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Posted on 04/29/2026 10:27:42 AM PDT by CondoleezzaProtege
Senators Elizabeth Warren (D, Massachusetts) and Josh Hawley (R, Missouri) introduced the Break Up Big Medicine Act, legislation aimed at prohibiting the joint ownership of health insurers, pharmacy benefit managers (PBMs), providers, and wholesalers to reduce health care costs and restore competition...
The legislation comes amid growing concerns about consolidation in the health care industry. In the US, 3 PBMs currently manage 80% of prescription drug claims, 2 and 3 wholesalers control 98% of prescription drug distribution...
These entities are often vertically integrated, meaning a single parent company can own every component of the health care supply chain, from the insurer that pays for services to the provider that delivers them...
“Americans are paying more and more for health care while the quality of care gets worse and worse,” Hawley said in a statement. “In their quest to put profits over people, Big Pharma and the insurance companies continue to gobble up every independent care provider and pharmacy they can find. Working Americans deserve better. This bipartisan legislation is a massive step towards making health care affordable for every American.”
To enforce the bill’s provisions, the Federal Trade Commission (FTC), HHS, Department of Justice (DOJ), state attorneys general, and private parties would be empowered to bring lawsuits against companies in violation. The FTC and DOJ would have the authority to review and block future transactions that would recreate prohibited conflicts of interest.
(Excerpt) Read more at ajmc.com ...
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OptumRx—22.2%.
CVS Health—18.9%.
Express Scripts—15.5%.
Prime Therapeutics—10.6%
The talk is usually about who will help pay the bill. My big question has always been why are the costs so high to begin with.
Maybe this “Break up big Pharma” Act will help lower costs.
The reason is because of the research costs that go into bringing a new drug to market. Since the Thalidomide fiasco of the 1950’s, FDA has made the approval process extremely slow and costly. About 10% of those drugs submitted for testing are passed by the FDA. The average cost of getting a drug to the FDA for testing is about $2.6 billion. So almost $25 billion are spent to get one drug on the shelf.
Yes, all true. But that argument doesn’t address the problem with PBMs.
“About 10% of those drugs submitted for testing are passed by the FDA. The average cost of getting a drug to the FDA for testing is about $2.6 billion. So almost $25 billion are spent to get one drug on the shelf.”
A lot of the 90% bomb out long before $2.6 billion is spent.
If N=128 & N=144, $2.6 billion wasn’t spent.
For health care, bring on market force:
1. Break most hospitals into two highly competitive entities.
2. Convert other hospitals into real estate leasing entities with competing surgical suites and nursing wings.
3. Separate out drug coverage so hospital systems can run care coverage systems and cut out insurance company overhead and meddlers.
4. Create interstate drug plans that don’t have to pay what the drugmaker wants for every drug. To qualify for exchange listing and federal subsidies, they would have to most (~80% or more) in all important types (large volume recombinant, small volume recombinant, breakthroughs under patent, etc.). Group and exchange plans to offer time-limited vouchers at plan set amounts for out-of-formulary drugs. Voucher plans would have variable premiums. Plans without minimums (or vouchers) could be vended directly to individuals and families.
5. These plans would be all the doctors (and AI) prescribe for formulary drugs with co-pays equal to manufacturing cost
6. Reform medical education, breaking down medicine and dentistry into simpler chunks and start it in the first year of college
7. Replace most primary care doctoring with AI.
(Insurers would pay human doctors to confirm AI diagnosis, orders for expensive tests[MRI, genetic], prescribe radiation imaging[CT, PET, X-ray]/treatment, and voucher/government co-pay drugs. Other human doctor care would be private pay.)
8. Place radioisotope-related care at international airport centers
Also - since some form of USA government directly administers 50% of USA health costs, why would any rational voter believe that USA government knows how to constrain those costs?
1. Your answer speaks only to the case of drug prices, not health care costs in general.
2. If your answer was totally valid Big Pharma would not be selling drugs in most of western Europe where governments set drug price limits, and yet they still make profits there, and where also drugs are not normally advertised on television as they are here (which is a $15 billion/year expense here).
parts of my reform plan:
PPACA AFFORDABILITY
Silver plans would be limited to a maximum deductible of three times the Medicare Part A amount [2026: $1736].
I would also make bronze plans low cost by having $10,000 50% co-pays with $10,000 paid up front to the insurance company by the insured. Unused amounts of the $10,000s would be refunded after the policy is closed out.
I would also make copper plans low cost by only covering Part A scope items plus what Part B would pay for any general or regional anesthesia surgery.
I would allow Federal PPACA exchanges to offer Interstate Class Drug Plans,
exempt from state control that cover under contract at the time of policy issue at least:
1. 80% of all FDA-approved recombinant drugs by key active entity
2. 80% of all key FDA breakthrough chemical active entities under patent as of January 1 of the coverage year
used in a drug approved by the FDA by August 1 prior
3. 80% of all key chemical active entities under patent as of January 1 of the coverage year
used in a drug approved by the FDA by August 1 prior
4. 90% of all WHO “essential” drugs
Interstate Class Drug Plans that don’t meet all those minimums could be sold off the exchanges.
This system would allow for genuine negotiation between drug plans and drug companies. Drug plans would have an incentive to try to buy drugs from drug companies and drug companies would have an incentive to make deals to make sales.
Plan formulary drugs would be supplied on an all-the-doctors prescribe basis. The co-pays on plan formulary drugs would be roughly equal to mere manufacturing cost.
Non-formulary drugs might be covered by timed vouchers with plan-set amounts ($700 plan pay, 30-day supply, TV_Drug_32, to be dispensed by plan-listed pharmacy in June 2026). Voucher plans would not have fixed premiums.
The copper, bronze and Interstate Class Drug Plans would not be subsidy eligible.
EMTALA (and Medicaid ER) Reform
To get care under the EMTALA or Medicaid for yourself or custodial child, the hospital might require you to
1. pay $100 in cash or by financial organization card accepted at the emergency care facility,
2. hand over your valid SNAP card and tender a matching valid domestic governmental picture ID,
3. hand over your valid domestic driver’s license,
4. hand over your valid US passport,
5. hand over your operable Apple or Samsung cellphone model listed by a current regulation issued by a Secretary of HHS, or
6. hand over a valid domestic governmental picture ID of yours and
a tender matching financial institution statement less than 70 days old showing a domestic governmental or employer direct deposit of at least $150, both for hospital photocopying and recordkeeping.
States might be allowed to authorize emergency care facilities to contemporaneously debit SNAP cards for EMTALA incidents.
Items handed over may be retained by the emergency care facility until retrieved within one month by the responsible party by paying $100, or more, for the care, plus a retrieval fee not exceeding $20 in a manner the facility accepts. Items not timely retrieved may be disposed of in a legally allowable manner.
NOTE: People can get the care they need, but only by paying $100, forfeiting an expensive cellphone, or going through the hassle of replacing a SNAP card or government picture ID.
HOSPITAL EMTALA COST ASSISTANCE
I would allow hospitals collect up to $1,000 per incident of EMTALA service from patient related employers, with payment not in excess of $50 per week per employee concerned being due to any and all EMTALA providers and not for more than 100 weeks after service. Such payments on behalf of an employee would be considered to be a debt of the employee to the employer. Employers could collect back from employees and ex-employees (and require EMTALA incident employees to participate in an employer plan).
They should include insurers in that health care vertical integration limitations.
CVS owns a PBM (one of the largest), a separate wholesale distribution unit, a retail operation (CVS retail stores) and a health care and prescription drug benefit insurer - Aetna. It is also now running a health care clinic unit named Oakstreet.
I think most patients that fall under the EMTALA legal requirements for emergency care do not have employers. That is often why they wind up at emergency, they have neither insurance nor an employer though they may have medicaid. Without regular employment or an employers health insurance they have poorly observed (or never seen) health care and wind up at “emergency” for zillions of things that would not be “emergencies” but for the fact that they have nowhere else to go to get care, care mandated (emergency and stabilization) care mandated by EMTALA.
“health care costs”
Hospitals are local monopolies, and price accordingly.
“Hospitals are local monopolies, and price accordingly.”
Not in my area. There are 11 major hospitals in my area and numerous specialty hospitals as well as many numerous specialty surgical and other treatment outfits.
“I think most patients that fall under the EMTALA legal requirements for emergency care do not have employers.”
Most adult patients or guardians have cellphones, with call logs.
Rural Roofing, how may we help?
Please pay $1,000 to Rural Hospital.
I lived in Reston, VA.
The Reston hospital was a mile away.
INOVA Fairfax Hospital was 10 miles (and 30 minutes to an hour away) away.
I live in northern New Jersey. I have a hospital less than a mile a way, but I’d never go there (they have a poor reputation) and I have a hospital about 5 miles away (been there once and vowed to never wind up there again) and I go - by preference - to a hospital about a 20 minute drive away, and could (but choose not to) go to several others.
Most people in the U.S. do not live in rural areas.
“There are 11 major hospitals in my area”
In DC, there was Washington Hospital Center, Sibley Hospital and George Washington Hospital.
One could bleed out if driven across town.
“Most people in the U.S. do not live in rural areas.”
There are claims that rural hospitals are often in financial difficulty.
In Baltimore, Johns Hopkins swallowed up the minor hospitals.
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