[nhashem]

This is basically the paradox of US healthcare innovation. Canada can tell its pharmaceutical companies, "yeah, that cool drug you just invented, we're not gonna pay you what you want for that." And what option does the pharmaceutical company have? Convince healthcare providers to charge retail prices to their patients as an out-of-pocket expense, or... reduce prices accordingly.

Because healthcare payments are not functionally a government-controlled monopoly (ie. socialized healthcare) in the US, this doesn't happen. So Novartis can sell Gleevec for $75,000 in the US, because a healthcare provider will agree to pay and just bill it to private insurance companies, and those private insurance company will agree to pay and just increase their premiums on the customers, who probably won't notice because, assuming they have employer-provided health insurance, their employer won't take anything more out of their paycheck, but then say increased operational costs means nobody can get a raise.

So US healthcare leads the way in innovation because device and pharmaceutical manufacturers can make a lot more money than in countries with socialized healthcare. So these companies make most of their profits in the US, and then they'll grumble and accept lower prices in every other country, because at that point it's just icing to them. After the profits made in the US, getting $2,500 from Indians for Gleevac is better than getting $0.

The US is effectively subsidizing advanced healthcare for every other country in the world. This is pretty crappy, obviously, but this is a complex problem to solve. Because if you move to a cost-controlling system, then you will stifle legitimate innovation. Why jump through all our FDA clinical trial hurdles if there's no promise of a big payout at the end? Why invest in R&D without the protections of patent law to prevent your drugs from being trivially replicated?

I'm not trying to say, "oh, those poor profits of the drug companies." I recognize this may not be a sympathetic argument. But it's likely to be tough to control costs and yet maintain R&D and innovation. Right now, every other country essentially gets the US to pay the bill for the innovation and they reap the benefits at a lower cost, but with US healthcare already consuming 1/6 of our economy, this isn't sustainable.

[snippyhollow]

US firms are investing less in R&D relatively to their rank http://en.wikipedia.org/wiki/Pharmaceutical_industry#Market_... than their French/UK (publicly-funded healthcare) counterparts. The US are not "subsidizing it for poor countries" more than other rich countries.

The truth in the case you're making is not specific to healthcare and is that "research (private and public) of rich countries that can afford it" benefits poorer countries. So what, let's stop advancing science? We're all better off this way!

[forrestthewoods]

From that list 48.17% of all health care R&D spend is by US based companies. Sounds like the US is subsidizing the world to me.

[belorn]

It should also be mentioned (since we are talking about statistics here), that 1/3 of the total US medical research spending is from taxes (congress) and has been consistently been so for 20-30 years. That money has no connections with the current health care system, or insurance companies and is just pure tax money sent into research.

From those 1/3, about 95% of all core research is supported, and around 80% of all research into medical conditions that are life threatening.

Health care system, insurance companies and patents are for everything else...

*The 95% and 80% is number from a talk, and for the moment I can't find references. What I could find is statements about majority funding is used on basic research (http://jama.jamanetwork.com/article.aspx?articleid=205216 and http://www.nsf.gov/statistics/seind12/c5/c5s1.htm). In the future I will hold off on those number in comments until I got direct sources to use with them.

[kingkawn]

If true these stat provide a compelling point of argument for expanded government research funding and less protection for the private insurance system. Do you have a source for it?

[belorn]

Mostly those was taken from a talk, but here is the data I could find: (https://en.wikipedia.org/wiki/Nih): for the total % of funding and where that money come from. (http://report.nih.gov/categorical_spending.aspx): For different Categorization.

I would also add a bit old paper about cancer research (http://www.iom.edu/~/media/Files/Activity%20Files/Disease/NC...), through they include all various stages of development. They attribute a 31% to industry.

[criley]

I'd be interested as well, because if he's trying to label all NIH-bound funds as imperative to this process, I think he's overstating his case.

Yes, academic institutions do a lot of low level work that pharma companies build on top of, but you'd be surprised how often potential new molecular entities (truly new drugs) do not originate from government sponsored academic sources.

(However, the tools, understanding and/or methodologies that made that new NME possible did likely come from those labs!)

[belorn]

One can read the data in different ways, and I don't think anyone doubt that pharma companies do contribute to the investments into new medical innovations. One interpretation that I listen/read about is that NiH and pharma operate on different levels, and thus sadly, NiH's contribution tend to be forgotten because they aren't the people with that pop out the pills bought in the store, even if the pills would not have existed if it hadn't been for the NiH funded research that made the new innovation possible.

Then we add patents and insurance companies into the mix, and some people want to paint a picture how innovation gets created. My comment was thus mostly to inform that the largest single funder to medical research is not some for-profit company like Pfizer, but rather tax supported NiH.

[anoncow]

Would love a source on the 95% figure.

[alive-or-not]

Health care R&D is extremely expensive in US (insanely high executive salaries, "lobbing" expenses, etc.). US companies may spend as much as the rest of the world, but deliver a lot less innovation.

[adventured]

I don't see any evidence to support your very dramatic claim.

Quite the opposite. From early chemotherapy on to the human genome, stem cells, the Allen Brain Atlas, The Gates Foundation, modern biotechnology, organ regrowth, medical devices like the CT scanner (half invented in the US) or the da Vinci system of robotic surgery, etc etc etc the modern healthcare / pharma / biotech world owes a spectacularly massive debt to the US. To say nothing of the surrounding infrastructure everything requires related to technology from the microprocessor to the Internet. How much did that tech speed up R&D, try quantifying that little contribution.

[ewoodrich]

"The Human Genome Project (HGP) is an international scientific research project with a primary goal of determining the sequence of chemical base pairs which make up DNA, and of identifying and mapping the approximately 20,000–25,000 genes of the human genome from both a physical and functional standpoint.[1] The first official funding for the Project originated with the Department of Energy’s Office of Health and Environmental Research, headed by Charles DeLisi, and was in the Reagan Administration’s 1987 budget submission to the Congress.[2] It subsequently passed both Houses. The Project was planned for 15 years.[3] "

I don't see how the HGP was unrelated to government investment...

[streptomycin]

He didn't say it was unrelated to government involvement, he said it's one of many examples of how the US private sector has delivered innovation. See Celera's role in sequencing the human genome. http://en.wikipedia.org/wiki/Celera_Corporation "Celera's use of the shotgun strategy spurred the public HGP to change its own strategy, leading to a rapid acceleration of the public effort."

[omd]

Such a useless comment. Everything you mentioned was arrived at by research which everyone shared when the vast majority of the research was happening...

[analog]

And all of that surrounding infrastructure is reliant on Mathematics which didn't originate in the US.

[fredsanford]

Such a useless comment. Mathematics was arrived at by research which everyone shared when the vast majority of the research was happening...

[coldtea]

Or that US health research produces far less bang for the buck, because the companies can charge whatever they want, and the suckers (citizens) have to bend over and cough up the money.

[bergheim]

By that logic, you should add the population for the other countries and compare to the US, which is about 345m compared to the US, 315m - which doesn't sound like the US is "subsidizing the world" to me.. Although I guess a big chunk of that revenue probably comes from the US.

[forrestthewoods]

No you shouldn't. Your 345m is heavily weighted by Japan's 127m population which accounts for 2.3% of the research spend from the chart in question.

If you want to play that game then Japan is incredibly subsidized by the US and Europe, but that's not the question at hand. :)

[baldfat]

Only profitable drugs. Pediatric Cancer is not one of them so no new Chemotherapy in the US for over 20 years now and counting.

Also manufacturing is stupid also. Only one company makes Oxycodone (Pain Killer) there use to be two companies. Now the price has sky rocked and can be in short supply. So my son suffered for a few days due to not getting all the pills he needed. Great system.

[ofacup]

keep on believing. you're the defender of freedoms after all

[adventured]

That's embarrassing. What does your glib, mostly obnoxious comment have to do with anything factual? You hate America so much you can't even give it credit for positive things that are factually accurate?

[jezfromfuture]

Sorry but america does not subsidise the health systems of the world , it just sad to see you argue so much when in all actuality your being fleeced tax payer wise & health insurance wise . Your health service doesn't really seem like its there to help most just the rich people.

[ofacup]

i'm sorry, but i'm not embarrassed. please show me where your "mostly obnoxious comment" has anything to do with anyone. the usa does not subsidise world healthcare. get over yourself

[omd]

I knew it was just a matter of time before American xenophobia came to HN.

[geebee]

I believe that the thesis was that health care companies make heavy investments in R&D that are only profitable because of very high prices in the US, and that these innovations probably wouldn't be available at the lower cost in other other countries without this profit center.

That's just a thesis. It's an interesting one, I'd be interested in reading some discussion of it, especially insightful comments backed with data.

[joelthelion]

The French/UK/Swiss pharmas also count on the US market as a large part of their revenue. The incorporation country of these multinationals is irrelevant.

[hexagonc]

Whether the US is subsidizing healthcare for other countries is not a function of the amount of research US companies or the government produces. Instead, it depends on the amount of revenue that those companies derive from the US health consumers. I don't have any numbers in front of me but if it turns out that the vast majority of profits for these companies comes from the US, due to our clusterfuck of a healthcare system, and if those extra profits offset the lower revenue from charging other countries less, then that looks like an indirect US subsidy to me (sorry for the unwieldy sentence).

If you're not American, I don't see what there is to take offense at. That's just the shitty (for us) way that it is. Due to structural problems, greed, boondoggles, lack of political will, lobbying/corruption, the US simply can't have low drug prices compared to other rich and poor countries. On the other hand, the US enjoys relatively low prices for electronics and other consumer goods (as our Australian friends can attest to). You win some and you lose some.

[venomsnake]

According to Ben Goldcare (Bad Science, Bad Pharma) the companies spend around 12% of their budgets on R&D and 30% on marketing ... so the R&D is the easy part to be funded - just outlaw the direct marketing to consumers and doctors and the companies can spend 3 times as much on R&D with no problems.

[takluyver]

Having heard Ben Goldacre speak, the problem isn't just direct-to-consumer marketing, which is already illegal in the UK for prescription drugs. Drug companies actually spend a lot of effort marketing to doctors, who think that they're smart enough to resist sales pitches. There's apparently evidence that they're not - doctors who see drug company reps prescribe those companies' drugs more often and have worse outcomes.

[FireBeyond]

"direct-to-consumer marketing, which is already illegal in the UK for prescription drugs".

No (well, yes), it's illegal in -every single country- in the world except for the US.

Only in America does your friendly pharmaceutical giant spend more money and energy on telling you what's wrong with you via non-individualized, vague 30 second spots - "Do you not get excited about anything? Cymbalta may help!" - than your healthcare providers.

As a healthcare professional -in the US-, this disturbs me hugely.

[arethuza]

Agreed - they are fantastic books.

His website is at: http://www.badscience.net/

[npsimons]

Haven't seen Goldacre's stuff, but I had heard (can't find a source right now) that it's actually closer to 80-85% of pharma companies costs are advertising and marketing. Can't think of a better place to cut costs, really.

[danielweber]

They spend money on marketing because it makes them money.

Say you spend $1 billion to develop a drug. That $1 billion number is a sunk cost; it is irrelevant to figuring out how much to spend on advertising and marketing.

Limiting marketing to less than that $1 billion that was spend on research makes no sense.

[npsimons]

Limiting marketing to less than that $1 billion that was spend on research makes no sense.

Perhaps; even if true, the fact is that drug companies claim they need patents (and other protections, both explicit and implied) to be able to recoup their R&D costs. If their R&D costs are swamped by their advertising costs, perhaps the problem isn't the cost of R&D, but mismanagement? I mean, honestly, it's not like they are producing luxury items. These companies are supposedly making a product that sells itself because their customers will die without it. To add to all that, arguments can (and have) been made that pharmaceutical advertising is a negative input to society by unduly influencing prescribers.

[twoodfin]

No problems? Why wouldn't your genius idea work in every sector of the economy? Surely Apple and Samsung could sell more, better phones if they didn't conduct market research or run ads...

[venomsnake]

Healthcare is unlike the rest of the economy. Drugs don't need marketing and market research. Because in healthcare you don't give what patients want but what they need.

If a drug is best in its class doctors will not need "seminars", "education" to use it - it will be self evident by the trials and outcomes. Oh but wait - you cannot compare drugs to other drugs. You only compare them to placebo thanks to the cuffs put on the various government agencies by the intense lobbying of the industry.

Edit: To get the drugs past the FDA you only need to show it behaves better than placebo. Comparative trials of drugs are a minority and rarely done.

[anoncow]

>You only compare them to placebo

I am not an expert, but look at the following study which compares two drugs.

http://clinicaltrials.gov/ct2/show/NCT00364806

[danielweber]

To get the drugs past the FDA you only need to show it behaves better than placebo

Not really. You need to show how it works compared to the current regimen.

If someone suffering from a disease currently takes drugs A, B, and C, and you have what you think is a better C (let's call it C++), then the study would compare people on (A,B,C) to people on (A,B,C++).

Unless there is no treatment at all for the disease, in which case, go for the placebo.

[twoodfin]

Because in healthcare you don't give what patients want but what they need.

Where's the line? Maybe I don't "need" a new prescription painkiller with substantially fewer gastrointestinal side effects than the OTC one I'm taking, but if it would greatly improve my quality of life, I certainly might want it. Maybe I'm lucky enough that I see my doctor regularly and he keeps up (without any pharmaceutical marketing?) on every medicine that might help me out, but why should consumers be force to depend on that?

The idea that there are hordes of people making doctor's appointments to demand brand name drugs they heard about on TV, and doctors are "forced" to write what they consider useless or overpriced prescriptions for these drugs seems silly to me.

[npsimons]

Maybe I'm lucky enough that I see my doctor regularly and he keeps up (without any pharmaceutical marketing?) on every medicine that might help me out, but why should consumers be force to depend on that?

You think that marketing helps? Maybe your doctor is unduly influenced by pharma marketing and prescribes you the worse drug that give you IBD; hell, maybe he prescribes you the wrong drug altogether because of marketing, and you die. It may sound beyond the pale, but borderline cases involving antidepressants (perhaps the most overmarketed drugs) have already happened.

[Avshalom]

humor.

That said you'll notice Samsung doesn't advertise it's chips or raw display panels, because they are not actually sold to the people watching The Daily Show.

[spartango]

> ...it's likely to be tough to control costs and yet maintain R&D and innovation

I'm running a biotech/healthcare startup, and this point is rather interesting for me.

Most of these arguments against "crazy high" drug pricing in the US work to vilify the large pharma and biotech companies. I don't seek to defend them, but perhaps we can look at some of these conundrums through a startup's lens:

Getting my product to market is incredibly challenging. There's a good amount of novel technology development and research around it, and we're not even developing a therapeutic. We're working in a scientifically challenging space (cancer pathology), so things aren't easy.

Even if we can build what we are trying to, that's not the sum total of our costs. We have to invest a huge amount of energy into validating that what we've built is scientifically accurate, and then medically appropriate. This isn't for regulatory approval, this is simply to convince our customers (and basic ethics/QA, I suppose).

The standards to which our product will be held are quite high because we influence peoples' lives. That's the curse and the blessing of healthcare.

Given all the work we're putting into this and the nontrivial cost of the project, we'll need to generate significant revenue to make it work out. It doesn't come cheaply, but in the US we think there's room in budgets for us. We don't seek to price exorbitantly, but there's a fine line between that and barely surviving.

[betterunix]

It sounds like the US might be better served if those research costs were funded by the government. If only we had an agency that gave researchers the money they needed for this sort of thing, some kind of national institutes of health that would be a medical counterpart to the NSF and DARPA...

The problem with market-based approaches to medical research and medicine distribution is that they force people to make economic decisions about their healthcare. Nobody, regardless of their income level, should have to sit down and ask themselves, "Do I want to treat my cancer now, or do I want to buy food for my children?" The same arguments for a universal healthcare system apply to federal funding for medical research. Yes, medical research is expensive; no, we do not want to fund it with a system that denies medicine to people who need it.

I do not want to be overly critical of your startup. Nobody says, "Man, there are too many ways to treat cancer!" On the other hand, your startup does need to bring in enough money to cover its costs, which means you cannot just give your drug to anyone who needs it -- you need to charge them for it. That is why the funding model needs to be overturned, so that the cost of developing the drug is not an issue in getting the drug to people who need it.

[refurb]

Is your biotech startup in the Bay area? Would love to chat. Email in profile.

[spartango]

Happy to chat. We actually moved from the Bay Area to the Boston area recently.

I didn't see your email in your profile, but feel free to shoot me an email through my profile (anand at percept dot us)

[nicktelford]

You're forgetting an important factor. Competition. Pharmaceutical companies operate in an environment with very little competition. Obviously, the purpose of patents are to grant a limited monopoly in return for the innovation, but when that innovation is the only viable treatment for something, the manufacturer can just name a price and everyone has to live with it.

The problem is that the US healthcare system isn't a capitalist system; it's an oligopoly.

[userulluipeste]

"the manufacturer can just name a price and everyone has to live with it"

Considering the context of the discussed business and that the offer is not always just something optional, I might add "or die with it..."

[refurb]

There isn't any competition? Ask Vertex about that! They just launched a new HCV drug that was expected to bring in several billion dollars per year of revenue at its peak. Now? It probably won't pass the $500M mark because other companies are bringing in competing therapies.

[BerislavLopac]

Actually, the problem in the US is in the lack of the balance between the producers and customers of medicine. In Canada, as you point out, there is a state monopoly on the purchasing side, but there is a similar monopoly on the selling side, in the form of medical patents. In India, there isn't a monopoly on either side.

In the US, you have no monopoly on the healthcare side, but the drug companies have a monopoly on the drugs they produce. I'm not saying neither that you should drop the patents nor that you should introduce social healthcare -- but you should restore the balance in some way.

Personally, I'm for dropping or drastically reducing the patents on new drugs. I know that the argument against it is that it will discourage the research, but I don't believe it -- actually, it would enable further research on already existing drugs, improving them, and finding new uses and applications (think Viagra). But that's my personal opinion, and I'm not even a US citizen; you should find the right solution for yourselves.

[objclxt]

> In the US, you have no monopoly on the healthcare side, but the drug companies have a monopoly on the drugs they produce.

In a way there is a monopoly on the healthcare side in the US, but it only impacts a certain segment of the population. Medicare is able to negotiate significant discounts on the cost of healthcare compared to private insurers precisely because for so many people it is the de facto provider.

There was a really interesting Planet Money podcast a month or so ago about healthcare costs in the US which covered why the difference between private insurers and Medicare is so great: http://www.npr.org/blogs/money/2013/02/26/172996963/episode-...

[rdl]

Medicare/Medicaid are specifically not allowed to bargain on drug prices, though. They are a monopsony for hospital/doctor services, with full pricing power, for the old and poor, but pay market prices for drugs by law.

[refurb]

More accurately, Medicare is not allowed to negotiate for drug prices, however, the don't pay more than the average selling price for a drug (ASP).

Medicaid is certainly allowed to negotiate over drug prices. Medicaid gets an automatic 23% off the drug price and if the states can get an even bigger discount, they often get to keep it.

[mansigandhi]

> The US is effectively subsidizing advanced healthcare for every other country in the world.

That's a very misinformed statement.

[coldtea]

>What if the European countries had to had to pay for their own defense?

The European countries pay big bucks for their own defense, thank you very much.

And the US doesn't provide any defense at all. It merely uses its pressure to get the European countries to participate in its inane crusades and wars, from Korea to Iraq, which are for it's own interests.

Plus, defense against what? The only thing that brings any trouble to European countries is mostly aligning with US interests in some wars (e.g EU got some terrorist attacks by islamist groups in revenge for this -- few and far between in any case).

Not to mention that what the US officially considers "threats" are either lies (like Bush's WMDs in Iraq) or BS third world countries that couldn't harm a duck even if they wanted to (and which could not care less about having any war with Europe) but happen to be rich in oil or other resources.

[electromagnetic]

I think when the UK paid 1/20th of the cost to R&D Trident 2, but got 1/5 of the orders, I'd say yeah that was pretty heavily subsidized by the US to have an ally country with stealth-nuclear capabilities.

I also think you have absolutely no clue who international politics works by your blatant naivety. There's a lot more at stake than "access to oil". FYI Iraq showed oil reserves far superior to that of Saudi Arabia, and FYI Saudi Arabia has a military far exceeding most European states (UK, France and Germany obviously excluded due to the amount they do spend, but the Saudi Air force exceeds the UK for active combat air planes). Iraq with more money than Saudi Arabia and an intense hatred for the US/Europe would have been a massive fucking deal. Saudi Arabias royal family however is on good terms with the US government, and I'm sure the US didn't want a regional war between Iraq and Saudi Arabia locking down all Middle Eastern Oil production to ever be a possibility.

The War in Iraq was less about getting our hands on Iraqi oil, but getting their Regimes hands off of Iraqi oil. Had they been left alone since before the first gulf war, allowed to buy Russian hardware and build a military superior to that of Saudi Arabia, the region would be under their thumb and so would a massive chunk of the western worlds oil supply for military purposes. Not to mention they would have been well within the budget range to develop nuclear weapons without ever having to test like North Korea.

The US also didn't sit around and leave Europe high and dry in conflicts like the Kosovo War, because following your logic why should the US be dragged into a purely European conflict. Basically, because the US gives a shit about keeping its allies in place and stable and their enemies crippled and weak, which is what the rest of the world is trying to do too.

So when NATO countries have a vested interest in keeping a country down (Iraq) because it developing a military will support an old adversary (Russia), you can bet they'll tell the public whatever they fucking want to justify a situation like the Cold War never gets the opportunity to arise.

It's a sad state of affairs that crippling the development of foreign countries is in our own best interest, but personally I enjoy my way of life and the world isn't a John Lennon song.

[coldtea]

>I think when the UK paid 1/20th of the cost to R&D Trident 2, but got 1/5 of the orders, I'd say yeah that was pretty heavily subsidized by the US to have an ally country with stealth-nuclear capabilities.

"Subsidized to have an ally country" is completely different to "subsidized" (as in, "we did them a favor"). Plus, did they get those 1/5 of the orders for free? If not, I can't see how the fact that they paid 1/20th of the cost of the R&D comes into play at all. Do you expect them to pay the R&D on top of the price they buy the stuff?

Plus, the UK is not "Europe". Heck, they're considered mostly US lackeys down in the "continent", what with Blair and all.

>I also think you have absolutely no clue who international politics works by your blatant naivety.

I don't think Americans not in the government have any clue of international policy. For one, their access to good information is extremely limited, and most of their coverage (from news to books) comes from officially sanctioned party lines (with some faux-heretics thrown in for good measure). Even the american leftists have very mediocre analysis and take for granted a lot of ideology.

>There's a lot more at stake than "access to oil". (...) The War in Iraq was less about getting our hands on Iraqi oil, but getting their Regimes hands off of Iraqi oil.

So the well known situation with Saudi Arabia aside, that people in Europe (where we actually read newspapers and discuss international politics all the time, and not just what our government wants to bring into the spotlight to prepare the public consensus for some aggressive foreign policy) know even in High School, you wrote all that just to come around to that it's all about "access to oil"?

>Had they been left alone since before the first gulf war, allowed to buy Russian hardware and build a military superior to that of Saudi Arabia, the region would be under their thumb and so would a massive chunk of the western worlds oil supply for military purposes. Not to mention they would have been well within the budget range to develop nuclear weapons without ever having to test like North Korea

And that makes the business of a sovereign country something the US has any say in it because?

>The US also didn't sit around and leave Europe high and dry in conflicts like the Kosovo War, because following your logic why should the US be dragged into a purely European conflict.

The US shouldn't have been involved at all in the Kossovo war. They just wanted to establish Kosovo as a protectorate, and have a solid base in the Balkans. If the European people had their say (instead of our governments) they would have told the US to go and shove their participation in this conflict.

>So when NATO countries have a vested interest in keeping a country down (Iraq) because it developing a military will support an old adversary (Russia), you can bet they'll tell the public whatever they fucking want to justify a situation like the Cold War never gets the opportunity to arise.

We really hope something like the Cold War does arise. The Cold War was an era where none of the two bloody superpowers could do as it pleased. The so-called "balance of terror" worked in the favor of smaller countries (hence the tons of sovereignty and anti-colonial fights all around the third world). Now we just have one global cop, which does as it pleases, invaded who they like, takes care of its interests by stepping down on sovereign countries and such. Let's hope China can play the counter-balance in the future. (Sure, China has it's flaws. But the counter-balance does have to be totally progressive or democratic. Just as the US is not. It just have to be there, and stand as a limit to the other's power0.

>It's a sad state of affairs that crippling the development of foreign countries is in our own best interest, but personally I enjoy my way of life

Sure. Who wouldn't, if his country fucked up the world for him to enjoy cheap gas, financial domination, et al?

[electromagnetic]

Thanks for the point by point there, but you basically just confirmed my initial opinion that you really have no clue beyond your own media-infused bias of the situation.

I don't think we have to introduce your head to your ass, because I think they're well acquainted with each other.

Boo hoo, US evil, blah blah.

[coldtea]

>Thanks for the point by point there, but you basically just confirmed my initial opinion that you really have no clue beyond your own media-infused bias of the situation.

Ironic, coming from a citizen of the same country where 80% of the people believe in "miracles" ( http://www.npr.org/templates/story/story.php?storyId=1240075... ) and a large percentage cannot point their country on a map, much less a foreign country. Heck, it's the country the Presidents and political candidates are even know to do grave mistakes on international affairs, even confusing whole countries with others on camera.

>Boo hoo, US evil, blah blah.

I don't believe in "evil". I'm rational. US is just ruthlessly pursuing it's interests, and fuck everybody else (literally). Including fuck them with illegal and unethical means (from invading a sovereign country to drone murders). You can afford it when you are top dog. It's not like European colonial powers on their day behaved any better.

[ownagefool]

That's a complete non-answer, which is usually done by a person with the same issue you're accusing the parent of.

Trident is a sore point for the UK for several reasons:-

> It's not an independent nuclear deterrent, we're on a US leash even if we try to sell it otherwise.

> They're based in Scotland, a country within the UK which has fairly low support for nuclear weapons, which the primary elected party are dead against having them, going as far to make it a platform for the independence vote in 2014.

> We need to buy them and pay for upkeep. Theres talk of £100bn costs to renew the things, and I believe the lions share of that goes right back to the US.

I can't tell you whether or not it was subsidised, but I doubt it was when you get down to it and the comparison you are making isn't completely apt.

[malkarouri]

"Saudi Arabia has a military far exceeding most European states"

Speaking about knowledge of international politics, this statement is simplistic and arguably wrong. Saudi Arabia does have one of the largest military budgets in the world, but that does not translate to better or more military. It translates to buying more equipment and giving more money to the weapons industry in the US, the UK and other countries. The US is the main beneficiary, so it is kind of like protection money.

In particular, Saudi Arabia is far from the biggest military force in the Middle East in practice. Israel, Egypt, Iran, and Saddam-era Iraq are/were all far stronger. The last fact is the reason that Saudi Arabia and Kuwait invited the US and the coalition when Saddam invaded Kuwait, despite the loss of face. And it is the reason the US is military active in the Gulf region: Saudi Arabia is nowhere near Iran military speaking..

[malkarouri]

Saudis spend the most money on hardware, yes. But the hardware is left unused, and the sole reason for it is as a token in lieu of payments for US and allies.

The Saudi Arabian army does not project any power in the region, and is not a player. Saudi Arabia is not even able to support its allies in Lebanon against Iran-backed military players.

[amalag]

So actually we can say Saudis spend the most money on the most expensive hardware.

[miloshadzic]

It sucked to be bombed for three months but now that I realize it made an improvement on your quality of life I feel much better!

[electromagnetic]

Not to be an ass, but Iraq was leading to either another war with Iran, or a war with Saudi Arabia as the Ba'athist party was at odds with both, or just another genocide. The Iraq-Iran war caused (depending on the figures) over a million deaths and at least a trillion dollars in economic damage. The extreme high estimate for the Invasion of Iraq sits at 100,000, and 1/100th the civilian casualties of the Iraq-Iran war.

Personally it didn't improve my quality of life one bit, I had friends and family get deployed over there and I would have preferred they weren't for their and my own sake. I was opposed to the war, I was calling the WMD claims bullshit from the start. I know why the war happened, but I'd have rather our people have been kept out of it and just let Saddam and Ahmadinejad fucktard it out by killing hundreds of thousands of their own people.

I don't know if you're actually Iraqi, or just trying to make a point, if you are I'm sorry for my callousness, but I honestly don't think my friend should have had to be in a Hummer that got hit by an IED because the Iraqi government had a history of going apeshit with mustard gas on civilian populations, just because my government didn't want some retard fiesta in the Middle East to put us into a great depression when the oil industry and all derivative industries halt.

[yequalsx]

Your view of Iraq's military capabilities and of it's military potential in 2000 is badly wrong. Iraq, by 2000, was a shell of its former self militarily speaking. The sanctions, no fly zones, and complete domination of its military in the early 90s ensured this.

Saudi Arabia, after the first Gulf War, was not in any way threatened by Iraq. Saudi Arabia supported Iraq in its war with Iran.

It is most interesting that you point out Iraq's usage of mustard gas. Said usage occurred during the Iran/Iraq war. The usage was supported by the U.S. until it was applied to Iraqi Kurds. Then there was some moral posturing but the weapons, support, and money kept flowing to Iraq so that they could continue the fight with Iran.

[miloshadzic]

I'm from Belgrade, Serbia.

[FireBeyond]

"I think when the UK paid 1/20th of the cost to R&D Trident 2, but got 1/5 of the orders, I'd say yeah that was pretty heavily subsidized by the US to have an ally country with stealth-nuclear capabilities."

That's a little one-sided. You forgot to mention that the US got the ability to build military bases on UK soil for no rent / charge.

[arethuza]

That's one of the more rational explanations of the causes of the Iraq war that I've heard....

[electromagnetic]

The Iran-Iraq war caused around a million deaths and a trillion in economic damage in the region. If Iraq went against Saudi Arabia, and started bombing the crude oil transports again, we'd be potentially looking at a Great Depression in the US and globally as it would shut down the massive oil refineries in the US gulf, and associated oil-derivative industries like having massive effects on US shipping.

Personally I don't think my friend should have had to be in a Hummer that got hit by an IED (he's fine, well tinnitus but I got that from a Motorhead concert) because Saddam liked bombing civilians with mustard gas, but given my work is solely dependent on petroleum products I kind of like having a job right now.

[throwawayG9]

TLDR:

> personally I enjoy my way of life

[solistice]

The sum of European defense spending is about as high as that of the US, but it's defense efficiency is at about 10% of that of the US due to duplicate hardware and parallel organisational structures.(I went to a Model UN Conference a couple of years ago, and our comitee wrote a resolution on establishing an Unified European Defense Force, and those numbers came up somewhere in my preliminary research, but I'm too lazy to dig them up again). What's intresting is that there are Community Medical Centers in the US, which offer the same medical procedures as regular hospitals, by the same doctors which are paid the same wage ,for 2,5k $ instead of 25k$ afaik. But then they don't charge 25$ for a disposable syringe that cost 50 cent to buy and 5 cent to produce.

[melling]

Please provide some data to back that up because it is a common belief that the high cost of producing a new drug is offset by the US consumer.

[coldtea]

What high cost? US companies pay more money for advertising than for creating the drug.

Add other regulation and inefficiencies, and subsidized research would work with 1/10 the money.

Not to mention that because of the commercialization of medicine, tons of research is for BS like Viagra and other such drugs (like the tons of stupid feel-good "energy" drugs, so that your boss can squeeze even more overtime out of you), where far more important but less lucrative stuff is ignored.

That's how you get the US sucking donkey's balls in infant mortality rates. As if it was some third world country.

[adventured]

If that were true, the rest of the world would have radically surpassed the US in terms of drug innovation, research breakthroughs, medical device technology and so on.

Because their lower investment levels should be producing returns so much higher, that they would quantum leap the US while spending less. That hasn't even remotely happened.

Sucking donkey balls on infant mortality? You should become better educated.

How about Canada, at 5.22/1000 versus 6.81 for the US. That's your magic line on 3rd world countries and donkey ball sucking? Well Singapore is 1.92, and Japan is 2.6, so Canada, New Zealand, Australia and Britain are apparently 3rd world countries by comparison.

Half of the US infant mortality rate is due to high black poverty. Maybe you should become informed on the root causes of problems in America before making bad assumptions.

[dontstealmyname]

Viagra was not initially being developed as an erection pill it was a heart medication (I think) but turned out to be better at causing erections so they ran with that.

[carbocation]

Sildenafil (Viagra) was developed to treat hypertension and angina. It had little effect, but was found to assist with maintaining erections, so it was further developed for that purpose. Later it was discovered to be effective for pulmonary hypertension and is approved for that use, as well.

[criley]

>What high cost? US companies pay more money for advertising than for creating the drug.

Misleading stat that doesn't look at the full cost of bringing a NME to market.

You're looking at a yearly budget for a company while ignoring reality: drug development isn't yearly, it takes about 8-12 years total. To analyze something on an 8 year cycle using 1 years worth of data is at best ignorant and at worst, intentionally dishonest.

They'll spend almost $1,000,000,000 USD to whittle 10,000 drug candidates into what is hopefully a single FDA approved new molecular entity.

>That's how you get the US sucking donkey's balls in infant mortality rates. As if it was some third world country.

Did you hear that loud crack? It was you smashing your head against correlation/causation. You might want to have that fallacy checked out. Looks bad, man.

[calibraxis]

Consider googling it, just as you'd investigate how to fix a bug in software you use. "Common beliefs" should be viewed with suspicion. (http://www.citizen.org/publications/publicationredirect.cfm?...)

Just as with the development of computers and the internet, we can thank the US taxpayer and government for subsidizing pharmaceutical innovations. Which is then sold back to us at hilarious rates.

Pharmas reap wonderful profits in other countries (otherwise they probably wouldn't operate in them), just not extreme profits they can extract from US people. It's propaganda that high US prices benevolently subsidize pharma for the rest of the world; this narrative increases nationalism, and sets up an entitlement complex. Propaganda's a great way to get your targets to believe in their own fleecing.

[melling]

Consider that when you are making a statement to tens of thousands of people that it would be best to provide supporting evidence so that exercise of "googling" doesn't have to repeated by everyone.

[calibraxis]

I try to spend the time to support my claims with evidence, as such arguments are more intellectually convincing. Once you depart from views frequently repeated in the media, you no longer have the luxury of soundbites, so providing evidence is best.

It takes more effort (particularly since you don't want to cite bad evidence), but is necessary.

And the issue is, people who want truth gotta dig. Otherwise they'll be doomed to live the rest of their lives believing lies written by some PR flack. (I've known some PR flacks. They eloquently phrase what their bosses want communicated. And even being careful, I'm sure I believe many serious lies and falsehoods, at least to some extent.)

[bitdiddle]

I think this notion of the drugs companies needing incentives for R&D is somewhat of a myth. A large amount of the research, which they avail themselves of, is publicly funded at places like NCI and NIH. That's right, we the taxpayer helps produce these 70K dollar drugs.

[DennisP]

So the problem is that healthcare innovation is a public good, which like all public goods is underprovisioned if you don't take steps. We approached this one by converting it to a private good within the U.S. But that's not the only solution.

A natural entity to pay for drug development is health insurance companies, who would save a lot of money if drugs were patent-free. But they don't in fact fund patent-free drugs, since their competitors could free-load.

Bernie Sanders proposed a solution: tax the insurers so none can freeload, and use the money for drug development, and keep everything patent-free. The insurers could come out ahead. (Iirc he had a slightly more complex arrangement that didn't require the government to decide who would be funded.)

It's worth noting that patents don't only reward inventors, they also increase their costs. The book The Gridlock Economy talks about this, and mentions one biotech firm that thought it had a cure for Alzheimer's. It infringed on thirty patents, and each patent-holder thought it had the most important part and charged accordingly. They had to abandon the whole thing.

[amalag]

Having the government fund patent-free drug development is a very interesting approach. Is the idea to do through proposals like Darpa?

[betterunix]

I would support such a system. In my ideal world, things look like this:

NIH pays for the research and development of new drugs, and we do not give out patents for any of it. Pharmaceutical companies are free to produce whatever drugs they want, and cannot prevent anyone else from producing those drugs; they must only meet the quality control standards set by the FDA. All drugs would be sold like today's "generics," in a competitive market that keeps prices down.

[adaml_623]

You say that US healthcare leads the way in innovation but in certain key measures like Infant Mortality and Life Expectancy it's not leading the field at all.

[InclinedPlane]

The US measures infant mortality very differently than other countries, you can't do an "apples to apples" comparison just by naively looking at statistics.

Edit: Here's a relevant reference, from the WHO, if anyone has doubts about this being a serious issue: http://www.who.int/bulletin/volumes/86/6/07-043471/en/

[adventured]

The US is within a small margin of error to being on par with both Japan (adjusting for their huge fraud in longevity) and South Korea on life expectancy. That sure sounds amazing considering our obesity / diet problems. I'd argue in fact that our advanced healthcare system and large investment is the only reason Americans aren't dying at 70 instead - we're able to keep people alive that would otherwise die much younger. I'd argue if you matched diets to other countries with very high life expectancies, we'd easily match or surpass them in longevity and live to 83 to 85. Our problem is mostly lifestyle.

Infant mortality? What, you think Bosnia and Russia actually beat the US in infant mortality, or is it more likely they're lying? (given Russian men live to 60).

[adaml_623]

I don't understand your reply. Two sources show that the US is 51st[1] and 40th[2] in the country rankings for life expectancy? I'm not sure what Japan and Korea have to do with it. Definitely not leading the field

[1] http://en.wikipedia.org/wiki/List_of_countries_by_life_expec...

[2] https://www.cia.gov/library/publications/the-world-factbook/...

[FireBeyond]

And for the average American, between 10 and 20 per cent of your lifetime healthcare costs accrue in the last 1-3 months of your life. Beyond healthcare, America has a problem with dying and death, and a willingness to spend vast amounts of money on someone who is at death's door, often in a manner that negatively affects the quality of the remainder of their life, and for what - other people? Sometimes even for no-one.

[analog]

Bosnia and Russia are both listed as having worse infant mortality rates than the US.

http://en.wikipedia.org/wiki/List_of_countries_by_infant_mor...

[adventured]

I was going by the CIA factbook.

It lists Bosnia at 6.1 (50% lower than the Wiki).

The Wiki entry claims it uses the CIA factbook as a source. So I'm not really sure which source that Wiki entry is relying on.

[analog]

The first table in the Wikipedia entry uses UN estimates which have Bosnia at 13 deaths per 1000 births.

[jellicle]

Has nothing to do with "innovation", since nearly all healthcare research is paid for by the U.S. government anyway, and it's much less money than you think.

The claimed expenses for "research" are mostly about bringing slight variations of drugs to market in order to extend patent protections - that is, they are rent-seeking.

> "More than four fifths of all funds for basic research to discover new drugs and vaccines come from public sources."

http://www.bmj.com/content/345/bmj.e4348?ijkey=Y1g4ZVUImIbtX...

The story of healthcare costs in the U.S. is entirely to do with profits for drug companies and hospitals, and has almost nothing to do with "innovation".

[refurb]

The key to your comment is "basic" research.

You can discover a new drug for a few tens of millions of dollars. Now to get that drug to market? You need to cough up a few hundred million dollars.

Discovering a drug doesn't save any patients, getting it to market does and THAT is paid for by private companies.

[Retric]

It costs tens of millions of dollars in large part because US healthcare is so expensive. The actual handing out of drugs is fairly low effort, it's everything else that makes trials so expensive.

[refurb]

It costs 10s of millions of dollars because that is how you prove a drug is safe. That isn't unique to the US. If you want to launch a new drug in the EU, it's not going to cost you any less.

[Retric]

the number of FDA-regulated investigators running trials abroad has increased by 15 percent each year, while the number of U.S.-based investigators declined 5.5 percent annually.

Several forces are pushing trials elsewhere, the researchers noted: cost (a trial at a top medical center in India may cost less than one-tenth per patient what it would cost at a second-tier U.S. center); faster approval times; and less red tape. http://health.usnews.com/health-news/managing-your-healthcar...

PS: Of note: In the US, sponsors may receive a 50% tax credit for certain clinical trials. http://en.wikipedia.org/wiki/Clinical_trial#Economics

[tete]

Which has another problem. Investors tend to force drugs onto the market, even when there is evidence for drugs having bad side effects, like killing you and that's nothing that ever changed.

[danielweber]

There are so many weasel words in "basic research to discover new drugs" that I can't even begin to evaluate it.

Or, you can look at the actual drugs that get approved, and back-trace them to their sources. Hey, someone already did that. Here: http://pipeline.corante.com/archives/2010/11/04/where_drugs_...

[LekkoscPiwa]

No, No, No. It is exactly opposite. It is the rest of the world subsidizing the US. The dollar is the world currency. It means that if any other country in the world wants to buy energy (i.e. oil or natural gas), or to trade internationally, it can do that only and only in the US dollars. About 90% of all dollars in circulation, circulate outside of the US borders. Think about it for a second. Your "genius" central banker Ben Bernanke may print and print and print and who gets hit by inflation? China does. Europe does. Japan does. You get just 10% of it and 100% of its benefit. So, yeah, with the whole world subsidizing you any, each and every time that a barrel of oil is bought, or m3 of gas is bought, or international trading deal done -- you can waste as much as you want, bragging how great you are, sure. But I tell you this: given unlimited and unrestricted credit any nation could innovate and create google's, healthcare and military equipment it wanted. It is just function of free credit. Someone else pays your bills. Clowns like Trump can go bankrupt every second year (as he does!) and still get even more borrowed money from a bank overflowing with it from the FED that gets it with only 10% downside, exporting 90% of the cost.

There are no miracles in this world and US is not an exception. Wait and see world turning back on the dollar, and we'll have a level playing field. Then we'll see how much the USA is really worth. Without subsidies.

[gte910h]

> Your "genius" central banker Ben Bernanke may print and print and print and who gets hit by inflation? China does

Inflation has been painfully low for years. Many have said it needs to be higher actually.

[tete]

Many in the US?

[ofacup]

well that's the biggest load of shit i've ever read