Nice work! Here is an article you may find helpful if you have not already come across it.[0]. You may also want to consider benchmarking against some non ML methods.[1]
This is going to catch some heat, but what if the most important professional “developer skill” to learn or improve is how to effectively use coding agents?
I saw something similar in ML when neural nets came around. The whole “stack moar layerz” thing is a meme, but it was a real sentiment about newer entrants into the field not learning anything about ML theory or best practices. As it turns out, neural nets “won” and using them effectively required development and acquisition of some new domain knowledge and best practices. And the kids are ok. The people who scoffed at neural nets and never got up to speed not so much.
Edit: as an aside, I have learned plenty from reviewing coding agent generated implementations of various algorithms or methods.
> what if the most important professional “developer skill” to learn or improve is how to effectively use coding agents?
Well, it's not. There's a small moat around that right now because the UX is still being ironed out, but in a short while able to use coding agents will be the new able to use Excel.
What will remain are the things that already differentiate a good developer from a bad one:
- Able to review the output of coding agents
- Able to guide the architecture of an application
> in a short while able to use coding agents will be the new able to use Excel.
Yeah, but there’s “able to use Excel”, and then there’s “able to use Excel.”
There is a vast skill gap between those with basic Excel, those who are proficient, and those who have mastered it.
As in intermittent user of Excel I fall somewhere in the middle, although I’m probably a master of knowing how to find out how to do what I need with Excel.
The same will be true for agentic development (which is more than just coding).
And the last two are much more important.
Don't forget that most decision makers and people with capital are normies, they don't live in a tech bubble.
If we know the outcome of that code, such as whether it caused bugs or data corruption or a crappy UX or tech debt -- which is potentially available in subsequent PR commit messages -- it's still valuable training data.
Probably even more valuable than code that just worked, because evidently we have enough of that and AI code still has issues.
I see this line of thought put out there many times, and I've been thinking: why do people do anything at all? What's the point? If no one at all is even reviewing the output of coding agents, genuinely, what are we doing as a society?
I fail to see how we transition society into a positive future without supplying means of verifying systemic integrity. There is a reason that Upton Sinclair became famous: wayward incentives behind closed doors generally cause subpar standards, which cause subpar results. If the FDA didn't exist, or they didn't "review the output", society would be materially worse off. If the whole pitch for AI ends with "and no one will even need to check anything" I find that highly convenient for the AI industry.
You could e.g. write specs and only review high level types plus have deterministic validation that no type escapes/"unsafe" hatches were used, or instruct another agent to create adversarial blackbox attempts to break functionality of the primary artifact (which is really just to say "perform QA").
As a simple use-case, I've found LLMs to be much better than me at macro programming, and I don't really need to care about what it does because ultimately the constraint is just that it bends the syntax I have into the syntax I want, and things compile. The details are basically irrelevant.
Code quality will impact the effectiveness of ai. Less code to read and change in subsequent changes is still useful. There was a while where I became more of a paper architect and stopped coding for a while and I realized I wasn't able to do sufficient code reviews anymore because I lacked context. I went back into the code at some point and realized the mess my team was making and spent a long while cleaning it up. This improved the productivity of everyone involved. I expect AI to fall into a similar predicament. Without first hand knowledge of the implementation details we won't know about the problems we need to tell the AI to address. There are also many systems which are constrained in terms of memory and compute and more code likely puts you up against those limits.
I don't disagree that code quality is currently more important than it's ever been (to get the most out of the tools). I expect that quality will increase though as people refine either training or instructions. I was able to get much better (well factored, aligned to business logic) output that I'm generally happy-ish with a couple months ago with some coding guidelines I wrote. It's possible that newer models don't even need that, but they work well enough with it that I haven't touched those instructions since.
I mean, sure, for programming macros. Or programming quick scripts, or type-safe or memory-safe programs. Or web frontends, or a11y, or whatever tasks for which people are using AI.
But if you peel back that layer to the point where you are no longer discussing the code, and just saying "code X that does Y"... how big is X going to get without verifying it? This is a basic, fundamental question that gets deflected by evaluating each case where AI is useful.
When you stop being specific about what the AI is doing, and switch to the general tense, there is a massive and obvious gap that nobody is adequately addressing. I don't think anyone would say that details are irrelevant in the case of life-threatening scenarios, and yet no one is acknowledging where the logical end to this line of thinking goes.
I mean, the promise of perfect AI and perfect robotics is that humans would no longer have to do anything. They could live a life of leisure. Unfortunately, we're going to get these perfect AI and perfect robotics before we transition socially into a post-scarcity, post-ownership society. So what will happen is that ownership of the AI and robots will be consolidated into the hands of the few, the vast rest of us will have nothing economically relevant to do, and we'll probably just subsist or die.
We're already seeing this today. Every year, thousands of people are becoming essentially irrelevant to the economy. They don't own much, they don't invest much, they don't spend much money, they don't make much money, and they are invisible to economics.
> They don't own much, they don't invest much, they don't spend much money, they don't make much money, and they are invisible to economics.
Indeed. Sometimes I think the so-called “lower classes” end up functioning more like crops to be farmed by the rich. Think, dollar stores that sell tiny packages of things at worse unit cost, checking account fees, rent-a-center, 15% interest auto loans and store credit cards with 30% interest…
I've definitely felt this kind of way in the past. But these days I'm not so sure.
Setting aside the AI point about it, the idea of people becoming essentially irrelevant to the economy is an indictment on society. But I'd argue that the indictment really is towards what constitutes measurement in the economy. Not an indictment on society itself, or technology.
Sure, someone may not spend much money or produce much money, but if they produce scientific research or cultural work that is intangibly valuable it is still valuable regardless of whether economists can point to a metric or not. Same goes for the infinite amounts of contributions to our world from nature: what is the economic value of a garden snake or a beetle? A meaningless question when the economy can only see things in dollars.
They will still be turning out the same problematic code in a few years that they do now, because they aren’t intelligent and won’t be intelligent unless there is a fundamental paradigm shift in how an LLM works.
I use LLMs with best practices to program professionally in an enterprise every day, and even Opus 4.6 still consistently makes some of the dumbest architectural decisions, even with full context, complete access to the codebase and me asking very specific questions that should point it in the right direction.
I keep hearing “they aren’t intelligent” and spit out “crap code”. That’s not been my experience. LLMs prevented and also caught intricate concurrency issues that would have taken me a long time.
I just went “hmmm, nice” and went on. The problem there is that I didn’t get that sense of accomplishment I crave and I really didn’t learn anything. Those are “me” problems but I think programmers are collectively grappling with this.
They are not intelligent. Full stop. Very sophisticated next word prediction is not intelligence. LLMs don’t comprehend or understand things. They don’t think, feel or comprehend things. That’s just not how they work.
That said, very sophisticated next word predictors can and sometimes do write good code. It’s amazing some of the things they get right and then can turn around and make the weirdest dumbest mistakes.
It’s a tool. Sometimes it’s the right tool, sometimes it’s not.
None of those things will be necessary if progress continues as it has. The AI will do all of that. In fact it will generate software that uses already proven architectures (instead of inventing new ones for every project as human developers like to do). The testing has already been done: they work. There are no vulnerabilites. They are able to communicate with stakeholders (management) using their native language, not technobabble that human developers like to use, so they understand the business needs natively.
If this is the case then none of us will have jobs; we will be completely useless.
I think, most likely, you'll still need developers in the mix to make sure the development is going right. You can't just have only business people, because they have no way to gauge if the AI is making the right decisions in regards to technical requirements. So even if the AI DOES get as good as you're saying, they wouldn't know that without developers.
For some definition of work, yes, not every definition. Their product is not without flaw, leaving room at for improvement, and room for improvement by more than only other AI.
> There are no vulnerabilities
That's just not true. There's loads of vulnerabilities, just as there's plenty of vulnerabilities in human written code. Try it, point an AI looking for vulns at the output of an AI that's been through the highest intensity and scrutiny workflow, even code that has already been AI reviewed for vulnerabilities.
> This is going to catch some heat, but what if the most important professional “developer skill” to learn or improve is how to effectively use coding agents?
If it does go as far that way as many seem to expect (or, indeed, want), then most people will be able to do it, there will be a dearth of jobs and many people wanting them so it'll be a race to the bottom for all but the lucky few: development will become a minimum wage job or so close to that it'll make no odds. If I'm earning minimum wage it isn't going to be sat on my own doing someone else's prompting, I'll find a job that involves not sitting along in front of a screen and reclaim programming for hobby time (or just stop doing it at all, I have other hobbies to divide my time between). I dislike (effectively) being a remote worker already, but put up with it for the salary, if the salary goes because “AI” turns it into a race-to-the-bottom job then I'm off.
Conversely: if that doesn't happen then I can continue to do what I want, which is program and not instruct someone else (be it a person I manage or an artificial construct) to program. I'm happy to accept the aid of tools for automation and such, I've written a few of my own, but there is a line past which my interest will just vanish.
What the people excited about the race to the bottom scenario don’t seem to understand is that it doesn’t mean low skill people will suddenly be more employable, it means fewer high skill people will be employable.
No one will be eager to employ “ai-natives” who don’t understand what the llm is pumping out, they’ll just keep the seasoned engineers who can manage and tame the output properly. Similarly, no one is going to hire a bunch of prompt engineers to replace their accountants, they’ll hire fewer seasoned accountants who can confidently review llm output.
And those that do have not yet understood what will happen when those seasoned workers retire, and there are no juniors or mid that can grow because they have been replaced by AI
> What the people excited about the race to the bottom scenario
I'm not excited about it. I just see it as a logical consequence if what people are predicting comes to pass, and I've thought about how I will deal with that.
The endgame in programming is reducing complexity before the codebase becomes impossible to reason about. This is not a solved problem, and most codebases the LLMs were trained on are either just before that phase transition or well past it.
Complexity is not just a matter of reducing the complexity of the code, it's also a matter of reducing the complexity of the problem. A programmer can do the former alone with the code, but the latter can only be done during a frank discussion with stakeholders.
A vibe coder using an LLM to generate complexity will not be able to tell which complexity to get rid of, and we don't have enough training data of well-curated complexity for LLMs to figure it out yet.
No kidding. So far the complexity introduced by LLM-generated code in my current codebase has taken far more time to deal with than the hand-written code.
Overall, we are trying to "silo" LLM-generated code into its own services with a well-defined interface so that the code can just be thrown away and regenerated (or rewritten by hand) because maintaining it is so difficult.
Yeah, same. I like the silo idea, I'll have to explore that.
I'm relieved to hear this because the LLM hype in this thread is seriously disorienting. Deeply convinced that coding "by hand" is just as defensible in the LLM age as handwriting was in the TTY age. My dopamine system is quite unconvinced though, killing me.
I have a silo’d service that handles file uploads of PDFs, images and so on. It was largely vibe coded.
It sits on an isolated tier and isn’t allowed to persist state or have permanent storage. We wanted to reduce the impact of a security flaw in this code.
We’ve ended up doing similar things for search and for an orchestration tool used for testing. The key thing is it’s non critical so we can live without it.
Yes, a retreading of the accidental vs. implicit complexity discussion is in order here. I asked an AI agent to implement function calls in a programming language the other day. It decided the best way to do this was to spin up a new interpreter for every function call and evaluate the function within that context. This actually worked but it was very very very slow.
The only way I was able to direct the AI to a better design was by saying the words I know in my head that describe better designs. Anyone without that knowledge wouldn't be able to tell the heavy interpreter architecture wasn't good, because it was fast enough for simple test cases which all passed.
And you can say "just prompt better" but we're very quickly coming to a place where people won't even have the words to say without AI first telling them what they are. At that point it might as well just say "The design is fine don't worry about it" and how would the user know any better.
I also remember a similar wave around 10-15 years ago regarding ML tooling and libraries becoming more accessible, more open source releases etc. People whose value add was knowing MATLAB toolboxes and keeping their code private got very afraid when Python numpy, scikit learn and Theano etc came to the forefront. And people started releasing the code with research papers on github. Anyone could just get that working code and start tweaking the equations put different tools and techniques together even if you didn't work in one of those few companies or didn't do an internship at a lab who were in the know.
Or other people who just kept their research dataset private and milked it for years training incrementally better ML models on the same data. Then similar datasets appeared openly and they threw a hissy fit.
Usually there are a million little tricks and oral culture around how to use various datasets, configurations, hyperparameters etc and papers often only gave the high level ideas and math away. But when the code started to become open it freaked out many who felt they won't be able to keep up and just wanted to keep on until retirement by simply guarding their knowledge and skill from getting too known. Many of them were convinced it's going to go away. "Python is just a silly, free language. Serious engineers use Matlab, after all, that's a serious paid product. All the kiddies stacking layers in Theano will just go away, it's just a fad and we will all go back to SVM which has real math backing it up from VC theory." (The Vapnik-Chervonenkis kind, not the venture capital kind.)
I don't want to be too dismissive though. People build up an identity, like the blacksmith of the village back in the day, and just want to keep doing it and build a life on a skill they learn in their youth and then just do it 9 to 5 and focus on family etc. I get it. But wishing it won't make it so.
Talented, skilled people with good intuition and judgements will be needed for a long time but that will still require adapting to changing tools and workflows. But the bulk of the workforce is not that.
This is so true... I am having issues with the change right now.. being older and trying to incorporate agentic workflow into MY workflow is difficult as I have trust issues with the new codebase.. I do have good people skills with my clients, but my secret sauce was my coding skilz.. and I built my identity around that..
The cure for me has been to write an agent myself from first principles.
Tailored to my workflow, style, goals, projects and as close as possible to what I think is how an agent should work. I’m deliberately only using an existing agent as a rubber duck.
Using a coding agent seems quite low skill to me. It’s hard to see it becoming a differentiator. Just look at the number of people who couldn’t code before and are suddenly churning out work to confirm that.
I think your argument is predicated on LLM coding tools providing significant benefit when used effectively. Personally I still think the answer is "not really" if you're doing any kind of interesting work that's not mostly boilerplate code writing all day.
Define interesting. In my experience most business logic is not innovative or difficult, but there are ways to do it well or ways to do it terribly. At the senior levels I feel 90% of the job is deciding the shape of what to build and what NOT to build. I find AI very useful in exploring and trying more things but it doesn’t really change the judgment part of the job.
How much of software programmer work is interesting? A fraction of a percent? I'd argue most of us including most startups work on things that help make businesses money and that's pretty "boring" work.
It absolutely is, but the fundamental misunderstanding around this seems to be that "effectively using coding agents" is a superset of the 2023-era general understanding of "Senior Software Engineer".
At least when you're talking about shipping software customers pay for, or debugging it, etc. Research, narrow specializations, etc may be a different category and some will indeed be obsoleted.
I don’t think it could be the most important skill to have. The most common, and the most standardized one for sure, but if coding agents are doing fundamental R&D or running ops then nobody needs skills anyway.
> As it turns out, neural nets “won”
> The people who scoffed at neural nets and never got up to speed not so much.
I get the feeling you don’t know what you’re talking about. LLMs are impressive but what have they “won” exactly? They require millions of dollars of infrastructure to run coming around a decade after their debut, and we’re really having trouble using them for anything all that serious. Now I’m sure in a few decades’ time this comment will read like a silly cynic but I bet that will only be after those old school machine learning losers come back around and start making improvements again.
Neural nets are used in way more applications than just LLMs. They did win. They won decisively in industry, for all kinds of tasks. Equating the use of one with the other is a pretty strong signal of:
> you don’t know what you’re talking about
Consider: Why did Google have a bazillion TPUs, anyway?
Not sure why this would catch heat rationally speaking. It is quite clear in a professional setting effective use of coding agents is the most important skill to develop as an individual developer.
It’s also the most important capability engineering orgs can be working on developing right now.
I'd offer an edit that the most important skill may be knowing when the agent is wrong.
There's so much hand wringing about people not understanding how LLMs work and not nearly enough hand wringing about people not understanding how computer systems work.
I'd say viewing it as most important is pretty unprofessional. But isn't it the point of this extreme AI push? To replace professional skills with dummy parrots.
> This is going to catch some heat, but what if the most important professional “developer skill” to learn or improve is how to effectively use coding agents?
Doing so will effectively force a (potentially unwanted) career change for many people and will lead to the end of software engineering (and software as a career), assuming AI continues to improve.
"Effectively" using agents means that you're writing specs and reading code (in batches through change diffs) instead of writing code directly. This requires the ability to write well (or well enough to get what you want from the agent) and clearly communicate intent (in your language of choice, not code; very different IMO).
The way that you read code is different with agents as well. Agents can produce a smattering of tests alongside implementation in a single turn. This is usually a lot of code. Thus, instead of red-green-refactor'ing a single change that you can cumulatively map in your head, you're prompt-build-executing entire features all at once and focusing on the result.
Code itself loses its importance as a result. See also: projects that are moving towards agentic-first development using agents for maintenance and PR review. Some maintainers don't even read their codebases anymore. They have no idea what the software is actually doing. Need security? Have an agent that does nothing but security look at it. DevOps? Use a DevOps agent.
This isn't too far off from what I was doing as a business analyst a little over 20 years ago (and what some technical product managers do now for spikes/prototypes). I wrote FRDs [^0] describing what the software should do. Architects would create TRDs [^1] from those FRDs. These got sent off to developers to get developed, then to QA to get bugs hammered out, then back to my team for UAT.
If agents existed back then, there would've been way fewer developers/QA in the middle. Architects would probably do a lot of what they would've done. I foresee that this is the direction we're heading in, but with agents powered by staff engineers/Enterprise Architects in the middle.
> Edit: as an aside, I have learned plenty from reviewing coding agent generated implementations of various algorithms or methods.
People learn differently. I (and others) learn from doing. Typing code from Stack Overflow/Expertsexchange/etc instead of pasting it, then modifying it is how I learned to code. Some can learn from reading alone.
> This requires the ability to write well (or well enough to get what you want from the agent) and clearly communicate intent (in your language of choice, not code; very different IMO).
I do not see why you can't write your spec in pseudocode if you really want to - communicating your intent to the LLM, for how the code should be developed is far closer to programming than writing skillwise.
Doing so will effectively force a (potentially unwanted) career change for many people and will lead to the end of software engineering (and software as a career), assuming AI continues to improve.
If you expected things to stay the same forever, maybe software engineering wasn't the right career move for you. Even though it looked safe enough, given that we've spent 50 years writing the same old code the same old way, that was never guaranteed.
I for one am glad to see something genuinely new come along. The last dozen or so "paradigm shifts" turned out to be disappointing variations on the same old paradigm. Not this one, though.
I think you missed the part where I outlined how software engineering will become a business analyst spec-writing kind of job, a job I did and know that I dislike...
But, hey! Different strokes for different folks. This might be for you, and that's cool! I'm allowed to be sad about it, though.
I think Peter Thiel is smart, but exhibiting one of smart people’s most common modes of failure, overestimating one’s ability while not maintaining a healthy sense of skepticism about the correctness of one’s own beliefs.
Put simply, he (and many other tech bros) have galaxy brained themselves into some very stupid stuff.
I associate this phrase with losers and people trying to sabotage the US. You know who is not wringing their hands about “elite overproduction”? China, who are pumping out tons of smart and capable STEM PhDs, and have in a relatively short time caught up to and in some cases surpassed the US in production of scientific output and technology.
Completely separate from the substance of your point, this sort of language does not encourage constructive dialog, it frames the discussion in such a way that you are either going to get
a. People who agree with you, resulting in you not learning anything
b. People who are triggered into fighting with you, once again, resulting in you not learning anything
c. People ignoring you, resulting in you not learning anything.
My constructive suggestion to you is that you simply don't write that first sentence. I suspect you (and everyone else!) will have a much more fruitful time online as a result!
Thank you for giving him the lesson on etiquette. I was going to do the same but you beat me to the punch, so instead I will just upvote you and move on without further remark.
Yeah, you are not wrong. The topic is a bit like troll bait for me. Probably because I have a first hand view of how the current strain of anti intellectualism and resulting policy in the US is destroying jobs and eroding competitive advantage. My observation is that this type of rhetoric tends to be produced and consumed by “elites”, and is often used to advocate for policy that limits socioeconomic mobility.
The irony is that in limiting mobility and competition from the “non elite” out-groups to preserve status, they end up shrinking the overall size of the pie.
I've always taken the elite overproduction thing as an _analytical tool_ to help us make sense of why we have experienced the rise of an oppositional anti intellectual position in contemporary culture.
But you make the good point that it can also be a _weapon_, leveraged by those oppositional groups, to justify their oppositional position.
Perhaps this seeming tautology can be resolved with some systems thinking. Maybe there's some insight in the elite overproduction analysis, but that means that, as an argument for further polarising society it's a pretty effective tool. It's actually reinforcing the feedback loop! A fascinating example of a self fulfilling prophecy.
The Economist only wants what's best for China. (As the article is paywalled, do they discuss the positive externalities of this glut or only the difficult labour market?)
In my view, STEM PhDs are not members of the “elite.”
Historically, in the US the elite are the managerial class, the lawyers (future politicians), and the coastal dilettantes who are already wealthy enough to major in the social sciences.
When 1+ million students are getting MBAs every year in the belief they will be members of the C-suite, but there’s only a few thousand such positions, you have a case of elite overproduction.
Have you looked at the Wikipedia article? China is specifically addressed there, with elite (as in - highly educated people) overproduction and unemployment reaching such levels that government is now suggesting they should seek manual labor jobs.
It works in China because they have growth. In the west thousands of college kids thought they could land cushy management positions or at least highly paid expert jobs.
Then these kids realise these jobs don’t exist, that they should have gone to trade school instead, and that their student debt will cripple them for life.
Same thing will happen in China. For now their economy grows so fast it can absorb many intellectuals, but that won’t last forever.
We live in a globalized economy. Rapid transport of people, goods, and information necessitates it. The high paying STEM jobs will go to wherever there is an abundance of talent, and the network effects are quite significant.
Per Turchin model, the declining population in China has created conditions for more elite-adjacent positions for all those STEM PhDs, preventing overproduction
I think the solution to “elite overproduction” is, not to educate people less, but to promise them a decent standard of living that seems throughout and ultimately is reasonably attainable (don’t over-promise and do minimize FUD).
The massive shift in careers, not just due to LLMs but technology and society in general, threaten the promises given to prior generations. And this is also happening in China, see “tang ping” / “lying flat”.
This is very easy to explain. Anthropic outlines some limitations in their terms of service. Palantir accepted those terms. The DoD did not.
OpenAI claims their terms of service for DoD contain the same limitations as Anthropics proposed service agreement. Anthropic claims that this is untrue.
Now given that (a) the DoD terminated their deal with Anthropic, (b) stated that they terminated because Anthropic refused modify their terms of service, and (c) then signed a deal with openAI; I am inclined to believe that there is in fact a substantial difference between the terms of service offered by Anthropic and OpenAI.
Yeah, it never made sense when Sam immediately said that they had the same constraints yet de DoW immediately agreed with that.
From what I can see, OpenAI’s terms basically say “need to comply with the law”, which provides them with plenty of wiggle room with executive orders and whatnot.
Are you sure about that? Every information I’ve seen suggests that the DoD has been using Anthropic’s models through Palantir.
My understanding is that Anthropic requested visibility and a say into how their models were being used for classified tasks, while the DoD wanted to expand the scope of those tasks into areas that Anthropic found objectionable. Both of those proposals were unacceptable for the other side.
Wasn’t the trigger for all this what happened with Maduro earlier this year? From what I understood, Anthropic wasn’t very happy how their systems were being used by the DoW through Palentir which caused this whole feud.
And why would they have an objection to that? They sold a product to a customer. They should have no business in how that customer uses their software.
> And why would they have an objection to that? They sold a product to a customer. They should have no business in how that customer uses their software.
They sold a service to a customer, contractually subject to terms they both agreed upon. How do people keep missing this? The government changed their mind after agreeing to the restrictions and tried to alter the deal with Anthropic ex-post-facto.
It’s a bit more complex than that, but to be fair I don’t know what they were expecting after they integrated a purpose-built model with Palantir to be deployed in high-security networks to carry out classified tasks.
I'd hate to break it to you, but companies do have a right to determine how their products are used. You were subject to that when you wrote that comment. Did you not notice that?
No, I do not think they do. If a buy a car a run somebody over on purpose, the manufacturer has no right to come take my car away. Even if it were to be written in a contract.
If you tell the car dealership that your plan is to run someone over with the car you are buying, they 100% have the right to refuse selling the car to you.
If you tell a gun dealer you're going to kill someone when you walk out of the shop, they have a right and an obligation to refuse the sale.
Please feel free to tell me how these analogies are incorrect.
“We’ve actually held our red lines with integrity rather than colluding with them to produce ‘safety theater’ for the benefit of employees (which, I absolutely swear to you, is what literally everyone at [the Pentagon], Palantir, our political consultants, etc, assumed was the problem we were trying to solve),” Amodei reportedly wrote.
“The real reasons [the Pentagon] and the Trump admin do not like us is that we haven’t donated to Trump (while OpenAI/Greg have donated a lot),” he wrote, referring to Greg Brockman, OpenAI’s president, who gave a Pac supporting Trump $25m in conjunction with his wife.
Another reason is that Sam Altman has been willing to "play ball" like providing high-profile (though meaningless) big announcements Trump likes to tout as successes. For example:
> "The Stargate AI data center project worth $500 billion, announced by US President Donald Trump in January 2025, is reportedly running into serious trouble.
More than a year after the announcement, the joint venture between OpenAI, Oracle, and Softbank hasn't hired any staff and isn't actively developing any data centers, The Information reports, citing three people involved in the "shelved idea."
Reminds me of when they cut the camera to Zuck and he made the $600 Billion Deal announcement, but was hot mic'd after and said "I'm sorry I wasn't ready... I wasn't sure what number you wanted to go with". I will be extremely surprised if half of these deals actually go through
I can see how being able to bring your chats with you would be appealing. But the truth is that context rot is real, context management is everything, and more often than not stating from a blank slate yields the best results.
That being said, if you have a library of images or some other collection artifacts / assets indexed on their servers that is a different story.
I have multiple years of extremely dense, technical design and planning conversations locked in the ChatGPT web interface.
Hearing that starting from a blank slate yields the best outcomes is sort of like hearing extremely wealthy people talk about how money doesn't make you happier.
Why not use Claude Code from the cli and follow along in your IDE? I did not quite believe when people were telling me or understand what I was missing until I tried it, but after trying that set up I am convinced that it is superior. I don’t have any hard data to back it up, but it feels much more capable that way.
AFAIK the claude vs code plugin uses claude code under the hood.
I recent switched from vs code copilot to open code and I kinda miss it. Just selecting text and directly asking the chat. Or seeing the generated code in the ide to accept it reject it. It's neat.
Looks like the statistical geneticists have jumped the shark with this one. This big problem here is that their endpoint (chills) is poorly defined, reported by subjects (and thus highly subjective), and not measured using any type of validated instrument. So I question whether they might be fitting a model to noise here.
In the land of drug development patient reported outcomes, even when captured with meticulously designed instruments in prospectively designed clinical trails, are notorious for being noisy and confounded by the placebo effect.
I had a similar experience in my genetics class in grad school- the professor explained that children of musicians were more likely to have perfect pitch, hence it was a genetic trait. Some folks suggested that perhaps it was possible that children of musicians were subjected to lots of labelled and unlabelled training data (musical notes) making it "environment" rather than genetic.
I pretty much figure from the title it's self reported and yep: "We gather self-reports from a genotyped sample of thousands of partly related individuals from the Netherland".
And the author summary goes on to state: "Many people experience chills when listening to music, reading poetry, or viewing art. Yet not everyone feels these reactions in the same way.". So the subjects aren't even self reporting the same thing.
Fine, but this is the land of genome-wide association studies. I am unaware of any overlap, considering that such 'GWAS' studies require tens or hundreds of thousands of participants to get any definitive signal... Such work is the nature of statistical genetics.
> So I question whether they might be fitting a model to noise here.
FDA regulates the marketing of drugs and medical devices. This is a case of Hims and Hers (and other compounding pharmacies) marketing drugs without having been granted approval.
There is an abbreviated application for new drug approval (ANDA) pathway meant for generics, but it does not seem like H&H has gone this route. It does require you to open your supply chain up to inspections and to provide evidence that your generic version basically works the same as the brand name.
In my opinion there two things going on here that I strongly feel are true.
1. Something is systemically wrong in the US when we are cutting off people’s access to meds, like GLP-1s, which have profound health benefits.
2. Hims and Hers are also in the wrong. The rules and laws are there for a good reason. It is not just for us to arbitrarily pick and choose when to enforce them.
I think the real surprise is that hims was able to sell the drug without approval in the first place. I do not support gatekeeping drugs from generic makers but their supply chain should be inspected just like any body else. The fact that they were able to sell a drug for so long without approval shows that something is really broken in the process.
I was under the impression that they were initially allowed to produce the drugs since they were on FDA drug shortage lists. As expected, the compounders scaled up their pipelines to meet demand and now that the drugs have been taken off the shortage list the compounders are incentivized to figure out how to keep things legal. (Of course, they should have had clean supply chains this whole time.)
I'm curious if one of these outfits got bought out to end the supply shortage.
I don’t think this is about inspecting supply chains, or keeping anybody safe. It’s about somebody’s profits. Other times it’s about the FDA’s incredibly overconservative approach, which keeps many meds you can buy OTC everywhere else, Rx only here, and keeps other drugs available elsewhere illegal here. Even for people facing terminal illness.
if it helps people facing terminal illness it doesn't mean it should be OTC. "facing terminal illness" probably needs strong stuff. something required for that can harm the normal guy. it's not like Vit D supplement.
No, what I mean is it takes pulling teeth to get someone who would die anyway, the ability to try experimental drugs even with a doctor’s prescription.
It’s a separate dysfunction than their obsession with making things Rx-only, such as for example, an albuterol inhaler. In Mexico you can just grab one at a drugstore.
> No, what I mean is it takes pulling teeth to get someone who would die anyway, the ability to try experimental drugs even with a doctor’s prescription.
This topic came up in another online community (which I'm intentionally not mentioning) a lot a few years ago. I left a comment about why giving experimental drugs to terminally ill patients is not a simple or obvious idea like many would assume. I got some very long, very intense replies from someone who was dying of a type of cancer who believed he had a good shot at recovery if he could get his hands on an experimental drug. He had all of the links and papers to prove it.
I remember trying to take it all in and reconsider my position.
A few years later, there was a post from his wife that he had died. It was a very sad situation. I clicked some of her links and found that he had a blog where he had written a lot. He actually did go through with the process of requesting the experimental drug and his request was granted. However, the drug not only didn't work, it had caused some irreversible damage to his body that made his final months a lot more painful and difficult than they had to be.
Apparently the "compassionate use" exemptions are not as hard to get as the anti-FDA writers have led us to believe. The harder part is often getting the companies to provide the drugs, because they know the risk profiles and uncertainties better than anyone and aren't always interested in letting terminally ill patients experiment on themselves outside of the process.
experimantal, not fully proven drugs available to help terminally ill patients (which should be true) needs first to make sure the patient is terminally ill. it is not about making them available OTC to anyone who asks. because what happens then is free for all, scams and corporate experimentation on live population.
What specifically do you think is problematic about this, and how do you propose that we mitigate companies from preying on desperate patients while making it easier for patients in need?
What about drugs that were initially prescribed, but have to be taken for a long time?
A long time ago I had a Lexapro prescription. This is a very, very common drug and is on the list of the WHO's essentials for bootstrapping a healthcare system.
Then I quit my job and spent a few months unemployed. I was no longer seeing the psych who prescribed them and I was not covered by health insurance.
The last few refills my prescription had? Walgreens bumped the price to $200 a bottle, and unless I paid another doctor there was no way to keep taking the medication I'd been on for two years.
Mind you, this drug is old and generics are CHEAP. I've also got all the knowledge I need to take it safely because I have been.
Instead of doing that, I made the decision to quit rather than deal with the doctor mafia. We let people buy industrial chemicals on the Internet and trust they're not gonna kill themselves with it, but somehow my situation was an unacceptable risk?
Any idea why they'd change their mind about point 4?
The regulatory agencies were understaffed for the work load even before recent layoffs. Why focus on this, of all the things they could put their effort into?
They didn't change their minds. The enforcement was consistent. It's the companies who scaled up their production to mass market levels who prompted the action.
There have been several examples in the past 5-6 years of the FDA loosening regulations to benefit patients and companies rushing in to abuse the opportunity at scale.
Another one that comes to mind is when the FDA loosened restrictions on telehealth prescribing of controlled substances during COVID. Several companies saw this as an opportunity to set up digital pill mills, advertising on TikTok and offering Adderall prescriptions as a service. Nurse practitioners were paid up to $60,000 per month to write prescriptions as fast as they could without interacting with patients.
The companies who bet several billions of dollars in literal decades of research on this stuff should absolutely be swimming in cash until the end of their days. Hims & Hers should be sued into oblivion for stealing the rewards of other companies' ingenuity, risk-taking, and dedication toward helping patients.
I am highly sympathetic to the argument that the government should just buy these patents and mass manufacture to increase availability, or just buy guarantee order vast amounts to scale up manufacturing and distribute cheaply, but the idea that a different private company ought to be able to profit in the way Hims & Hers has is absolutely flatly fucking insane.
So millions of Americans should deal with years of obesity because Novo is a disaster, insurance coverage is ridiculous (any insurer accurately charging for the purpose of risk mitigation should be paying people to take GLP-1s, when instead they are out of coverage for most plans), and there exists no government body to do what you’ve said?
While I'm sympathetic to this argument, I should point out patent time to expiration for medicine in the US is pretty inoffensive (relative to how bad it could be, like software patents), and we already have plenty of drugs for excreting excess. We get a big basket of drugs into public domain each year, and government would be wise to publicly celebrate this, I think; would help with the general sense of impending doom citizens feel.
Semaglutide molecule patent will expire in 2031 here (many caveats to this). For the most part, you can get any pill ~15+ years old for ~nothing without insurance, but associated devices like auto-injectors can extend this due to goofy rules; I expect execs thoughtfully considered medical patent law when deciding to initially trial and release GLP-1s as an injection.
Because “this” is about the biggest in-your-face blatant disregard for FDA rules that has quite literally ever existed in history. The scale is unprecedented.
If there was a single thing an understaffed FDA would go after it would be the compounding pharmacies and that whole ecosystem blatantly thumbing their nose at it all.
Not that I agree with the rules - but if this is allowed it’s essentially an end-around the entire prescription drug regime as we know it.
The fact that they could sell in the first place I think implies some corruption occurred at some point in the past that permitted them to do so (not necessarily by them, but someone must have lobbied for "compounding" since that afaik doesn't exist in other proper countries). Then they failed to pay the necessary bribe to be allowed to continue. To be fair, the bribe would have been very large given the GLP-1 manufacturers' position in the pension savings of ordinary Americans.
Compounding pharmacies are in many ways just a continuation of the original apothecaries and pharmacies, and the US is hardly the only country with the legal framework that allows this.
Australia was basically a carbon copy of the US in this regard until 2024, but they have specifically started targeting a lot of the "wellness" compounding that includes peptides, GLP-1s, etc. since then.
Germany has two classes of pharmacy that are nearly the exact same as 503A and 503B compounders in the US
Canada is similar but stricter about the big pharmacies turning into de facto manufacturers, pumping out huge quantities for downstream compounders and clinics, which is what happened in the US.
Lots of other countries that you might not consider "proper countries" (whatever that means) follow a very similar system to the US, and lots of countries that allow some form of compounding, like the UK through their "specials" program, but it's much more centralized - basically cutting out the 503A compounders in the US.
Fundamentally compounding pharmacies offer pretty important services - there are people out there that would literally not be able to take the most effective medication for their condition without the compounding pharmacies making formulation changes that the larger manufacturers might not have incentive to make. Their existence quite literally saves lives. So it becomes a matter of not making that so restrictive that you wind up killing people due to restricted access vs. letting it get abused in situations like we're seeing today with tirzepatide and semaglutide.
When dealing with depression I suffered ED. So I looked at Hims.
They have a fairly cavalier attitude to medication administration at best - the goal is sell, sell, sell.
I filled out the questionnaire on symptoms prior to my virtual physician interview...
"Based on your answers to questions 3, 4 and 8, this would not meet the criteria for prescription. You would need to answer differently. Would you like a minute or two to review your answers for accuracy?"
Hims is mostly marketing. They are using compounding pharmacies to fulfill orders. Compounders are a shady industry in general, and most the GLP places are using Florida pharmacies, which are notoriously extra shady, as Floridas regulatory function is deliberately incompetent.
Compounders are primarily regulated at the state level, and regulatory effectiveness varies. The more legit ones are mostly buying Rybelsus (the pill version of Ozempic for Type 2 diabetes) at wholesale and crushing it. The shadier ones are using precursors, sourcing from questionable & unregulated suppliers or watering down does and adding stuff like vitamin B-12.
The FDA has more limited jurisdiction, and they have been busy firing people.
The federal attention probably has more to do with whatever grift POTUS has going with Eli Lily and Novo Nordisk. Both companies are about to scale up their daily tablet versions of Wegovy and Zepbound at lower price points, and that availability will push the cost of compounded injectables way down.
They are adding B12 as a way to say that it’s tailored to individuals and not available.
I’ve used mainly compounded medicine over the last five years and find the fervent dislike that people have for compounders bizarre.
If you look into generic regulation in the US, the standards are already through the floor. I’d rather work with someone who has a more direct financial incentive to not fuck up.
Sure, and Novo spent 2M last quarter on lobbying. Nobody in this industry comes out looking wonderful. But the compounders who are meeting demand are not Hims & Hers.
that reminds me, as in Canada the semaglutide patent expired, Sandoz said they will put a generic on the market in Canada, could that be imported into the US and be sold?
> The US is the only country, aside from New Zealand, that allows direct-to-consumer marketing of prescription only medicines.
What interesting here is that Hims & Hers are able to skirt the pharmaceutical marketing regulations. They are able to blanket the world in their ads whereas pharma companies have to abide by strict safety information requirements in their commercials. Him/Hers give literally zero safety and side effect info.
The other weird thing is that the companies like Hims/Hers are basically dial a script. You call them and get whatever you want. They probably deny no one and don't turn anyone away. Unethical and lacks physician oversight.
Not quite, the physicians or NPs or whomever will actively coach you on how to correctly answer their (very simplistic) questionnaires to get the drug you want. And if you fill it out incorrectly, they'll tell you what to correct and offer you a chance to "review your answers for accuracy".
GLP-1 drugs don’t require marketing. There are tons of people who have been prescribed them and aren’t being covered by insurance. Both Novo and Eli Lily are now selling them direct to consumers with prescriptions that don’t have insurance coverage.
They market the service that gives you the drugs with the smallest oversight possible. These services are becoming popular among people who shouldn't be taking GLP-1s (eating disorders, body dysmorphia, people who are too thin but want to lose more weight) because most of their providers are just trying to write prescriptions as fast as possible to collect their payments.
Also the elderly and poor who cannot afford the prescriptions.
GLP-1 drugs range from $100-$200 a month from mail order compounding pharmacies, or $500 a month on "discount" plans from the drug makers.
This change to FDA enforcement is going to prevent a lot of people from getting help.
The positive impact of GLP-1 drugs is huge, but the price is out of reach for most people. The people who most benefit, elderly obese people at high risk of injury due to falls, who have a low quality of life from morbid obesity, are least able to afford access to the drugs.
These compounding pharmacies were improving a lot of lives.
Anthony Kiedis isn't headlining an event that's being put on by an expressly christian organization. He also is not closely tied to someone who's mentioned more in the Epstein Files than Harry Potter is mentioned in the Harry Potter books.
Kid Rock has some pretty infamous, explicit lyrics I won’t be pasting here. Just look it up, there are dozens of articles about this right now. It’s not rumors or something ambiguous, he is a disgusting person with some pretty awful things to say. Given TP’s christian mission/focus and constant moral panic stance, coupled with the MAGA movement’s alleged concern for minors, “he is not appropriate” is an understatement.
Unfortunately he stays somewhat relevant because he drapes himself in an American flag.
In the UK there's a lot of TV advertising for "weight loss medication" that never refers to any drug by name. But if you look at the small print, it refers to "Orlistat", which is technically available without a prescription. Of course, nobody (or few) actually want Orlistat or end up being prescribed it after the consultation.
The law prohibits ads from simultaneously naming a prescription drug and its therapeutic use. So you might see an ad pushing a specific drug, but it will never say what it's used for. Or you might see an ad where people talk about treatments for a condition but never mention the drug, just saying talk to your doctor.
Sometimes they get around this subtly. In one ad a number of overweight actors discuss how much they love a specific drug, but it's never mentioned what it's for but is implied.
And of course when US channels are simulcast in Canada, US ads just run as is.
This is a vacuous statement because in much of the world (ie most of the developing world), there's no such thing as "prescription only" medicine, people can buy whatever they want over the counter.
In Germany, I cannot buy ibuprofen, paracetamol (acetamenophen), or ASS (Aspirin - TM Bayer) at a grocery or "Drogerie" (place to buy cosmetics and other health & beauty items). I have to go to a pharmacy and ask for it at the counter - truly "OTC", and they're expensive compared to their US retail equivalents. That said, most common prescription drugs are significantly cheaper in Germany than in the US, even without insurance.
Antibiotics are definitely prescription-only, as are birth control and morning after ("Plan B") pills. I was once able to talk an airport pharmacy into selling me an albuterol inhaler without a script in hand, but only when I promised that I'd had it before and explained how to use it, and that I was about to get on a flight.
I just started taking Wegovy. Went the regulated route through my doctor, getting a prescription. She’s been monitoring loads of patients and noted that some of her patients going the ‘compound’ route had, in fact, had allergic reactions to their shots, or experienced their shots being less effective, after months of no problems. Nothing life threatening. But the fact is there is no oversight to what the GLP-1 is compounded with.
People report this with HPLC tested stuff that is proven to be of the same purity/concentration too, "feels" reports are notoriously unreliable in medicine.
Yes, they can 'prove' what is in something to the limits of the physics.
However, the human in the loop is quite frail for most operators. In that, these very fancy and very expensive instruments are mostly run by high school grads and serviced by field engineers with a huge backlog.
For a first time one off test of something's composition, I'd go for at least 3 companies and preferably you have a history with them. This stuff is terribly complicated and misinterpretation is shockingly common. If the tech hasn't used the standards before then your at the mercy of fate.
Like, we have 5 (!) places on the home screen that do the exact same function of ending a run because when we try to consolidate it to just 1, our customers freak out and can't find where the button went to. Granted they pay $100k+ per instrument plus service plan, so we add it back in no question ( and this is life critical equipment in many cases), but I hope that shows how embedded to routine these operators get.
Janoshik is the primary company people use here, and their business is basically entirely peptides and anabolic steroids, and the GLP-1 stuff exploded their business from gym bros to soccer moms everywhere. https://janoshik.com/
But they basically test the same 12ish compounds day in and day out, with another couple of dozen making up the remainder. They don't have most of the worries that you are referring to - first time for a tech running a specific set of standards, limited experience interpreting them, etc., and when people head to head their results against different labs, they are consistent.
What she presented to me was that more than one of her patients taking unregulated GLP-1s simply stopped losing weight, and in an unexpected way. I have no idea how many patients this was. My doctor is rad and very much pro-GLP-1s and pro-preventative-care. This is ultimately an anecdote.
There's a well known plateau effect with GLP-1s where the body adjusts to the changes in caloric intake and the medication itself so that weight loss levels off and stops after a period of time. It could be that but it's hard to tell with 2nd hand info.
Personally I feel the hims etc of this world need to go away. They give a false sense of security and they mask an incredibly shady industry.
I also think people should be able to source from the grey market if they can figure it out. This means they understand the risks and likely take measures like ensuring their compounds are properly tested before injecting them.
I’d feel differently if I didn’t understand how the average medspa gets their product and the corners they cut. I honestly trust some outright black market dealers better than most of those shops. They actually do testing on their product before shipping it. Likely sourced from exactly the same manufacturer as the guy in the locker room buys from.
So long as the choices are informed I agree. The issue is hims/hers puts a fancy veneer of “sanctioned medical system” on top of what amounts to a black market. They are laundering and obscuring the risk and many patients simply do not understand this fact.
It’s the difference between buying Xanax from a legit pharmacy vs a street dealer. The street dealer transaction you understand the risks involved and are making an informed decision. If you thought you were buying from a legit pharmaceutical company but they ended up just rebranding the same shit the street dealer is selling from his wholesaler - that is not informed consent even a little bit.
There is something in the middle here but some HLPC testing I’ve seen of supposed legit compounding pharmacies hasn’t been great for these drugs.
Their industry is only shady because lots of fairly harmless drugs require a prescription. Viagra, the GLPs, and minoxidi+finasteride come to mind.
For a long time in this country, a flesh-eating bacteria infection required an amputation. In Russia and Eastern Europe, it was easily treatable with bacteriophages and people normally kept their limbs. There's still no process for approving a bacteriophage treatment in this country for general use.
Our system is ossified to protect big pharma and doctors. Liberalization is needed; hims and their like need to be regulated, but with a lighter touch than the current requirements.
Can you quote from the five sentences I wrote where I said anything about telling people what to do? I simply noted that my medical provider has first-hand experience with people getting questionable results from unregulated GLP-1s.
This is precisely why we have clinical studies. We want to measure the efficiency and the innocuousness of drugs. You seem to imply we should just go ahead and try those directly on the general population.
Has anybody ever been forced anyone else to take any drug? The problem is not about being forced, it is about making an informed decision. When you don't have enough safety data you are effectively gambling with your health.
The individually compounded versions have a higher risk because there's a person involved who can make mistakes, as opposed to a carefully controlled and tested manufacturing line.
Compounded drugs have higher rates of bacterial problems, doses being too high or low, and other issues.
Someone I know worked for a company that took over a poorly run compounding pharmacy and cleaned up their process. Some of the stories I've heard have made me want to avoid compounded medications wherever possible.
Yes. Drugs are too damn expensive and innovation is too damn slow. Better to allow higher risk options. And if you don't like it, you are always free not to use them.
"If you don't like it don't take it" ignores all of human history. A huge majority of substances can be fatal if ingested. Are you sure you want to live in a world where Elon can speed run figuring out what won't kill "most" people?
I'm on death row. So are you. The only thing that has a chance of giving me a stay of execution is rapid technological advancement so I'm willing to accept a lot of risk here. It's a matter of self preservation.
To be fair, most medication in the US is overpriced due to patents and what not. The "cost" is hardly the real, legitimate cost and generally inflated 1000%+ compared to other countries.
This is not really the correct way to think about this.
Pharma is ultra R&D heavy so yes, medications are deeply profitable on a per-pill cost to manufacture basis. However, drug companies by and large are not extremely profitable. This is because to produce a single drug (which is high-margin from point of production), they have to sink billions of dollars into literally thousands of other drug candidates to figure out which ones are viable.
This is all "real, legitimate cost," as is reflected in their rather abysmal overall profitability.
As for the disparity between US and foreign markets, it's a basic tenet of commercialization to sell to every buyer at the highest price they'll accept, so long as that price is above your price to produce. All sorts of companies engage in "price discrimination" to achieve this. For example, cereal manufacturers will sell their own brand at $4/box, and sell the exact same product in a store brand box for $3.25/box. A lot of products in your local retail stores do this.
Overall, no one is really hurt by this per se. Every consumer is making a transaction they're willing to make, and the company is making the most money it can in aggregate, which actually gives it room to push the price at every price point lower than it would be able to if it could only sell to a single segment.
This is actually extremely important in the drug context due to the aforementioned abysmal profitability.
Let's take Trump's attempt to force a Most Favored Nation (MFN) clause onto drug manufacturers which guarantees US consumers pay the same price as the lowest price internationally. The intended effect is for US prices to come down to the level paid elsewhere.
But here's Pfizer CEO: "When [we] do the math, shall we reduce the US price to France’s level or stop supplying France? We [will] stop supplying France. So they will stay without new medicines. The system will force us not to be able to accept the lower prices.”
Not only does this obviously not result in lower US prices, but it very possibly results in higher US prices (since now there is less net revenue from lower priced consumers) and, more troubling in the pharma case, there is now even less net revenue coming in to justify new drug development.
It's hard to overstate how asinine this entire endeavor is. US consumers certainly pay too-high prices for drugs, but this intervention does very little to actually address that problem. The much more proximal issue is the incredible degree of intermediation in the US market between payers, providers, PBMs, GPOs, and more.
> Not only does this obviously not result in lower US prices
Maybe in Pfizer’s portfolio this is true. However, I just watched the Amazon Pharmacy pricing for GLP-1s drop substantially immediately following this. I think you may be being too black and white on claiming this categorically does not work.
Businesses will adapt pricing models, obviously this hurts Pfizer in some way, but Lilly and Novo found the new system was worth negotiating into. Like most things - when people say “always” or “never” - it’s reducing the spectrum of possibilities
GLP-1s are already under immense pricing pressure due to competition, direct to consumer sales outside of the insurance system (to the point of forging entire new markets for drug companies never possible before - what other drugs have millions of customers paying $300-400/mo for prescription medications?), compounding pharmacies end-arouding patent law like this article is about, and outright black market sales that dwarf any other prescription medication classes outside of opioids and benzodiazepines.
It has nearly nothing to do with government action. These will be the most profitable medications ever invented once the dust settles and it’s a game of price optimization right now.
GLP-1 prices are ultra-competitive and in an honest-to-god price war.
Not only are there multiple current-generation GLP-1s on the market (Novo's and Lilly's), but there are at least 2 or 3 more generations approaching the market.
> Not only does this obviously not result in lower US prices, but it very possibly results in higher US prices
Here's the thing: yes, you may "very possibly" be right, but that means you may also "very possibly" be wrong. The truth is, we don't know, and we can't really trust the CEO of any business to openly admit that they could tolerate a policy disadvantageous to them. So how would you suggest testing the case where you're wrong?
There is no world in which an MFN clause does anything other than reduce the overall revenues to the pharma companies.
There is no world in which lower overall revenues does not reduce R&D spend.
There is no world in which lower R&D spend does not reduce the number and quality of new drugs.
This doesn't require trusting anyone about anything other than trusting that pharma companies are generally profit-seeking and therefore an MFN clause imposed by USG will create less optimal pricing (for the pharma companies' own incentives) than currently exists.
The exact price changes that happen in different localities that net out to "less revenue → less R&D → fewer drugs" is hard to predict, but the fact that it will be lower and it nets out to "less revenue → less R&D → fewer drugs" is absolutely predictable.
Please suggest an alternative outcome, if you can think of one.
> But here's Pfizer CEO: "When [we] do the math, shall we reduce the US price to France’s level or stop supplying France? We [will] stop supplying France. So they will stay without new medicines. The system will force us not to be able to accept the lower prices.”
This person is a less than neutral source in an industry that's already infamous for lying through its teeth to grind out every red cent from its customers. I would lend precisely zero credence to what he says when he's trying to justify why his poor billion dollar company wouldn't be able to lighten up on its wholesale fleecing of American customers.
"Poor billion dollar company" cannot possibly be a slur in an industry that requires $2 billion in investment (and rising!) to make each subsequent product. Maybe if the product were a luxury good that the world could do without, but it's not, and we cannot.
You don't need to trust anything except that left to their own devices, those greedy pharma companies will price as efficiently as possible in order to maximize revenues. Despite this revenue maximization, the industry as a whole is nearly uninvestable.
Any deviation from the optimal pricing will reduce their overall revenues, which will obviously make the industry even less investable.
In an R&D heavy sector means they will no longer make new products, i.e. no new breakthrough medications that you or I or our parents or children may need.
Sure, I doubt Pfizer et al will just outright stop selling medications to France. Far more likely they will both reduce US prices and raise EU+ prices, but this still ultimately results in fewer drugs for fewer people today, and definitely much slower innovation toward new drugs by virtue of having less cash on hand and much worse expected ROI.
You do not need "trust" whatsoever, this is just basic logic.
> Sure, I doubt Pfizer et al will just outright stop selling medications to France. Far more likely they will both reduce US prices and raise EU+ prices
This is my point – quoting the man on what he says will happen is pointless because he's just using scary hypotheticals to make the best case to keep the cash hose turned on. He's not some altruistic saint bestowing new formulations upon the world if only he had more money, he's a slimeball pharma CEO trying to balance that R&D with reaping maximum profits.
Would lowering prices for Americans mean the world has less R&D bankrolled by American consumers? Probably. But the current situation is untenable.
> Please engage with the substance of the argument put in front of you.
Back at you bub. My original comment was addressing why a quote from the guy who would be most affected by drug prices changing is hog wash, and you skillfully dodged my whole point to talk about R&D, investments and revenue. I didn't write my comment to dive into those things, I wrote it to point out that Pfizer's CEO would say anything if it means his company will get more money.
Your point being that you don't trust the words of a pharma CEO?
Fine! Why is that relevant to me?
Just because you're starting from the prior of "pharma CEOs are liars" doesn't mean everyone else is. Some people find it quite helpful to hear from the most powerful and most informed people on issues they want to learn about, even if you have to discount them due to conflicted interests (spoiler alert: nearly everyone who's well-informed on an issue will have some type of conflict to be discounted).
Evidently you are fine writing the words of Pfizer's CEO down to zero value, which is fine!
That's why I provided an alternative path by which applying your own critical thinking skills would get you to the same conclusion.
"Applying basic logic gets me to a similar conclusion as Pfizer's CEO, but Pfizer's CEO is a liar and conflicted and can't be trusted, therefore... [ ??? ]"
Edit in response to your edit: Don't act as if I introduced revenue/investment/R&D/etc after you raised the issue about Bourla's quote. That was the entire basis of the conversation from the start. Profoundly low-quality contribution to just chime in with "pharma CEO is conflicted." Yeah, everyone is aware of that. That's why there's an entire comment around the quote.
Literally you yourself said a few comments above that you "doubt Pfizer et al will just outright stop selling medications to France." It sounds like you don't trust his words either, so why are you going to bat for this guy?
> That's why I provided an alternative path by which applying your own critical thinking skills would get you to the same conclusion.
To be clear, the only thing I've taken issue with here is his own words and how you've quoted him. I don't believe I've said anything regarding your overall position on drug prices and pharma profits, so it's weird that you're attacking me like I've specifically taken a position against it.
Lmao imagine thinking that separately deriving the same conclusion using such sophisticated economic knowledge as “how prices work” was equivalent to “taking someone’s word at face value.”
You can derive the same conclusion yourself! As stated over and over, much to your chagrin and denial, because “pharma bad.”
Americans are willing to pay higher prices because direct to consumer advertising is allowed, making people more willing to pay a higher price because an ad convinced them it will be worth it. If people wouldn't pay, then pharma companies would lower the prices.
Fix the demand side and the supply side will adjust.
I would suggest it's the reverse. Americans accept higher prices because they have many many layers of intermediation.
Americans pick their employer. Their employer picks their health plan. Their health plan picks which drugs are covered and which doctors and pharmacies they can use.
With the "innovation" of vertical integration between insurers, healthcare providers, and PBMs, there is effectively zero incentive for health insurers to manage costs, because those costs show up as revenue for their own subsidiaries. This is actually hugely advantageous for insurers because they are required by law to spend a certain percentage (~80%) of their members' premiums on healthcare goods and services, not profit or business development.
Well... if you own the pharmacies, the PBMs, the GPOs, and especially the healthcare providers... you can arbitrarily siphon money at any % rate you want while increasing the gross dollar intake by simply raising prices at your subsidiary companies!
All of this is well documented. Here are a few places to start:
At some point when the compounding was ramping up it was difficult to get the drugs even with a prescription and being willing to pay the full no-insurance price. Nowadays you can mostly get it, but insurance coverage is spotty. Because of weird incentives, the no-insurance prices of drugs are highly inflated so the amount that they cost isn't a realistic price for most people to afford. The manufacturers offer coupons but the conditions on them, and the fact that they still leave you with a pretty inflated price tag means that the compounded versions like what HIMS sell are the most cost effective option for a lot of people - it's still highly marked up, but to a level that is manageable for way more people.
ANDA is for drugs that have gotten off patent. Semaglutide has not gone off patent in the US. It won’t until 2032 at the earliest.
And ANDA absolutely does require supply chain inspections, first at approval then random inspections there after.
Whats Hims and Hers was doing was compounding (turning the chemical into a formulation patients can take) under an exception due to limited supply. Supply issues are over, so they can not longer compound.
I do t think anything is wrong with the US system here. These patients got access under a temporary exception, they have the option to obtain a supply through other channels going forward. If affordability is an issue, the manufacturers have several programs that make these drugs affordablez
You are misrepresenting the FDA post. They focus on the fact that the API was not approved for use, which means removing the marketing authorisation is something perfectly fine to do. All API sources need FDA inspections proving the GMP practices are respected and compliant.
Are they? This example seems to be a clear contradiction of your first point. Stuff like this weakens the authority and credibility of the FDA, allowing legitimacy to people like RFK.
If the description in the first comment isn't missing anything important, and this could be fixed with some paperwork and inspections, then I don't think taking action makes the FDA look bad.
The particular complaint of "cannot state compounded drugs use the same active ingredient" is weird but if it only applies to marketing then sure crack down on that too.
Eli Lilly will categorically state it is impossible for the compounders to be using the same API as they are due to being the sole source of manufacturing for it on the planet.
From what I can tell they are technically correct. The FDA approved method of manufacturing the peptide chain is different than the Chinese sources these compounders are sourcing from. It may not make an actual biological difference (and hefty evidence of millions of people on it show there is unlikely to be a material difference) but it’s not the same as a generic medication being approved.
This is about as Wild West as most of us have lived through for the U.S. drug market.
> This is about as Wild West as most of us have lived through for the U.S. drug market.
I don't know about that. I'm old enough to remember The Vaping Panic of 2019, where (medical and/or recreational) cannabis vape liquid was adulterated with Vitamin E acetate in industrial quantities, which caused widespread injury and death. The real cause was called out very quickly (thanks in part to investigative reporting by...WeedMaps[1]), but health departments flailed and spent months blaming it on Juul and teen e-cigarettes. The panic evaporated because right as the public health community realized what was happening, Covid broke out.
To this day, afaik no testing of vapes is required to ensure they don't contain this toxic ingredient.
> To this day, afaik no testing of vapes is required to ensure they don't contain this toxic ingredient.
This is a pretty good example of how "testing requirements" tend to be reactionary and effectively useless.
Vapes contained Vitamin E because the sellers were cutting the product with it, the same way drug dealers cut drugs with starch or sugar or something worse. It wasn't a manufacturing mistake, they were adding it on purpose to rip off the customer. It makes sense for that to be a crime -- it's fraud and negligence -- so the argument comes that we should require testing for it.
But if you add a test for something like that, they either cut it with something else that the test won't show (which might be even worse) or they add the cutting agent to the distribution pipeline somewhere after the point where the testing requirement is imposed. Testing for something works against mistakes, not purposeful behavior.
Meanwhile the people doing it were probably idiots who didn't know it would cause physiological harmful and thought they were just ripping people off, so then the argument comes that we should be testing to make sure they're not doing that. Except there is no generic test for every possible problem, so at the point they first started adding it, the government would have had no reason to test for that in particular, and by the time it becomes generally known that adding that substance is harmful, they'd have stopped adding it because they don't want to be sued or arrested when their customers have those symptoms and then permanently testing everything for something everybody has already independently stopped doing is a waste of resources.
The problem is people want the generic test that could catch every possible problem and that isn't a real thing, and there is no point in doing the specific test for something that has already stopped happening.
I wouldn’t put vapes in the same category as patented pharmaceuticals.
They are already an unhealthy vice for one thing. They do not require a prescription and are sold over the counter to anyone who presents an ID showing they are of age.
Those vapes were also largely made by relatively fly-by-night manufacturers selling into mostly shady retail shops. Additionally there was (still is? Haven’t kept up on it) no real consensus that vitamin E acetate was a dangerous chemical unfit for purpose.
This is the first time in my lifetime that I can recall of major companies blatantly end-arounding the entire pharmaceutical approval process for a prescription drug. Full on advertising their disregard for the rules on public airwaves and everything.
FDA being slow to react to a public health concern due to an adulterated over the counter product imo is not the same category. This is literally telling the FDA and major pharma “come at me bro” and expecting the delay to be profitable enough to offset any future penalties.
That specific medicine is about a molecule that was insufficiently vetted.
It does not seem as egregious as the risk of getting medication made in other countries. As far as I know, all the patented medicine comes from barely audited factories in places like India anyway.
Yes yes, it's super beneficial to destroy the incentive for anyone to risk billions of dollars and decades of research to develop new breakthrough medications for people
As stated elsewhere, the competition in pharmaceuticals does not live (nor should it) in cost of production. It's in R&D. So no, pharma companies cannot systematically dump billions of dollars into developing new medical breakthroughs and then race to the bottom on production efficiency with unregulated pill mills from every backwater on the planet with an Internet connection and a parcel service.
At least, not if you want science to move forward in your lifetime. As a person who has used, currently uses, and will in the future use medicines, I really prefer that we don't eliminate the financial viability of efforts to continue making better ones.
0. https://pubmed.ncbi.nlm.nih.gov/35318324/
1. https://www.nature.com/articles/s41586-023-06127-z
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