What costs four hundred dollars and has to be bought 24 times a year?
Insulin.

[Title Card: Insuline Glargine]
[Cite "The Evolution of Insulin Glargine..."?]

Diabetes has been written about since the ancient Egyptians, with the
first known description in 1500 BC and the name in 230 BC.
It was known natively as "pissing evil" because it was characterized by
frequent urination followed by death.
And that's about all philosophers understood about the disease until the
late 19th century.

[https://www.etymonline.com/word/diabetes]

After one laboratory discovered the link between an injured pancreas and
diabetes by performing a full pancreatectomy, there launched a
three-decade search for a way to isolate the substance in the pancreas
keeping the dogs alive.
Various scientists tried extracting the essence by soaking raw pancreas
in solutions of saltwater, alcohol, cold water, hot water, and several
acids, but these all had the same problem: the production was toxic.
Four University of Toronto scientists, Banting, Best, McCloud, Collip
shared two Nobels for the development of a manufacturing process: slowly
inject another hormone, secretin, into a cow's pancreas, and then soak
the pancreas in solution.
The patent was sold to the University of Toronto for one dollar so that
drug companies wouldn't create dangerous knockoffs and patent those to
gain monopoly.
According to *The discovery of insulin,* the scientists wrote a joint
letter saying:
    The patent would not be used for any other purpose than to prevent
    the taking out of a patent by other persons. When the details of the
    method of preparation are published anyone would be free to prepare
    the extract, but no one could secure a profitable monopoly.
[https://en.wikipedia.org/wiki/Insulin#cite_note-134]

The university licensed the right to produce insulin to Eli Lilly and a
dozen other companies for free, hoping that insulin could help as many
people as possible, allowing the companies to patent discoveries about
manufacturing and other improvements.
Animal insulin from pigs and cows is a "bolus" insulin, meaning that
it's meant to be injected before meals or infused continuously because
it peaks and dissipates quickly.
Neutral protamine Hagedorn (NPH) complemented it by slowing down
absorption of insulin, allowing diabetics to take fewer shots, but it
also was the first major patent encumbrance, in 1946.
Other innovations like lente insulin in the 50s, purification processes
for safer insulin in the 70s, all carried with their own patents,
ensuring that generic companies couldn't set up shop.
But during this time, there is a remarkable anti-monopoly feeling: since
the Roosevelt days, both Teddy and Franklin, Americans rallied against
mergers and patent monopolies because competition was the prevailing
ethos.

[Cite "Why is there no generic insulin?"]

[https://www.healthline.com/diabetesmine/history-of-insulin-costs]

[Section: Reagan and Synthetic Insulin]

In the 1980s, synthetic human insulin was developing, and so was
Reagan's monopoly strategy.
Insulin is a protein---a biological machine that is programmed by a
"gene" in DNA.
Specifically, it's a hormone: it "plugs in" to a detector on the outside
of a cell and tells it to use more energy by consuming more sugar.
Remarkably, the genetic language for proteins is understood by every
living thing, so the gene can be taken out of humans and spliced into
bacteria, and describe the exact same structure.
Like bovine and porcine insulins, human insulin is a "bolus" and only
lasts for about 8 hours.
An NPH version of human insulin was created, too, to create a basal
version.
Still, there is evidence that NPH is less safe because it peaks
inconsistently, making it harder to manage blood sugar.
Genetic engineering is very powerful, and a new class of insulins was
invented: ultralongs.
With no peak and a 36 hour duration, insulin glargine, also called
Lantus or Toujeo (made by Sanofi) or Basaglar (started by Eli Lilly in
2015), was patented in 2000, continuing the patent monopolies until
2027.

Reagan helped create the megacorporations that make these drugs,
and his lasting influence on American politics keeps them there.
Reagan was outright pro-monopoly, believing that the failures of America
to compete internationally aren't because bloated industries are being
challenged by leaner startups but industries don't have enough
concentrated power to respond.
President Reagan's Justice Department asserted that, to prevent a
merger, the court must be certain of its harmful effect.
From 1980 to 1984, the number of annual mergers doubled.

[cite https://www.multinationalmonitor.org/hyper/issues/1986/0215/

From 1995 to 2015, 60 pharma companies merged into just 10, including
Sanofi, manufacturer of insulin glargine, that now maintains a 42
billion dollar revenue year-to-year.

[cite the fantastic openmarketsinstitute.org one]

Patents, too: they're intended to reward creativity with a temporary
monopoly, but before the Reagan era, patents were seen as a potential
danger: if a company gets too many or abuses what they have, they might
get broken up or fined.
But while the pharma corporations were developing this fiscal monopoly,
the Rehnquist Court was redefining patents as a declaration, by the
United States, of a "legitimate monopoly."

[cite nber]

[Section: The profit motive]

Glargine has done some good for diabetics, as a marginal improvement on
previous therapies, but it's probably not worth 375 dollars.
That's what Sanofi, Lantus's manufacturer, lists ten milliliters of the
drug for.
This comes down to "only" 50 dollars or 1200 per year when copays are
accounted for.
But based on a conservative analysis of the market, they only need seven
dollars to cover costs.
"Competition" came in, and it too is a criminally expensive 165.

[cite the price analysis and drugs.org]

Other than Reagan's relentless support, how did these companies get
there?
Last year, Sanofi spent four million dollars on lobbying.
Eli Lilly spent seven million.
PhRMA, the industry lobbying group that both are members of: 29 million.
Government-granted patent monopolies drive up prices for everyone,
to the exclusive benefit of ten massive multinationals.
Eli Lilly, Sanofi spend 6 billion each per year on R&D, but who pays for
it?
The American people
Not only does the federal government subsidize the majority of basic
research done by pharmaceutical companies, the pharmaceutical companies
do their best to drain their victims' cash at every turn.

[https://go.gale.com/ps/retrieve.do?tabID=Journals&resultListType=RESULT_LIST&searchResultsType=MultiTab&hitCount=6&searchType=BasicSearchForm&currentPosition=2&docId=GALE%7CA101569966&docType=Article&sort=Relevance&contentSegment=ZICC-MOD1&prodId=CSIC&pageNum=1&contentSet=GALE%7CA101569966&searchId=R2&userGroupName=gainstoftech&inPS=true%2Chttps%3A%2F%2Fgaleapps.gale.com%2Fapps%2Fauth]

[Image: https://upload.wikimedia.org/wikipedia/commons/thumb/f/f2/
Insulin_short-intermediate-long_acting.svg/2000px-Insulin_short-
intermediate-long_acting.svg.png (graph of insulin stuff)]
[Image of insulin vial from Wikipedia]