in universal programs that provide concrete material benefits, especially to the working class. Medicare for All is the prime example, but tuition-free college and a Post Office Bank also fall under this heading. So do a Jobs Guarantee and a Debt Jubilee. Clearly, neither liberal Democrats nor conservative Republicans can deliver on such programs, because the two are different flavors of neoliberalism (“Because markets”). I don’t much care about the “ism” that delivers the benefits, although whichever one does have to put common humanity first, as opposed to markets. Could be a second FDR saving capitalism, democratic socialism leashing and collaring it, or communism razing it. I don’t much care, as long as the benefits are delivered. To me, the key issue — and this is why Medicare for All is always first with me — is the tens of thousands of excess “deaths from despair,” as described by the Case-Deaton study, and other recent studies. That enormous body count makes Medicare for All, at the very least, a moral and strategic imperative. And that level of suffering and organic damage makes the concerns of identity politics — even the worthy fight to help the refugees Bush, Obama, and Clinton’s wars created — bright shiny objects by comparison. Hence my frustration with the news flow — currently in my view the swirling intersection of two, separate Shock Doctrine campaigns, one by the Administration, and the other by out-of-power liberals and their allies in the State and in the press — a news flow that constantly forces me to focus on matters that I regard as of secondary importance to the excess deaths. What kind of political economy is it that halts or even reverses the increases in life expectancy that civilized societies have achieved? I am also very hopeful that the continuing destruction of both party establishments will open the space for voices supporting programs similar to those I have listed; let’s call such voices “the left.” Volatility creates opportunity, especially if the Democrat establishment, which puts markets first and opposes all such programs, isn’t allowed to get back into the saddle. Eyes on the prize! I love the tactical level, and secretly love even the horse race, since I’ve been blogging about it daily for fourteen years, but everything I write has this perspective at the back of it.


  1. Hayek's Heelbiter

    About the sale of the patent of insulin for $1 Banting [the discoverer of insulin] reportedly said, “Insulin belongs to the world, not to me.”

    No, it doesn’t. The patent now belongs to rapacious, amoral, criminal Big Pharma vampires, determined to extract every last drop of blood from hundreds of thousands unfortunate victims like yourself.

    1. Felix_47

      The fault lies at the feet of your congressmen who benefit mightily from pharma money and have for many decades. I note that Wal Mart had insulin for 25 dollars but the writer was not sure how to take it. That is the fault of his first doctor who, out of fear of litigation or habit or worse, prescribed one of the newer formulations of the same thing rationalizing it with some hot air about convenience or better control. Perhaps doctors could counsel their patients that they learn how to use the 25 dollar insulin as a backup in case something like this happens. And perhaps we can read the recent article in the New York times about the dark money in politics and consider the Söuth Carolina primary and the southern democratic belt and its role in the last ridiculous exercise in ‘democracy.’ The Black Congressional Caucus has long been opposed to campaign finance reform and their constituents in the South are not really dependent on private insurance because the poor ones get Medicaid and the only ones with a middle class income are government workers, veterans, military or militariy industrial complex workers…..all covered by the Federal Government. If they get into such a situation they just go to the ER….it is free. The private employers in the South stick with Mexicans for low wage labor and agriculture and whites for the higher wage jobs to a large degree and they don’t vote for democrats. Therefore the health care industry got exactly the puppet they wanted in the White House. Assuming they can prop him up for another 7 years and the Repubs are who they are expect nothing better for a long time. And I worked as a doctor for many years in many ERs in the South and that is exactly what I saw. Blacks, Clyburn’s voters, are insulated from the real costs of medical care. The insurance industry makes money as agents for the Federal government with the Black patients but the real payers and victims are the workers in the private sector or the Mexicans without insurance here illegally with their wives and kids (who are covered by Medicaid as a rule.) So the writers mistake was to be a middle class worker with private insurance. Poor women, children and Blacks are pretty much covered at outrageous cost to the taxpayer. But if we had a national health care system people would probably not get a choice of insulin. They would get the most cost effective insulin without bells and whistles. Perhaps the voters have been scared into believing the hype. In England ineffective or me too formulations are not covered by the NHS and that is the case in Germany as well. If you want the 600 per month insulin you are going to pay for it. The easiest and best course would be for the US to adopt the NHS and improve it with better funding. Why reinvent the wheel? Just improve it. It is no conincidence that the best data we are getting on COVID is not coming out of the US but out of England. And now the conservatives are trying to underfinance the NHS and tear it down.

      1. Rudolf

        The California legislature just killed the single payer program for the state’s population.
        Cowards, mountebanks and criminals.
        Nothing will change until the entire system collapses.

  2. Earl Erland

    Type 1 Diabetes: It should renamed Lambert Xoas. But of course, the field of Lambert Xaos is growing. I forget if it is exponential or logarithmic, or if my local news is @ 15% Positivity and getting higher or lower before or after I’m switching to National news for Hopium. When scams are obvious, Pandemic or Endemic or both (why not?) and when the wheel simply goes round and round, and Biden’s in nappy time (sleep or diapers) and the smartest voices say No Helmets Across Germany, and why not invade? Why not invade? Why not be called a Thinker, an Empath, or Angry? Lie about your income. Rich folks do it all the time, and it’s not a life or death thing for them. Think about it as a General Strike, not just about employers.

    1. aletheia33

      could you provide a how-to for lying about your income? what if you are a 1099er–always have been, have managed OK, barely, so far–who is over 65 now, still working, no savings whatsoever, dependent on the system you would be lying to for healthcare (medicare and medicaid), some of your income (SSA), and a low mortgage rate (USDA), all of which you know you are lucky to have “access” to. in your best earnings year ever, you once hit $45K.

      any tips for joining the suggested general strike appreciated!

      1. flora

        could you provide a how-to for lying about your income?

        Different topic, but, get a subprime loan for a mortgage with a so-called NINJA loan . Of course, those only helped the banks, not the borrowers. The banks were the instigators and the beneficiaries of that scam. Ninja loans wiped out a huge portion of low income and minority wealth in the subprime meltdown. Banks did well, though, so there’s that. / :(

  3. upstater

    We have a similar problem with my son’s antipsychotic medication. Lack of insulin will kill a person, while lack of antipsychotics makes people crazy and unable to function in the most simple of life’s tasks.

    In the decade-plus of this journey, perhaps a dozen medications have been tried. Some work, but have very severe side effects. Some don’t work at all. We found a brand named medication (clozaril, generic=clozapine, initially developed in the 1960s) that works quite well. But it costs $1000+ monthly for the first 4 months, then drops to ~$150. The generic versions have caused problems and our understanding is generics can be +/- 20% of the active ingredients and use different fillers.

    Needless to say, every single year it is a continual battle with the Medicare part D insurer, the psychiatrists, pharmacists, and the manufacturer’s discount program to get his medications. It wastes everyone’s time. There is no rational reason for this quagmire. The only purpose is to milk the public and government to enrich a band of thieves. Without parental help I don’t think our son could navigate the bureaucratic hassles. Then think about the 2% of the population with these problems, many without any support network.

    When he attended university in Ontario he had to purchase a health insurance plan which mirrored OHIP. The university had a nominally priced drug plan. It was no problem to get the brand medication and the $3 dispensing fee was inconsequential.

    Nothing will fundamentally change…

    1. Bob

      “It wastes everyone’s time. There is no rational reason for this quagmire. ”

      Yes, there is a rational reason..

      Big Pharma and Financialized Health Insurance !!!!

  4. Joe Well

    Re: antipsychotics, I knew someone who tried to kill himself (nearly successful, restrained by police, ambulance to emergency room, stomach pumped, mandatory involuntary commitment, locked ward, etc.) about a month after a job loss and loss of insurance meant he could not stay on the same medication for bipolar. He was put on a different medication that is available in generic, but several years of controlled management disappeared in a little over a month.

    When I think of every smug PMC who said the country wasn’t ready for Bernie…

  5. Robert Hahl

    This kind of story never involves dialysis because Richard Nixon made all of our kidneys honorary Canadians. We could just as easily make all our pancreases Canadians too.

    1. Parker Dooley

      Banting & Best were Canadians, by the way.

      I estimate that 50% of the costs and staffing in my former primary care practice were wasted on battles with these vampires.

      1. Janie

        In the 1970s and 80s I worked in the medical industry. Our billing and collections staff was the biggest department in the company. The frustrations were endless and the bureaucracy unbelievable. An employee could spend an hour on hold with Medicare and then be disconnected promptly at 4:30 when they closed. Insurance companies payment detail had the name of the insured but not the patient whose last name may be different and no invoice number. Et cetera ad nauseam.

  6. Pavel

    But the Congress rushed through urgent arms aid to Israel (Iron Dome) and raised the USA military budget despite the Afghan war’s having ended.

    And the Dems have spent the last 5 years obsessing over Russia Russia Russia and now “the Insurrection” instead of doing anything serious about the health care crisis.

    But hey, Biden wants to start WW3 in the Ukraine so it’s all moot.

  7. Mikeyjoe

    After my mother suffered congestive heart failure 2 years ago, she was prescribed Entesto. She had to wait for approval for the prescription. Fortunately the cardiologist had some free samples in his office or she would have had to pay about $500 for a bottle of pills.

  8. LowellHighlander

    This article, well worth everyone’s time in reading, serves well as a rebuttal from the neo-liberals (of both corporate-funded parties) to the argument that people in this country don’t want Medicare-for-All because then we’ll be having the government tell us what to do with regard to healthcare: corporate bureaucracies are already telling us what to do – and it’s proving deadly.

    1. Questa Nota

      Mayo Pete is on hold, saying only he can solve those medical and logistics problems once he finishes blanketing the country with speed cameras. He really, truly knows what is best for us and will work diligently to help his fellow humans. Has anyone ever seen a more brilliant, capable or selfless public servant? /s

  9. MinNY

    Yes, it’s impossible to understand the logic behind the requirement for prior authorization if health (as opposed to wealth) is what’s important.

    About 5 years ago I developed a chronic, life-threatening disease caused by a random genetic mutation. The disease is monitored/treated monthly by visits to a specialist; visits, of course, which require prior authorization.

    This disease is never going away — it’s not something you mutate out of — and will always need monitoring and treatment, without which I die.

    The prior authorization kabuki is just a hurdle put in place by insurers to give themselves an excuse to avoid paying. Greed, pure and simple.

    1. JBird4049

      Well, if you die, the vampire squids don’t have to pay anything. Reminds of how getting on SSDI (social security disability) can take years to get and doing any paid work at all is an automatic denial. Any. Work. At. All.

      The system is set up with the appearance of help to hide it being an abattoir.

  10. diptherio

    The craziest thing to me about this article is this sentence: “My insurance really is exceptional, recent events aside.”

    This is like saying, “Apart from occasionally driving down the wrong side of the highway for several miles, he’s really quite a safe driver.” W.T.F.?

    1. Pat

      Our system has so perverted our perception of good healthcare and insurance that I think Medicare is great. I haven’t been able to find a doctor yet, but unlike before I know that once I do I will be able to afford to make an appointment and go to it. (And even with a medigap policy and the increased Medicare premiums I am paying the same per month I was before and not facing a high deductible and a 50% co pay).

      My point being that this gentleman writes about insurance issues for a living. Unlike me he probably isn’t looking forward to Medicare. The loss of perception is not that his insurance is exceptional, by American standards I am sure it is. It is the choice to work within the system for change, as in this X policy needs to change. No our entire healthcare system needs to change. Pharma should not be charging what they do for drugs, pharmacies should not be big business for large chains, private equity should be banned from anything healthcare related, we should have single payer, we should be paying for all healthcare tuition, and yes private insurers should be an indulgence for the rich and plastic surgery obsessed. But that goes contrary to his job, hell he may even doubt single payer works and believe the problems with it are greater than those he sees. So he notes a problem and goes with the small picture solution.

      Or he is a privileged ignorant despite his job.

    2. PHLDenizen

      And he’s completely internalized PMCese:

      I’ve never really struggled to access insulin…


      I’m exposed to the list price of insulin…

      “Exposed” isn’t forceful enough. It’s almost glib. It also gets agency confused. Labeling the phenomenon as an exposure to something is an endorsement of the market based health insurance clusterfuck. The problem is framed as a choice to willingly “expose” yourself to a bad vendor, remedied by shopping for another (a PMC pastime) vendor that is better suited to your needs.

      The power dynamics are the opposite. The cartel of insurers and pharma are the ones with agency. Not people like this “journalist”. This is sloppy writing, IMHO. I also read it as a tax on time exploration rather than an adequate contextualization into the broader picture. It’s a tax on being alive and he omits that part in sufficient detail.

    3. Questa Nota

      This is like saying, “Apart from occasionally driving down the wrong side of the highway for several miles, he’s really quite a safe driver.” W.T.F.?

      Other than that, Mrs. Lincoln, how was the play, and did you get pre-approval for the gunshot wound treatment?

  11. juanholio

    Are there multiple kinds of insulin? My dog needed it, and the vet told me to get it at the human pharmacy. When I went in to Walmart, the insulin that they had prescribed was available OTC for ~$30 for quite a big bottle + syringes.

    1. Parker Dooley

      There are numerous types of insulin, almost all (if not all) produced by recombinant DNA technology. They are differentiated primarily by their rapidity and/or duration of action. Most insulin treatment involves use of a long-acting (basal) insulin, combined with a rapid-acting insulin to cover glucose loads at mealtimes. The original insulins were derived from animal pancreases obtained from slaughterhouses. They had issues related to immune response to the animal derived material (a peptide). Modern insulins are identical to human insulin, or are modified to improve their pharmokinetic properties.

      The price of insulin, even the older semisynthetic varieties has increased “exponentially” over the years, with no fundamental improvement in utility. As an example, one type sold at retail ~20 years ago for $22.00 for a vial, now priced at over $300.00 “Because they can.”

      1. Tom

        Before the Canadians closed their border, you could drive to Canada and buy insulin for $30 Canadian a vial. That’s $22.50 US, and I can assure you the companies aren’t losing money selling there.

        Big Pharma must have hated that. Now they have vaccines that everyone will need to take every 6 months forever. Just like insulin.

  12. James KOSS, MD FAAEM (ret)

    Medicine, once an honerable calling, has morphed into an industry. Like all industries, the workers are there to enrich the owners and controllers. Protocol treatments rather than diagnostic acumen is taught. Creative diagnostic and treatment thinking is now discouraged to not offend the lawyers when an inevitable lawsuit is posted. I have seen acredditd physicians ignore the obvious to follow the rigid protocol taught to satisfy the chart and billers, also designed to protect them from lawyers. Only the patient thus suffers.
    – A retired board certified ER physician taught to diagnose by touch, examintion and discussion, not just by testing.

  13. Parker Dooley

    There are numerous types of insulin, almost all (if not all) produced by recombinant DNA technology. They are differentiated primarily by their rapidity and/or duration of action. Most insulin treatment involves use of a long-acting (basal) insulin, combined with a rapid-acting insulin to cover with glucose loads at mealtimes. The original insulins were derived from animal pancreases obtained from slaughterhouses. They had issues related to immune response to the animal derived material (a peptide). Modern insulins are identical to human insulin, or are modified to improve their pharmacokinetic properties.

    The price of insulin, even the older semisynthetic varieties has increased “exponentially” over the years, with no fundamental improvement in utility. As an example, one type sold at retail ~20 years ago for $22.00 for a vial, now priced at over $300.00 “Because they can.”

  14. Societal Illusions

    I’m left with the conclusion that my health is the only thing that allows me to be free. And as what percentage of disease or I’ll health is lifestyle or piehole related, I suffer this incredibly unjust and greedy and psychotic system that can only be said to be emblematic of the entire system and most all of it parts. It’s comforting to have this called out so clearly in such a forum, but the proof the apparent and applied power imbalance remains stunning. What will it take?

    1. 1 Kings

      Did you see how/where Sean Bean ended the first season of Game of Thrones. Though he was a ‘good’ guy, his head endedup on a pike. Use your own imagination what should be done to the plague of medical middlemen.

  15. antidlc

    All of this nonsense would be fixed ASAP if Congress had to deal with the same system we deal with:


    Special Health Care for Congress: Lawmakers’ Health Care Perks

    A little known office on Capitol Hill provides quality care at a low price.

    Services offered by the Office of the Attending Physician include physicals and routine examinations, on-site X-rays and lab work, physical therapy and referrals to medical specialists from military hospitals and private medical practices. According to congressional budget records, the office is staffed by at least four Navy doctors as well as at least a dozen medical and X-ray technicians, nurses and a pharmacist.

    Sources said when specialists are needed, they are brought to the Capitol, often at no charge to members of Congress.

    “If you had, for example, prostate cancer, you would go to one of the centers of excellence for the country, which would be Johns Hopkins. If you had coronary artery disease, we would engage specialists at the Cleveland Clinic. You would go to the best care in the country. And, for the most part, nobody asked what your insurance was,” Balbona said.

  16. Keith Newman

    Sadly Big Pharma rules in Canada. True, the US is way out in an unequaled bizarro world of pharma costs and unfairness but Canada still has the third highest per capita costs for pharma in the OECD and plenty of unfairness, including deaths from people unable to get insulin.
    I have been involved in promoting the addition of prescription drugs to (Canadian) Medicare for 17 years in a coalition of unions, doctors, retirees, honest patient groups, and others. A big jump forward occurred when the Canadian Labour Congress came strongly on board in 2017 with full country-wide support (meetings across the country, social media, etc.). It became a national issue including in an election campaign. It looked like we were going to finally get it but then Covid derailed all our efforts despite polls showing 85% of people wanted it. It is indeed very popular at a grass-roots level as I have found personally when I have mentioned my work on the issue to my barber, the woman renting me a car, the farmer selling me vegetables, who were very enthusiastic supporters.
    The fight continues…

  17. CASD

    I don’t understand why you don’t ask your Endo how to dose the $25 insulin available at Walmart, while not ideal it works in a pinch. There are also several dozen T1D forums that would have helped you out. No one should have to put up with a bunch of insurance BS for a life saving drug, but if you had used a different approach than leaning in to the most difficult pathway it would not have been as dire. If I asked for help on those forums, I would have the insulin I needed tomorrow, same with my Endo of GP, if I called them telling them I needed help dosing Walmart insulin, they would be on the phone with me in an hour.

    1. IM Doc

      This is not a valid answer in many states of this country.

      After much Pharma lobbying when all the newer insulin products started coming out, Lantus, Tresiba, Levemir and others, many states now characterize the old standbys of NPH and Regular Insulin as animal products. In large swaths of the country, they are completely banned. In a few states, they are available OTC just as meat is available.

      It is a total mishmash and a total disgrace.

      And thanks to Obamacare plans with their stratospheric deductibles, I have all kinds of younger type I patients who literally struggle to feed their family from Jan 1 until about June or so when their deductibles are met. Imagine yourself as a 25 year old father of three trying desperately to survive and working two jobs and having to pay 800 bucks a month for insulin. For years until the Obamacare deductibles started, it was unusual to admit a DKA in an established diabetic. I admitted two this week. It was pay the rent on Tuesday or pay for insulin. Not both. And no one cares. One of Biden’s first executive orders was to rescind the paltry help a Trump executive order had given to these young people.

      Yes Americans, that is Obamacare in action.

      There is something that gets you seeing a 26 year old father in a coma in the ICU with his two kids and wife looking on in horror.

      I really feel that instead of meditating on the New York Times so much, our ruling class should be marinating in The Sermon on the Mount. I know political heroes in my lifetime like Moynihan, Kennedy, and MLK used to bring that passage up all the time. Our current crop of politicos probably do not even know what it is. Maybe a preacher in Aspen, or something like that.

      1. Roger

        My mother was a Type 2 diabetic (got it in her 50s) and when they took her off the “pigs” insulin to the “new” insulin she starting getting no warnings of going hypo – a complete nightmare. It took years for the UK Diabetic Association to get access back for pigs insulin, which immediately fixed the problem for my mother. The sheer arrogance of the “experts” during this period was disgusting. Do they still cover pigs insulin if needed or have they now fixed the new stuff?

      2. RandyGreene

        “One of Biden’s first executive orders was to rescind the paltry help a Trump executive order had given to these young people.”

        Don’t forget Trump’s Operation Warp Speed that provided vaccines to people in record time and for free.

        In retropect, Trump is looking better and better compared to sleepy Joe. Maybe we should reelect that clown, just to shove it in the face of the PMCucks.

        1. T_Reg

          For free to the recipents. The US government happily paid Big Pharma for them, to the tune of tens of billions of dollars in profit.

      3. CASD

        The Walmart insulin is available (for humans) in every state but Indiana, where Lilly has blocked it. They have expanded their line last year even.

        1. IM Doc

          I live close and somewhat close to 4 different states. I have visited WalMart in all 4 unfortunately. I have yet to see “Walmart insulin” in any of them. I have asked the pharmacies in 2 locations in 2 states and have been told they do not carry it. It was absolutely available in the state in which I used to practice assuming they did not have inventory issues which was very common.

      4. T_Reg

        “many states now characterize the old standbys of NPH and Regular Insulin as animal products”. Interesting. I was unaware that the “horse paste” tactic was being used elsewhere. I shouldn’t be surprised.

  18. Susan the other

    What we need until we can get single payer for all of this unmitigated shit is Medical Emergency Intervention Clinics. Not 800 phone numbers; not insurance jockeys; not even endocrinologists et.al. We need a way to resolve these situations rapidly and effectively. Single payer would by definition handle all this nonsense, but it will be sporadic until we get that luxury. Even though every other country on earth has it… but this is what we need to do now. Probably best to start at the State level but make sure our representatives and senators know what is happening. So, a new Agency of Medical Emergency Intervention or AMEI. To serve everyone who is caught in an endless loop of neoliberal medical profiteering and lives are at stake because nobody can get their shit together. These Agencies can buy, stockpile and distribute all essential drugs from insulin, to BP, to antibiotics. And all anyone has to do is call them on the phone and request a medication. Delivered to your door. Fuck Pharma and Insurance both at the same time.

  19. Kris Alman

    I feel your pain. And it makes my blood boil.

    A 2015 KHN article:
    You Can Buy Insulin Without A Prescription, But Should You?

    There are two types of human insulin available over the counter: one made by Eli Lilly and the other by Novo Nordisk. These versions of the medicine are older, and take longer to metabolize than some of the newer, prescription versions; they were created in the early 1980s, and the prices range from more than $200 a vial to as little as $25, depending on where you buy them.

    I, for one, am not sold on how great the newest analogues are. But the underlying challenge for diabetics is that the prices of these essential medicines are not correlated at all with the costs of producing them.

    As an endocrinologist who left medicine in my prime years over two decades ago, I am outraged by the profiteering. Insulin was previously derived from the pancreases of pigs and cows. There was regular and NPH, long acting insulin. Recombinant technology could theoretically end allergic reactions to these non-human insulins.

    That was not true as recombinant human insulin allergies were recognized as early as 1990. https://pubmed.ncbi.nlm.nih.gov/2196303/

    And, “Currently, the prevalence of allergic reactions to insulin products appears to be approximately 2%, and less than one-third of these events have been considered related to the insulin itself. Other reactions occur due to the preservatives added to insulin, including zinc, protamine, and meta-cresol.”


    Q-1. Why can’t I obtain beef or pork insulin manufactured in the U.S.?

    A. The manufacturing of beef insulin for human use in the U.S. was discontinued in 1998. In 2006, the manufacturing of pork insulin (Iletin II) for human use was discontinued. The discontinuation of animal-sourced insulins was a voluntary withdrawal of these products made by the manufacturers and not based on any FDA regulatory action. Although there are no FDA-approved animal-sourced insulins available in the U.S., recombinant human insulins and their analogs are safe and effective FDA-approved products available for the treatment of type 1 and 2 diabetes mellitus.

    Starting with human insulin, the big 3 manufacturers (Lilly, Novo, and Sanofi) in the 1990s started churning out synthetic analogues that had different peaks and durations, using E. Coli and yeast as manufacturers of these peptide hormones.

    Where insulin, without insurance covering drugs, could be purchased for $10-$20 in the mid to late 1990s, it skyrocketed in price (no doubt related to phaseout of beef and pork insulins and consolidation of the market). Indeed, the gotcha for patients at that time was the high out-of-pocket costs for the strips to monitor blood sugars!

    There has been no impetus to create a generic biosimilar. (Though, quite frankly, the market would still command a high price for biosimilars of insulin if they were available.)


    Results The manufacturing processes for RHI and insulin analogues are similar. API prices were US$24 750/kg for RHI, US$68 757/kg for insulin glargine and an estimated US$100 000/kg for other analogues. Estimated biosimilar prices were US$48–71 per patient per year for RHI, US$49–72 for neutral protamine Hagedorn (NPH) insulin and US$78–133 for analogues (except detemir: US$283–365).

    Conclusion Treatment with biosimilar RHI and insulin NPH could cost ≤US$72 per year and with insulin analogues ≤US$133 per year. Estimated biosimilar prices were markedly lower than the current prices for insulin analogues. Widespread availability at estimated prices may allow substantial savings globally.

    So what gives??? These prices are affordable.

    Keep an eye on this RICO lawsuit, Lambert.

    Drug manufacturers Eli Lilly and Co, Novo Nordisk Inc and Sanofi-Aventis US LLC, along with leading pharmacy benefit managers must face drug wholesalers’ class action claims that they schemed to inflate the price of insulin drugs, a federal judge has ruled.

  20. Sparagmos

    The only way out of this may be outspending PhARMA. If we can “find” about 2,000 lobbyists and a budget of about $400 millions, we may not beat them, but we could impress upon their associates in Congress the value of human life–temporarily. At least, we could do that until they begin to spend more than we can spend. It’s worth a try, isn’t is?

    We’ll need about one million dollars per Congress member.

    Maybe another way out would be something like a representative democracy, but obviously, that would take too long to develop, and in the meantime, people would die. Well, about a quarter million annually, according to Hopkins, but that hasn’t led to any positive changes yet. Possibly if it hits several millions, but maybe not…

    1. Tom

      Go to Canada and buy a year’s supply at once. Costs $30CDN for a bottle of insulin. They dispense in Quebec without a prescription because it’s life-saving. But call ahead: most pharmacies have only one or two vials of all types. You might have to go to Montreal and visit a few. It’s a nice town, worth a visit.

  21. Tom Bradford

    Jesus wept.

    Every day I read articles and comments in Naked Capitalism and thank God I’m not American.

    1. T_Reg

      Then there are the Americans who think it’s the best place on Earth – and will become enraged if you point out our many problems.

  22. timbers

    “my new employer-provided insurance wouldn’t cover insulin without something called a prior authorization.”

    This makes no sense to me, because if medical records are “portable” shouldn’t your new insurance have access to more than sufficient evidence of what they need? If it than what’s the point of portable in the first place?

    1. IM Doc

      A prior authorization is needed on most everything that is more than about 100 dollars or so a month.

      We have to process about 30-50 of these a day in my office. I would say the acceptance rate is about 98%. It is unusual – maybe once a week – that I have to talk to the insurance company myself. In brief, the entire prior auth system is a total waste of time.

      The paperwork is profoundly time consuming. The prior authorization system is a fairly recent situation. This simply did not happen until about 5-7 years ago. Now, I have 1.5 full time staff members in the office – doing nothing but processing these – pushing paper – all day long. A completely useless task, again, given the fact that 98% of the time – it is accepted.

      When you cannot get hold of your physician, or they are late with your lab results, or you cannot get answers – please realize that your PCP office has to devote all these resources to this useless garbage task – or many will not get their meds. It, among many other useless bureaucratic tasks have completely overwhelmed the PCP office these days.

      I am old enough to remember what a scandal it was when FOSAMAX was introduced – and was going to cost a dollar a pill. In those days, the entire office was devoted to customer and patient service. Those 2 items rank nowhere now. We are just desperately trying to get the very sick their meds so they will not die.

      When you hear about all the PCPs retiring and resigning – you can thank the above problem and the abomination that is the EMR – on top of having moron MBAs in charge.

      Thank you very much – Obamacare. For you had a hand in ALL of these things happening to medicine.

      Since the advent of Obamacare – has your medical care and service gotten better or worse?

      1. timbers

        Thanks for the info. Better or worse? Thankfully I’m a healthy 61 and just haven’t needed healthcare much, yet. I take blood pressure meds and used to take statins for high cholesterol, but recently stopped because was persuaded it interferes with vitamin K2 and promotes calcium buildup on arteries. Am eating foods rich in K2 (European cheeses, Japanese Natto) which many believe removes calcium from veins.

      2. Keith Newman

        Here’s the position of the Canadian Health Coalition on prescription drug coverage: there should be public coverage for all prescription drugs, no deductibles, no co-pays. If your doctor prescribes a drug you should be able to go to a pharmacy and just get it with no insurance company involved. Insurance in prescription drug coverage is a fifth wheel. (This is how Canadian Medicare operates for doctors and hospitals)
        All drugs on the public list of available drugs (the “formulary”) should be safe and effective and be broad enough to include all the prescription drugs people require. If your doctor is heavily influenced by Big Pharma salespeople and over-prescribes or prescribes badly the plan should pick that up and ask questions. If could be all right if the patient has non-standard needs.
        Importantly there should be national negotiations for the ability to supply the drugs on the public formulary and for the cost of the drugs on the plan. One factor for cost determination should be effectiveness.
        Countries that do the above things spend about two thirds what we do in Canada on a per capita basis, or for the US about one third. Their health outcomes are no worse than ours.

    2. Jeff

      Electronic medical records is a bit of misnomer. It’s really an electronic billing system to help speed up payments to hospitals and getting fewer kicked back for inaccuracies.

    3. ddt

      Prior auth is a messed up process meant to save money. There is a process called “continuity of care” but it depends on the provider or system you migrate to if they use it to bypass prior auth. You wanna hear screwed up? Step Therapy… Now that’s a bleeping process where when you’re new to the provider or system, say due to a change of employment, then that system’s drs have the right to start you on cheaper, generic drugs and move “step by step” to the more expensive ones regardless of what you were taking that probably worked for you before…

  23. flora

    Thanks for this post.

    I left this link in another thread yesterday.

    There’s an ‘arms (profits) race’ of sorts in the docs>hospitals>pharma>insurance companies sphere of action dependencies and profits motives, imo. And I don’t blame the docs, who are doing their best to get their patients the right treatments.

    Decent US regulations could rein this in, but we are in neoliberal “because markets” land.


    1. Bill Carson

      Yep. It’s been obvious for years. Modern medicine is not in the business of curing disease because there is no profit in cures: only in treatment. When my then-5yo daughter was diagnosed with type 1 diabetes, we were told that a cure was only five years away. Researchers were supposed to be busy perfecting a way to transplant beta cells into the pancreas. Twenty years years later we are no closer to a cure. I wonder if they are still telling parents this.

  24. Bill Carson

    There’s a way to get back at your health insurance company, if you’re willing to put your life on the line. Just let your prescription run out and then head to the Emergency Room when you start feeling the symptoms of diabetic ketoacidosis. You’ll have to spend a night or two in the hospital while the doctors and nurses precariously rebalance your glucose, sodium, and potassium levels, and by the time you head home, your insurance company will be on the hook for $30,000 or so. (My daughter is a T1D–been there, done that.) They jack you around so the *might* save $300 and it ends up costing them $30,000.

  25. Sue inSoCal

    It’s not medical care. I’m not certain what GPs here in SoCal are for anymore. Certainly not to diagnose or heaven help us, treat. The referrals to specialists are often unfortunate because our GPs don’t know those specialists. To boot, try to get in to see your GP. Chances are they’re split between 2 to 4 locations.

    I’m amazed (though I should not be) at the lack of knowledge of the “ordinary” person regarding who belongs to the AMA, what state laws and federal laws apply and the relative impossibility of prevailing in a California medical malpractice action, despite the whinging of the elite about “tort reform”. They are equally unaware of the rapid expansion of private equity in the industry of “health care”. Since, imho, our government runs on legal bribery, I don’t see any significant improvement on the horizon in the monolithic health industry.

    Billions at the top, hoops such as “prior auth” stress at the bottom. As an aside, the thing I love (sarc) is “we want you to pay huge premiums, and we also want mandatory arbitration and no exposure for malpractice.” People really believe these industries and their billions need a break. They already get it through not for profit status in most cases.

    1. Bill Carson

      When it comes to doctors and hospitals trying to limit their liability, I think there’s something worse than tort reform and arbitration clauses—it’s the “standards of care.” Standards of care are in place not to give the patient the best medical care possible, but so that if you die during a procedure or treatment, you can’t sue the doctor because he was only following the standards of care.

      1. Questa Nota

        Unfortunate patients also find that pharma is relatively immune from lawsuits, having their own Caveat Vendor legislation courtesy of friendly legislators corrupt whores. You accept more unknown risks now against cruel adversaries. Progress.

        Stay healthy!

      2. Sue inSoCal

        Excellent point. Years ago, my oncologist in Sacramento was sued by a patient under active treatment for lymphoma who was worth money. Good job, working, young, married etc. Patient lived a good 25 mi from hospital and drove down to the ER. The on-call physician, a partner from the cancer clinic, gave some treatment in emergency and sent the person home, where they promptly died. When I was (as I joked) “dead on paper” when, like this patient, all of my blood counts were wiped out, I was instructed to simply get my blood typed and was told sanguinely (pun intended) to go home, come back in the morning for the blood transfusion and “don’t cut [myself]”.

        The kicker regarding the patient that they sent home? My physician angrily told me later that lawyers twist words – the usual screed. They’d do it all the same way again, because that was their “standard of care”. (And mind you, their clinic lost big…)

  26. Kris Alman

    Julia Boss and Charles Fournier, parents of a daughter with type I DM and President/ Vice-President of the (now inactive) Type 1 Diabetes Defense Foundation, have been fighting for affordable insulin in Oregon for years.

    Here’s a great summary of the problem.

    When class-action attorneys sued insulin manufacturers early in 2017 on a flawed “Big 3 only” fact pattern, T1DF filed Boss v. CVS Health to add PBM/payer defendants to that litigation. We recognized that manufacturers have also earned supra-competitive net prices, but that to make viable federal RICO claims plaintiffs would need to focus on the PBMs/payers who receive rebates, misrepresent plan cost, and peg patients’ payments to unrebated list prices.

    The ADA’s list of states with capped co-pays needs updating. Last year, Oregon legislators passed HB 2623, which capped cost-sharing or other out-of-pocket costs, to $75 for each 30-day supply or $225 for each 90-day supply of a type of insulin prescribed for the treatment of diabetes.

    Of note, most diabetics are on two types of insulin. So double those costs.

  27. KFritz

    The United States doesn’t have a “health care system.” It has a rent extraction system that uses health care as its toolkit.

  28. PCM

    Well, what do you expect in a country where health insurance has been run as a protection racket and medical pricing as an extortion racket for decades? But I’ll focus on one aspect of this story that no one else has:

    I’d been waiting since September for an appointment with an endocrinologist in St. Louis; the doctor’s office couldn’t get me in until Dec. 23 and wouldn’t handle my prescriptions before then.

    Most American economics students learn at some point in their studies that American physicians run one of the most effective networks of professional cartels in the country. They artificially limit med-school admissions domestically and do everything they can to limit immigration and licensing of foreign-trained physicians. I’m sure the cover story is that they want to ensure that only the best and brightest can be doctors in the United States, but the “side effect” is that we have around a third fewer physicians per capita in the US than the developed-country average. Three major end-results ensue: (1) American physicians earn nearly double the developed-country average for physicians (the obvious goal of the profession’s contrived barriers to entry and the result that draws the most focus from economists); (2) the American profession tends to attract candidates who are more concerned about personal wealth than about helping and healing people (public-school teachers are so much more admirable by comparison); and (3) there are seriously harmful treatment delays (like the one the author experienced) because there aren’t enough damn physicians!

    Not a bad gig! Make patients wait forever to be seen; get the worst overall outcomes in the developed world (unless you count Mexico and Turkey as developed countries); and get paid double for doing it! God, would I have loved to have been there when Tommy Douglas began flying in “scab” physicians from Britain to break the Saskatchewan doctors’ strike against the North American continent’s first government “single-payer” plan! (Don’t feel too sorry for Canadian physicians, though. They earn almost as much as their American counterparts, despite Canada’s having adopted a 15-plus-payer system in 1984. I have a sneaking suspicion that that’s because the Canadian profession is organized in a network of provincial/territorial cartels that is very similar to the US but that restricts supply even more. [That’s right! Canada has even fewer physicians per capita than the US!] I also have a sneaking suspicion that Canada’s artificially contrived undersupply of physicians is one of the leading factors behind the country’s much-decried wait times for non-urgent treatment…)

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