Pharma is a small component of US health care spending

Huge US–Foreign Price Gaps

• Multiple anecdotes: eczema cream $1,000 in the US vs ~$100 in Canada; IVF meds ~$5,000 US vs ~$1,000 from Germany; rabies post‑exposure course ~$25,000 list / $2,500 with insurance vs ~£150–300 in UK private clinics; EpiPens and certain eye drops costing hundreds in US vs tens abroad.
• Several people buy identical branded products from Canada/Europe at a fraction of US prices, sometimes even OTC there.

Who Is Actually Gouging?

• One camp: this is straightforward proof that “Big Pharma gouges Americans.”
• Others: the high US price is a system outcome, not just manufacturers—insurers, PBMs, hospitals, and other middlemen capture “rents” via opacity and negotiated discounts off inflated list prices.

Market Structure, Monopolies, and Middlemen

• Long‑term consolidation: pharma → insurers → hospitals, all seeking bargaining power; consumers, unable to “consolidate,” are left with no leverage.
• Commenters see similar consolidation patterns across sectors, but healthcare is special due to inelastic demand and size (~17–20% of GDP).

Role of Insurers and PBMs

• ACA caps insurer profit margins, so some argue insurers are a relatively small slice of total spending; they may instead push overall prices up to grow profits in absolute dollars.
• PBMs and insurer‑owned mail‑order pharmacies are described as major profit centers, exploiting spread pricing, captive mail‑order rules, and opaque rebates.
• Dispute over whether insurers’ small share in CMS data means they’re minor actors or hidden drivers of high prices.

Doctors, Hospitals, and Overuse

• CMS data cited: most spending flows to “hospital care” and “physician/clinical services,” not drugs or insurers.
• US physicians and nurses earn 2–3.5× European peers and often work under RVU systems that incentivize more procedures (imaging, surgeries, hernia repairs, etc.).
• Some argue high clinician pay and overuse are central cost drivers; others emphasize med‑school debt, malpractice, and administrative bloat.

Comparative and R&D Arguments

• The claim that high US prices “subsidize” low foreign prices is challenged; commenters note generous public R&D abroad and very high pharma profits.
• Debate over how to amortize drug R&D (8–12 vs 15 years of exclusivity) and what counts as “enough” profit.

Policy Proposals and Systemic Fixes

• Suggested fixes: break up monopolies; single‑payer with government negotiation; or a large non‑profit public option (federal employees/Medicare/VA) open to all.
• Others stress price transparency, simplified billing, and loosening prescription requirements for low‑risk drugs.
• Some are pessimistic: piecemeal savings get absorbed by the system; structural change or full system redesign may be required.

Regulation, Importation, and Quality

• US law generally bans importing non‑FDA‑approved versions; even identical foreign‑made drugs can be technically illegal.
• Some doctors warn about counterfeit/poor‑quality injectables in gray markets, especially for complex biologics, while acknowledging US QC problems too.