Has Insulin Become a Privilege Rather Than a Right in America?
This is an editorial by Dr Irl B. Hirsch of the University of Washington School of Medicine, published in Diabetes Spectrum in 2016. It is a physician’s commentary and personal account of insulin pricing in the United States, not a trial or a systematic study. Its argument: insulin, whose patent the University of Toronto sold for $1 with the understanding that cheap insulin would follow, has become unaffordable for many of the people who need it to stay alive.
Dr. Kumar’s Take
The pricing history in this editorial is hard to read as anything other than a moral failure. The Toronto group sold the patent for a dollar so that insulin would be cheap. Hirsch traces the line from there to a clinic where patients on commercial insurance face copayments they cannot meet, and quotes a woman on an insulin pump who said her insulin now costs more than her home mortgage. That is a drug required for survival. Patient assistance programs exist and are underused, but as Hirsch puts it, it would make more sense to price the drug reasonably in the first place. I agree.
Key Findings
Hirsch tracks the price of a vial through his own career. Human insulin arrived in 1982 at $14 per vial and insulin analogs in 1996 at $24 per vial. By 2005, when he published a review of insulin analogs, vials of analog insulin cost about $60. By 2012, insulin lispro was $138 per vial and insulin glargine $125, increases of 134% and 116% respectively since 2005. All of those figures come from drugstore.com listings.
The global market moved in step. A $7.3 billion business in 2005 became a $21 billion global market by 2013, driven largely by the U.S. health care system’s willingness to pay for modest differentiation and its acceptance of repeated price increases. North America accounts for 7% of the world’s diabetes but 52% of global insulin sales. China accounts for 25% of the world’s diabetes and 4% of global insulin sales. Hirsch attributes the gap primarily to the absence of real price controls of the kind found in Canada, the United Kingdom, Germany, and most other countries.
Insulin pricing increased threefold between 2002 and 2013, and expenditure for insulin per patient in the United States exceeded that for all other antihyperglycemic medications combined.
Brief Summary
This editorial follows insulin from a $1 patent to a medication many Americans cannot afford. Hirsch describes what changed in his own practice: patients in the Medicare “donut hole,” patients without insurance, and, most surprising to him, patients with commercial insurance facing very high copayments. His hospital had a 340B drug pricing program that let his patients obtain insulin at extremely low prices, often several hundred dollars less than their copayments for a three-month supply. That program was lost in early 2016, and those patients now pay full retail.
Study Design
This is an editorial, not a study, so there is no protocol, sample, or statistical analysis. Hirsch builds the argument from his own experience as an endocrinologist, from price listings he collected on drugstore.com in 2005 and 2012, from published market analyses of global insulin sales, and from patient accounts in his own clinic. The distribution chain is discussed through secondary sources, including a New York Times article by Kasia Lipska on pharmacy benefit managers.
Results You Can Use
The middlemen matter as much as the manufacturers. Hirsch notes that he did not initially understand how pharmacy benefit managers, wholesalers, and chain pharmacies affect the final price a patient pays. Citing Lipska, he reports that the three largest PBMs bring in more than $200 billion per year in revenue, and that the rebates they receive from drug companies look suspiciously similar to kickbacks. He also recounts being contacted by a representative of an insulin company, upset that he had published retail prices at all.
On his 2012 conclusion slide he predicted that many U.S. patients would be forced to go back in time to human insulin because neither payers nor patients could afford analogs. Most of the audience rolled their eyes.
Why This Matters For Health And Performance
Roughly 1.5 million people in the United States require insulin for survival, and another 4.5 million use it. Insulin is required for survival by 10% of those with diabetes. When the drug becomes unaffordable, patients are left deciding whether to pay for insulin or for housing and food, and for patients with type 1 diabetes there are not many options.
How to Apply These Findings in Daily Life
- Ask your prescriber directly what your insulin will cost at the pharmacy counter before you leave the office
- Ask about patient assistance programs, which Hirsch describes as helpful and underutilized
- If your hospital participates in a 340B drug pricing program, ask whether your insulin qualifies
- Compare retail vial prices across pharmacies rather than assuming the copayment is the lowest price
- Weigh insulin coverage specifically when choosing an insurance plan, including the Medicare coverage gap
- Ask your prescriber whether human insulin is a clinically reasonable option for you if analogs are out of reach
- Support price transparency and pricing reform if this matters to you
Limitations To Keep In Mind
This is one physician’s editorial, so it carries the weight of argument and clinical experience rather than of a designed study. The price figures come from a single retail web site and reflect list prices, not what every patient pays. The account is specific to the United States, and to a single academic practice within it. It was written in 2016 and does not cover anything that has happened since.
Related Studies
- The Internal Secretion of the Pancreas
- 100 Years of Insulin: Why Is It So Expensive?
- Expenditures and Prices of Diabetes Medications 2002-2013
- Frederick Banting: Discoverer of Insulin
- Episode 24: The Discovery of Insulin
FAQs
Why is insulin expensive in the United States specifically?
Hirsch points to the absence of real price controls of the kind used in the government-run systems of Canada, the United Kingdom, Germany, and most other countries. He also describes a distribution chain of pharmacy benefit managers, wholesalers, and chain pharmacies whose rebate arrangements affect what patients ultimately pay.
What should I do if I cannot afford my insulin?
Talk to your prescriber rather than skipping doses. Hirsch notes that patient assistance programs can be helpful and are underutilized, though they add bureaucracy. He also observes that some patients are being pushed back toward human insulin, which is cheaper than the analogs, and that is a conversation to have with your physician rather than a change to make alone.
Was insulin always expensive?
No. Human insulin was $14 per vial when it was introduced in 1982 and analogs were $24 per vial in 1996. Hirsch writes that for decades the increases did not seem to be a concern, and that the vast majority of U.S. patients requiring insulin had access to every analog as it was developed.
Conclusion
The University of Toronto sold the insulin patent for $1 so that cheap insulin would become available. Hirsch asks whether the current situation is what that group wanted in 1922, and answers that it was never the goal. A drug that roughly 1.5 million Americans need to survive has become something people weigh against rent and groceries. I do not think a threefold price increase over eleven years can be explained by innovation, and I do not think the people paying it should have to make that calculation.
