At the corner of suck my cock and fuck you too pal

Being the disorganized anxious-avoidant dipshit I am who knows as much about psychiatry as a keen observer would expect, I ran out of lamotrigine on a trip back east and had to get my prescription transferred from California to New York. There’s no Safeway here, which, oops, but there is Walgreens, so I got to spend $68 for would have cost me about $20.

They couldn’t even make it nice.

That was after all the discounts. I had to pay $20 to get it for $47.99. They’re probably trying to shave another penny or two off their rewards rebates, but they’re definitely trying to bamboozle customers who aren’t in the habit of rounding up to the nearest dollar in the presence of sleazy retailers. The $20 was to join the prescription discount club. You have to pay for prescription coupons at Walgreens. Membership is good for a year, so I can now get all the lamotrigine I want for a 150% markup until next June, unless they raise the discounted subtotal again.

The online coupons I was finding for Walgreens were horrifying. The cheapest was something like $150. I asked the pharmacist about the rack rate. $389. Bitch the fuck? It wasn’t her fault, of course, but dear fucking God. It has to be awful to complete pharmacy school and then discover how many of the job openings are with the same sleazy passive-aggressive shakedown behemoth. It has to be annoying, to say the least, to be professionally trained to spot and intercept drugs with potentially fatal interactions and be forced to tell customers that because they don’t have the proper coupon and their insurance is out-of-network they’ll be paying $400 for a bottle the size of a shot glass half full of universally available generic antidepressant tablets the size of Grape Nuts. Is it under $20 at Price Chopper, with that other coupon? Yes. Is it $389 here at the MSRP? Yes. Why? Fuck me, man; I only work here.

In a country with the rule of law, it would be possible for any customer getting Shanghaied like that to have government auditors collect and return $369 in change the next business day, along with the change due every other customer for every other gross overcharge. Real Heads of Depression recognized it as the 25, and everybody recognizes lamotrigine as definitely not an artisanal antidepressant ground, mixed, measured, and packaged by hand by Ye Olde Village Compounding Apothecary. This shit isn’t Charlie Smithgall walking into the garden with a mortar, a pestle, and a pair of scissors to custom-cut an order of St. John’s Wort. I’m pretty sure he wouldn’t charge $389 for that, either.

None of this has shit to do with the free market or supply and demand or economies of scale. It’s extortion. The real retail break-even point for lamotrigine 25 mg 240 count is probably under $10. That should be enough to cover what it costs to manufacture, ship, stock, and dispense the pills. If it isn’t, Walgreens would do fine running the pharmacy as a loss leader for the rest of the store, to get the goobers in for the markups. The cost of getting that shit from the factory floor to the patient’s hands is not $1.62 a fucking tablet. Break me off a piece of something weaker, Stossel; I’m already hallucinating.

This bullshit has yielded Canada much tourism. Drug prices, eh. It’s like how my parents had to drive an hour and a half to Plattsburgh instead of 45 minutes to Queensbury for their Rona shots, and had to go to the old SAC base four times, because their Honorable Governor’s high orations about public health and how much he cared, did not extend to making it feasible to get the damn vaccine. I’m a low-grade paranoiac who keeps up with fellow travelers, and yes, there have been irregularities with these vaccines, and by God do the overwrought incentives raise questions, but when I got over my paranoia last month, I’d waited long enough to walk in for the J&J one-and-done at the Aviation Mall and walk out less than an hour later. They have brined me now alhamdulillah; alhumdulillah I am brined in full. Plattsburgh was so popular nobody went there anymore. That’s why the putz is noisily offering a SUNY/CUNY tuition lottery in a desperate effort to shoot all the kids. Business is down.

Greetings from the Hellstate. Montreal is always worth a visit, and many wouldn’t go unless they had to run errands, but that’s the problem. Who the fuck wants to take a bus to Montreal just to go to some random pharmacy? It’s no accident that our Canadian vice president graduated from Westmount. Neither of our dogshit major parties, if we even conceive of any others, have space under the big tent for a Francopopulist who figures ya hon hon hon have to represent Trois-Rivieres but sure, we can fund a friend’s Metro trip, too, but why the fuck wouldn’t you base the whole system on pneumatic tires, are you a goddamn Toronto limey bastard.

It’s so different now anyway. It’s so much worse. Canada is currently indisposed, to us a(ll), at least. It wishes not to catch sick, and we’d be inconsiderate not to show full trust, confidence, and deference before the demands of a couple of greasy nepotists like Justin Trudeau and Doug Ford when they insist that they’re just trying to keep their constituents healthy and alive. It’s a disappointingly American story, one reminiscent of Cuomo and any number of shitbags in and around the White House. Thank God Canada hasn’t vomited its own Anthony Fauci into a position of supreme epidemiological authority. Of course, Canadians can always borrow Tony, same as they can listen to NPR, watch NBC over the air if they’re close enough, and go shopping in New Hampshire lol jk sucka.

NAFTA Schengen is even farther away than it was. The only way to come close to enjoying it now is to know where to shimmy up against the cliff to evade the sensors and know you shit in dumpsters a few times, just not exactly how many. That’s what happens when you’ve done all the drugs, just like Keith Richards, except you always took the generic versions.

I repot, you de shite. What’s especially shitty about this for me is that, absent the still-indefinite closure of the land border and my parents’ screwiness about driving places when they live in a municipality with absolutely no public transit, we’d pretty reliably be able to drive to Montreal in under three hours and get hella drugs hella cheap. In October 2015 I got an ENT PA to scoop some special fall colors out of my ears. After he spent under ten minutes examining and rotorootering my ear canals, he got one of The Doctors to write me prescriptions for oral ciprofloxacin and Ciprodex ear drops. The Ciprodex came in the same style of itty-bitty bottle used for food coloring. It isn’t particularly complicated shit: same antibiotic as the tablets, cipro, plus dexamethasone, a common steroid, in normal saline. Yeah, it has to be medical-grade, not a thimble out of the Dead Sea, but it doesn’t fucking take CERN to produce that shit.

It cost $231. I’m not kidding. It was definitely well over $200. My dad was, quite reasonably, taken aback. I went online and found a forum where a Canadian pharmacist reported having it in stock for a retail price of about $30.

The loony is more or less worth something, but never by that much. We’re getting scammed. We’re all getting shaken down.

The germane question here isn’t anything about how enterprising and innovative America’s pharmaceutical companies are, leading the world in the development of new drugs; they either get the government to pay for that shit, throw a bit of their own money here and there at Boomer Dick Pills, or don’t do R&D at all. No, the germane question is the cost of toothpaste. Toothpaste, like prescription pharmaceuticals, is manufactured under strict quality control. Industrial chemists make sure it’s to spec. If we feel like being way too fucking generous and assuming that the suspension of a long proven, widely used antibiotic and steroid require quality control costs a hundredfold greater per cc than toothpaste, Cirprodex would cost, like, $5 a bottle. AIM sells for a buck a tube at Fred Meyer.

We don’t need to be exact here; leave that for the chemists. All the math we need for this STEM project, for making good minds GRRRREAT!, is this problem, using examples from the community: Compare and contrast Mr. Charles with Ming. In this problem, Mr. Charles is a normal-size housecat I met in a B&B in the Shenandoah, while Ming is the adult tiger Antoine Yates kept in the ghetto (in the ghetto), with family buckets of KFC and also an alligator.

Cat people. Many such cases!

I was probably too generous with the $5 estimate. I don’t give a shit. I took statistics in college becuase everybody would have made me even more self-loathing than usual if I’d dropped out. Whatever. The problem with this country, and others, too, but definitely the God-blessed US of A, is that our ability to work with orders of magnitude is fucked. It doesn’t work. In a vague conceptual way, Americans understand that Bill Gates has a higher net worth than a dentist. What they don’t get is, okay, look: Assuming Bill Gates is worth an even million, your dentist is worth a plate of spaghett at Denny’s. Depending on circumstances, that might include an iced tea, dessert (why?), or even the tip, as a special treat. Your dentist isn’t going out for dinner at Cattlemens in this scenario without a HELOC.

America’s Dumber Is Always Open. For real, using the same ratios, Bill Gates the bare millionaire would make it impossible for a successful dentist to take the wife (or husband!) and kids out to lunch without getting in hock to Donald Trump’s lenders. (Ronald Reagan went for free.)

Raise the fucking marginal rates, of course. The same people who don’t grok the dire significance of not dispossessing thugs like Gates, Musk, Bezos, and Buffett into mere multimillionaires–yes, Sir Warren gets the haircut, too–often don’t understand just how astoundingly widely the possibly nonfictional R&D costs borne by pharmaceutical companies are distributed once a drug is in production. Lamotrigine isn’t artisanally hand-pressed by Keebler Elves. It pours off the production lines like wheat down a combine harvester’s spout into a hopper. Yeah, they pay a lot of people a lot of money to keep the operation running smoothly, with fewer recalls for fatal side effects in theory than in practice, but that’s because they churn out absolute shitloads of drugs. Yeah, a 757 costs more than my Civic. It’s because I’m not clown-carring a manifest of 200 from O’Hare to LAX in four hours.

What if United loses money flying my fat ass across the country? Good. Century Boulevard! We LOVE it! Actually, some of us don’t so much. Beyond the incomprehension of scale, there’s a deeper principle of trying not to get cucked and suck cock for The Brands when they sustain operating losses on some transactions. They’re what we call too big to fail, and they’re called that for a reason. They do not just kind of oopsy-doopsy lose money and not get it back. That only happens when they’re looted down to the nuts and bolts. But that’s okay, too. That’s why we have a government. They need their constituent services. The grand or so I lost on United and American stock after 9/11 so they could float new offerings and then charge me thirty a bag at check-in wasn’t enough.

Drug prices make airfares look comprehensible. The system is based on the assumption that nobody actually pays the full price because everybody has insurance or a coupon or something. Okay, so why the fuck is that the list price? I’m prudent to demand to know exactly what the pills will cost me if I cut the bullshit and just pay upfront. For one thing, Kaiser was out of network, just as I expected. For $20 or $36 or whatever at Safeway, I don’t mind. It’s different at a pharmacy that offers what amounts to a $321 convenience fee. That’s the difference I would have had to pay just to pay for it and leave. To get it for *only* $68 I had to wait nervously while the pharmacist and a tech punched God and they alone knew what into a computer terminal.

Only a tiny number of unlucky customers, chosen arbitrarily, get to pay full freight while everybody else gets a steep discount. Cool, Walgreens is the Menands Police Department. Real normal, honest, ethical way to run a business here, chief.

What’s so insane about this shit, not just evil, is that the more the customer pays, the less work the other parties to the transaction have to do. The discounts go only to those who put up with transaction delays for gratuitous bookkeeping or somehow joined one of the specific health insurance programs contractually permitted to enter into billing disputes with the specific pharmacy filling the prescription.

Nobody who doesn’t get paid to deal with that shit should have to deal with it. Entire workforces are trained to consider it normal and appropriate to dump pointless administrative burdens onto their customers on behalf of their employers and then act like they’re doing their customers favors by typing some hocus pocus into a computer for a discount code. Any grocery store doing this would go out of business. Price Chopper doesn’t offer five-pound sacks of potatoes for a hundred dollars but let customers wait around nervously at the register for a discount of 30-95%.

It rules that so many Americans resent the poor for getting free medical care or prescriptions in the Obamaphone tradition instead of just demanding free shit for themselves, too. They already scheme for free shit; fuck around with the mortgage interest deduction and find out. What they don’t like is being forced to admit that they get free shit–they work hard to live in a neighborhood with good schools and Kwesi Millington for Sheriff, you see–or sharing social services wth the poor. Medicaid you get for being a lazy freeloader, but Medicare, now that you earn.

Fuck off. If Medcaid sounds good, demand it as a public option. Demand admission. Demand it for everybody, right here, right now. Bang on the door at HHS: I lives here; can I come in? If enough people join the chorus, the answer becomes yes. The drug benefit needs to stop being this copay and that deductible and start just being drugs. Like, time out, boss, this shit’s been on the formulary forever, five spot and a receipt if I pay cash, but I have my number, so I’m getting it for free. You assholes can talk to the government about it; I’ve already paid.

Dat R&D tho. We can’t be disincentivizing innovation. Otherwise our pharmacorps will stop hiring research scientists and turn into stock buyback operations. What on earth would happen if Amerca stopped believing in hard work?

Buddy that ship’s been sailing for decades, centuries if there’s a free slip in Charleston. A mighty ocean is our national self-esteem. It isn’t seaworthy, but it’s out there.

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