[basch]

People dont want insulin (traditional insulin.) They want fancy insulin (modern insulin), because it is convenient. They want modern rapid and long acting insulin. They want pens. Maybe people want the inhalable powder. Those innovations exist outside the original insulin patent. They are also mixing other drugs with the insulin.

>Average retail prices of Novolin and Humulin (traditional short- and intermediate-acting insulins) have gone down, or held steady, while prices of modern rapid- and long-acting insulins continue to go up. On average, traditional insulins now cost less than half of what modern insulins cost.

https://www.goodrx.com/healthcare-access/research/how-much-d...

There is a lot more going on that makes high end insulin expensive. A lot of conversation around insulin is people talking past each other because they are referring to different things that they think should be free, usually one of these additional features on top of the hormone itself.

[ksaun]

I do agree with the statement that some of the language around the lack of insulin availability is misleading, but it's not just that it's more convenient. "Fancy" insulin allows one to better manage blood glucose levels. Poorly managed blood glucose strains various organs/systems in the body and over years and decades leads to various health complications, some resulting in death. (It's still a lot of work and stress -- modern insulin isn't an automatic improvement; but it does allow greater success in managing diabetes.)

(My comments here are in the context of type 1 diabetes. The (potential) positive health impact of modern insulin may be less pronounced for other diabetics.)

[basch]

I dont mean to be dismissive or elitist. There is enough wrong with the medical system, that if somebody loses coverage and needs to see a doctor to get their prescription changed, that change alone becomes insurmountable, behavioral change not included.

My rub is that the conversation is dishonest. Saying "access to insulin is a right" and then changing the topic to modern delivery methods and such. Call a spade a spade, and have the direct honest conversation the first time. My pertubement goes beyond this topic into social justice/political correctness and just about anything. I may believe in the cause and the result, but be dismissive of how to get there by cheating and hacking peoples attention spans. It seems the only way to be an activist and get attention is to start with a lie, and now everybody is competing for the most inflammatory headline.

Everything you said is the conversation everybody should be having, instead of truncating it to "insulin is way too expensive."

[wanderingmoose]

I think a big problem is that short acting insulin, which was available 25 years ago, used to cost $9usd / 10 mL bottle now costs ~$80 with insurance (in california) or $200+ list price for an effectively equivalent short acting insulin. (numbers were from my insurance statements which include the cost for current prices, and from a family member who was on the pharma board at one of the large managed health facilities in california in the 90s.

To me, that cost inflation is purely artificial and not driven by any new tech relating to the insulin itself.

For T1 diabetics, the cost increases have been moving to insulin pumps which have infusion set costs in addition to the actual pump, and for continuous glucose sensors.

[basch]

Are you sure about this? 25 years ago, rapid insulin would have still been under patent.

Is anybody buying short acting anymore? At those prices? Rapid onset is $72.88.

https://www.walmart.com/cp/3769564

That's basically a 4.4x increase, after inflation to jump from short to rapid. Not saying its justified. Why pay $200 list for something that is less than $80.

[bombcar]

Yeah, you can do some quite easy motte-and-bailey with it.

Everyone will agree that (cheap, out of patent) insulin should be available to all; it's literally lifesaving.

But then switching that to the (modern, convenient) insulin should be available to all is a bit of a slight of hand, especially when it is NOT a "you will die without this" but a "you will have more hassle taking medication to not die" scenario.

[spiznnx]

I do want to bring up that insulin management is extremely taxing to individuals, and hard to get right. See https://news.ycombinator.com/item?id=30376777 for previous discussion.

Obviously the costs involved in implementing these technologies should be part of the discussion, but I don't think it's unreasonable to want to make anything that eases management of diabetes way more affordable.

[basch]

Which is what the conversation should be, and how it should be framed.

The press writing "life saving insulin" headlines takes away from the ability to discuss that: within the last decade or two, modern improvements made the process of managing diabetes significantly easier and else stressful. The drug companies gave everybody a taste of an easier life, and then jacked up the price, saying "pay us more or go back to the old way." At what level should the government step in and subsidize or control this quality of life improvement? At what level should its creators be rewarded?

I am old enough to remember when the entire world took traditional insulin. It wasn't pretty.

[ProjectInsulin]

I would like to point out that these fancy insulins have been around since 1996. I do agree that there is cheaper insulin available, but as others mentioned there is a significant change in quality. But I agree with you that the conversation should be affordable high quality insulin.

Another piece of the insulin ad drug saga that I haven't seen many people discuss here is the distribution of drugs. The distribution from manufacturers to patients is incredibly inefficent with a variety of middle organizations increasing the cost associated with distributing the insulin and those costs are pushed down onto patients. Our website has a simplified graph showing the current model vs what we plan on doing: https://projectinsulin.org/why-insulin/

For a more in-depth look the Wall Street Journal has a great video from 2019: https://www.wsj.com/video/series/news-explainers/how-drug-pr...

[basch]

I assume when you say 1996, you mean Humalog/insulin lispro? That falls in the rapid category, but I feel like most of the conversation about people wanting cheap modern insulin is the long acting right? The primary quality of life improvement people seek is having to inject only once a day, plus extra if diet requires?

I was dating 20 years from glargine (invented 1994, approved 2000), which is technically still patent protected somehow, despite biosimilars being approved. It takes a while too for Doctors to switch over when new paradigms are delivered. The real metric should be when long acting overtook intermediate acting prescriptions.

For anyone looking for history of modern insulin. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4045187/

[ProjectInsulin]

yes apologies glargine was approved in 2000. And I agree it does take a while for doctors to switch. Something interesting that I have recently learned is that it may even be hard to find clinical trial participants because doctors will be hesitant to take patients who have good reactions to their current insulin off of that insulin to be a part of a clinical trial.

I will also say that Pharmacy Benefit Managers (PBMs) also have a lot of power when it comes to influencing doctors to begin prescribing new drugs.

[dmitriid]

> At what level should the government step in and subsidize or control this quality of life improvement? At what level should its creators be rewarded?

You assume that creators are rewarded.

In Sweden you get the insulin and pens for free (that is, you've paid for it with your taxes).

[basch]

And it was invented there? When I say create I mean discovered not manufactured. The R&D.

And the answer/solution is somewhere in the realm of a public/private hybrid, where the government is funding short term expensive, long tail benefit research.

[dmitriid]

> And it was invented there?

This is beside the point. You pay for insulin, but with taxes. In return, you don't have to deal with "do I eat or do I get insulin".

> When I say create I mean discovered not manufactured. The R&D.

The question remains: are the creators actually rewarded?

In the US most R&D now is performed by small companies, government entities, or with government money. Large companies buy this research cheap and profit from it immensely. There are cases when all new drugs that appear on the market are based on public government-funded research.

The amount of revenue that goes back into R&D decreased while revenues increased.

More data here: https://www.cbo.gov/publication/57126

[basch]

Novolin 70/30 ReliOn vial (10 mL; 100 iU/mL) has had a flat price since 2014. The Novolin 70/30 ReliOn FlexPen (3 mL; 100 iU/mL) pen has been the same price as the vial since mid 2018 when it came out.

The price of these drugs NEVER went up.

Framing it as only "more hassle" or "purely convenience" really downplays the difference in the quality of life improvement the last decade has brought everyone.