Most readers of this blog will be familiar with the story of Sovaldi (sofosbuvir), a breakthrough treatment for Hepatitis C. Sovaldi is a transformative cure for a devastating disease, but priced at $84,000 per 12-week course, it has distressed insurance budgets (particularly Medicaid) and in many instances, led to rationing of access. As a result, there has been much debate about the appropriate price for such a valuable treatment.
Many have made the case that $84,000 is a pretty good value proposition compared with the ongoing expenses of living with Hepatitis C, or the cost of a liver transplant. Indeed, most of the people whose opinions I admire are willing to accept the $1,000 per-pill price tag (pills cost about $1/ea. to make) as a reward for innovation and incentive for R&D.
Even though I can accept the merits of these arguments, I find that I still cannot shake a visceral sense of injustice. I’m glad Sovaldi exists. I don’t mind that Gilead is making money. And yet, the situation feels profoundly unfair. It took me a long time to figure out why.
First, I’ll acknowledge that there are many good things about Sovaldi, starting with the fact that Hepatitis C is a dreadful disease. It affects your liver, an organ that places a crucial role in many of the processes that keep us alive, like making sure our blood can clot, and making sure we have enough protein to keep the fluid in our body from leaking into our tissues or weeping from our skin. Patients with Hepatitis C who progress to end-stage liver failure can suffer terribly, and we should be very glad that it is now possible to prevent this. Sovaldi (and other drugs in its class) are a massive improvement over the treatment we had before, interferon, which only works about half the time, and is extremely hard for patients to tolerate. (See this excellent series for details on the treatment of Hepatitis C.) Given the many merits of Sovaldi, it seems fair that the company who produced it, Gilead Sciences, should be rewarded. And, indeed, they have been: Gilead’s revenues in 2014 were $24.9 billion, more than double what they made in 2013.
What strikes me as unfair is not that Gilead is being rewarded, but that it feels arbitrary. The attention we’ve given to Sovaldi, and the lengths to which we have gone to rationalize the price tag, far outpaces our willingness to support – financially and otherwise – other, equally vital interventions. Contrast the dialogue around Sovaldi with how we talk about the opioid epidemic, chronic homelessness, or our abysmal maternal mortality rate. Our willingness to pay for Sovaldi illuminates our comparative apathy towards fixing other problems.
Why does Sovaldi strike us as so singularly valuable? Why do we judge the value some kinds of cures more highly than others? Is the idea of a one-shot solution more seductive than multidimensional interventions? Is it more straightforward to understand? Do new technologies (e.g., new medication) feel more significant than tools we have already? Or is there something truly special about the Sovaldi case?
My concern about justice comes down to whether it is okay to favor a solution because it is elegant and lends itself to interesting policy dialogue. (Is that enough?) I’m not sure I have answers to the questions this dilemma raises for me, but I do wish that more life-saving interventions got the level of financial support and intellectual engagement that we’ve given to Sovaldi.