On January 28 2020, the Facebook page “Drug Prices are Too High” shared the following Twitter screenshot, about the purported price of insulin outside the United States (USD$20) versus its cost in the U.S. (USD$300+) per vial:
That tweet referenced three companies, and an attached status update named Eli Lilly, Novo Nordisk, and Sanofi as the primary manufacturers of insulin worldwide. The tweet was sent on the same day by Laura Marston (@Kidfears99):
Although it was short, the tweet contained a few claims::
- Three companies make all insulin for every country on Earth;
- Those three companies charged $20 a vial for insulin in every country other than the United States;
- The same three companies charged $300 or more per vial of insulin, “the exact same insulin,” in the United States.
According to an editorial on insulin pricing in the United States in medical news outlet STAT News, the first claim — that three companies “make insulin for every country on Earth” — was largely accurate. It began:
When Frederick Banting, Charles Best, and James Collip filed for a U.S. patent on insulin in 1923 and sold it to the University of Toronto for $1 each, they did it because, as Best once said, “insulin belongs to the world.”
They also believed that securing the patent was a form of publication, and wrote to the university president, “When the details of the method of preparation are published anyone would be free to prepare the extract, but no one could secure a profitable monopoly.”
Sadly, they were mistaken.
Today, three companies — Eli Lilly, Novo Nordisk, and Sanofi Aventis — control virtually the entire global market for insulin. This oligopoly, which may have colluded to fix insulin prices, charges exorbitant amounts for a medicine that people with type 1 diabetes cannot live without. Since the 1990s, they have raised the price of insulin more than 1,200%.
A BBC report in November 2018 about a projected global shortage of insulin indicated that Eli Lilly, Novo Nordisk, and Sanofi Aventis controlled 99 percent of the global market for insulin (96 percent by volume), and 100 percent of the United States market:
One reason, say scientists, is that three multinational companies — Novo Nordisk, Eli Lilly and Company, and Sanofi — control 99% of the $21bn (£16bn) global insulin market in terms of value and 96% in terms of volume. (The same companies control the entire US market.)
That reporting suggested that some insulin outside the United States came from elsewhere, but in a share small enough to total one to four percent of insulin (depending on whether the measure was volume of money or volume of insulin). And outside the U.S., most insulin-dependent diabetics relied on products from Eli Lilly, Novo Nordisk, and Sanofi.
In a separate article, we examined a viral meme about the cost of insulin pens in particular in and outside the United States; an expert explained that the claim was accurate in its basis, but the numbers were exaggerated. Further complicating direct comparisons was that the price of insulin was only one metric in terms of its availability to insulin-dependent diabetics.
A 2019 study of 13 low and middle-income countries published in the medical journal BMJ found:
Mean availability was higher for human (55%–80%) versus analogue insulins (55%–63%), but only short-acting human insulin reached 80% availability (public sector). Median government procurement prices were $5 (human insulins) and $33 (long-acting analogues). In all three sectors, median patient prices were $9 for human insulins. Median patient prices for analogues varied between the public sector ($34) and the two private sectors ($44). Vials were cheaper than pens and cartridges. Biosimilars, when available, were mostly cheaper than originators. A low-income person had to work 4 and 7 days to buy 10 mL human and analogue insulin, respectively. For isophane human insulin, only three countries meet the WHO target of 80% availability of affordable essential medicines for non-communicable diseases in any sector.
The tweet’s second claim was that outside the United States, the three companies (Eli Lilly, Novo Nordisk, and Sanofi) charged a static USD$20 for an insulin ampoule. An extensive joint April 2016 study [PDF] between Health Action International (HAI) and Addressing the Challenge and Constraints of Insulin Sources and Supply (ACCISS), titled Insulin Prices Profile, endeavored to “to identify the causes of poor availability and high insulin prices and develop policies and interventions to improve access to this essential medicine, particularly in the world’s most under-served regions.”
Its introductory paragraphs again indicated that the cost of insulin was one of several factors in terms of global insulin access, and the prominence of those factors appeared to vary between countries and cultures. For instance, American insulin-dependent diabetics might struggle with retail pricing in their country, but not access to an insulin-dispensing pharmacy. People in rural areas of underdeveloped countries might or might not be better able to afford insulin, but struggle to obtain supplies from far-away supplies.
This sort of disparity was described in example form on pages nine and ten of the report, where United States dollars are the metric used for other countries:
Work by the International Insulin Foundation (IIF) in Kyrgyzstan, Mali, Mozambique, Nicaragua, the Philippines, Vietnam and Zambia found a variety of barriers to insulin access, one of which was its overall price in comparison to other medicines. Insulin costs on average US$ 4.20 per month for treatment, which is up to 74 times higher, priced than for other treatment courses of medicines for NCDs.(4-14) In addition, for example, in Mali and Mozambique insulin was present at only 20 percent of the facilities where it should have been meaning that availability was an issue as well as affordability. The factors causing poor insulin availability are present both at global and national levels and cannot be addressed in isolation. Therefore it is important to understand the path of insulin from “production” to “administration” in order to improve access.
Another large element of the report involved the kind of insulin dispensed — vials, pens, disks among them. Cost of insulin was dependent in part on its form.
The report was extensive and involved several different comparisons regarding insulin costs, availability, accessibility, and reimbursements. It would be virtually impossible to compress the breadth of those figures into a static sum. It was true that almost all countries had adjusted and raw costs for insulin far below the $300 cited as the United States cost in the tweet, but they fluctuated up to nearly $40 in some calculations.
The third claim was that insulin was essentially price-fixed in the United States, retailing at $300 a vial regardless of manufacturer — Eli Lilly, Novo Nordisk, or Sanofi. For that, we looked at an August 2018 study published by Diabetes Care, which read in part:
Another important trend affecting overall costs for insulin in the last decade is the shift in insulin utilization from the less expensive human insulins to more expensive human insulin analogs. While the prices of both types of insulin have increased, the difference in pricing between them has substantially added to insulin costs — both to the health care system and to many patients (human insulins are available at the pharmacy for $25 to $100 per vial compared with human insulin analogs at $174 to $300 per vial.)
That excerpted portion addressed the disparity in cost between types of insulin. It was also published in mid-2018, a year and a half prior to the January 2020 tweet. In the intervening 17 months (not counting the passage of time between collection of data and publication), insulin prices might have fluctuated and even increased.
All that said, the $300 a vial figure appeared to be the higher end of a range, and it was further possible that those paying $300 a vial for insulin did not have the option of “selecting” a cheaper insulin analog. As noted, those decisions were made between manufacturers of insulin analogs and pharmacy benefit manufacturers without input from most patients:
Based on the Working Group’s review of the insulin supply chain, it is clear that the insulin manufacturers still control the list price of insulin, but a meaningful share of the negotiating power has shifted from manufacturers to the PBMs. PBMs attempt to keep medication costs down by moving market share between competing products, and their market power is directly related to their ability to provide exclusive formulary coverage for particular brands of medications.
The study in Diabetes Care referenced the ACCISS/HAI study, noting that while its scope concerned the United States, the prior study examined insulin costs and access worldwide:
Insulin affordability and accessibility issues, however, are not restricted to the U.S. Data from the global ACCISS (Addressing the Challenges and Constraints of Insulin Sources and Supply) study found several overarching trends. First, even for the same insulin product, there is a wide range of prices across the world. Second, there is a large price differential between the lower prices of human insulin formulations and the higher prices of human insulin analog formulations on a global level. Third, there has been increasing use of human insulin analogs compared with normal human insulin over the recent past, which is greater in more developed parts of the world. This study also reported that the global insulin market is dominated by the same three large multinational corporations that manufacture and sell insulin in the U.S. Those companies represent 99% of the total insulin by value, 96% by total market volume, and 88% of global product registrations.
The $300 a vial cost is only part of a larger financial burden placed on insulin-dependent diabetics, for whom access to insulin can be a life-or-death matter. A June 2019 AMJC editorial first mentioned various limited initiatives to lower the cost of insulin, but added:
These proposals and others like them are coming about simply because the price of insulin doesn’t make sense logically, financially, or morally.
The piece continued, citing costs for insulin in the United States:
What about the other 29.3 million patients who are paying anywhere from $300 to $800+ a month for their necessary insulin?
Back in 1996, when Eli Lilly’s Humalog first came out, the price for a 1-month supply of insulin was $21. As of 2001, that exact vial’s price increased by $14 to $35. Now, in 2019, that vial is said to be around $275. That is a 1200% increase on the original price.
Since 1996, the value of the dollar has only decreased by roughly 62%. So, why has the price of insulin increased so much over the years? The world may never know since pharmaceutical companies continue to hold their tongue when asked about it.
Although twenty-year increases were often cited in the articles and studies, the problem was not just one of slow escalation. One study found that insulin’s cost to the patient nearly doubled between 2012 and 2016. Researchers said that spike had nothing to do with new, better drugs or higher rates of usage in patients:
“It’s not that individuals are using more insulin or that new products are particularly innovative or provide immense benefits,” Jeannie Fuglesten Biniek, a senior institute researcher and the report’s co-author, said in a phone interview.
“Use is pretty flat, and the price changes are occurring in both older and newer products. That surprised me. The exact same products are costing double,” she said.
It is true that insulin-dependent Americans were faced with an atypically high financial burden compared to their peers in Europe, and that in many countries, the same exact insulin products retailed for a fluctuating tiny fraction of its cost in the United States. It is further accurate to say Eli Lilly, Novo Nordisk, and Sanofi maintained what was essentially a monopoly on insulin worldwide, and thus had a large hand in its pricing. But the underlying information was a bit more complex, and the $300 versus $20 figures cited were a bit more variable.