Everything is becoming more unaffordable, but health care may lead this list!

A Mar 23, 2026 NY Times article, “When voters talk about ‘affordability’, many point to health care”, emphasizes how big a deal this is to the American people – and for those who consider this finer point -- American voters. Lots of things have been becoming increasingly unaffordable, so why should health care be different? Housing is ridiculous, and if you live in one of the larger cities in this country, it may well be out of reach. The Times had another piece the same day, “How a Family of 3 Lives on $500,000 on the Upper West Side”, and apparently it is not that easy. In most of America, a family of 3 making a half-million dollars a year, would be rich, but in New York City (and it is similar or worse in San Francisco, Boston, LA, San Diego, DC, etc.) you’re living in a one-bedroom apartment (near Central Park, though) and trying to save up for something bigger, made more difficult by the $4200/month you pay for childcare for your one-year-old, more than the $3900 yoy pay in rent. Doing the math, those two expenses come to less than $100K a year, so they should still have money left, but I guess other things cost a lot as well.

Food is another big issue; even more than housing it is a necessity (there are, sadly, too many unhoused people but no one can go too long without food) and it is a real issue. I had a friend who was from Colombia, and decades ago he observed that he could understand how people could be homeless in the US, but not hungry. Unlike in his country, where housing was cheap and food expensive, you could get a dozen eggs for $1. Well, recently in many places a dozen eggs were above $6. Whatever you think about eating meat, it has become a rare luxury for many families. And gas? Thanks to the US/Israeli attacks on Iran (I take a deep breath and don’t offer more comments) and Iran’s response, gas prices have shot up. I see articles about it being up 20-30%, but where I live in Tucson, AZ it was $2.79 before the attacks and in the same stations is now $4.45 or more (that is about a 60% increase!) The administration has also cut back incentives for non-gasoline cars as they want to push oil and gas – whoops! Since public transportation is so lousy in many places, people depend on cars to get around and get to work when they have a job.

So, with those 3 things – housing, food, and gas (4 if you add childcare) costing so much, it is pretty salient that the people in the Times article single out health care as a main concern about affordability. And, as I have often written, its unaffordability has been increasing and increasing and increasing. Health insurance premiums are up, and for those who receive it through their employers the percent that the employee must contribute is also up. Deductibles are up. Co-payments are up. And even when you pay all that – and frequently people cannot – you may well not get the care you need because insurance companies have ratcheted up their delay-and-deny game, hoping you will give up and not appeal when they deny you coverage for or require your doctor to get “prior authorization” for something you really need, keeping you away with algorithms that stymie your doctors. Or, maybe they completely deny payment because you went to the “wrong” hospital, one that is not in your (really, their) network. Maybe because you were, well, really sick!

Or you could have Medicaid and find that that, as bad as it was, is being cut. Or even more, is cutting you out entirely! Or you may have had health insurance that you could almost afford as an individual through the health insurance exchanges set up by ACA (Obamacare), but now find that subsidies have been cut and there is no way you can continue to afford it. Or maybe you live in a state that never expanded Medicaid (which was the way the ACA sought to cover those too “rich” for Medicaid but too poor to afford insurance on an exchange), and so you have been without access to care for years. Or, maybe are already dead.

Or you could have “traded in” your Medicare, a single-payer program for senior and some disabled people, for “Medicare Advantage”, an insurance company product that sounded great at the start but puts you right back in an HMO, where you have limited providers and the insurance company can deny you coverage. Or, just to be sure that we are not letting anyone out of being screwed, you can have opted for traditional Medicare and find out that the new WiSER program is allowing companies to use AI-based algorithms to deny care in 6 states (so far)!

Wendell Potter’s substack “Health Care Un-Covered” published With CVS’s Vertical Empire Under Threat in Tennessee, the Company Threatens to Leave on the same day (Mar 23) helps explain the reason. While the headline is somewhat optimistic (that the state of Tennessee is trying to reign them in) the real importance is the description of that vertical integration of CVS’ empire, in which they control not just local pharmacies and the health insurance giant Aetna, but also the pharmacy benefit manager (PBM), Caremark, which is now its largest cash cow! It’s a great deal for them, as they pay themselves, and have little competition from small agencies. They do have competition from UnitedHealth, which owns the PBM OptumRx and the provider group Optum, and CIGNA, which owns ExpressScripts, (which Potter explains Just Got Sued for Racketeering), so it is not an monopoly, just an oligopoly with a small number of players. And not one of those players is at all interested in your health. They are entirely focused on their bottom lines, as I discussed on Feb 26, 2026 in The problem with the US healthcare 'system': THE INSATIABLE PURSUIT OF EVER MORE MONEY BY CORPORATIONS AND WALL ST.  

The Times article emphasizes the political conflict between Republicans, who have been responsible for all the cuts and are trying to make it worse, acting exactly as if their goal is to hurt and kill lower-income people, and the Democrats who are trying (unsuccessfully so far) to block cuts to ACA and Medicaid, and perhaps place some limits on Medicare Advantage. But most “mainstream” (read “corporate”) Democrats are severely limiting their suggestions to, basically, returning to Obama-era goals. A significant minority of Democrats in both the House and Senate have signed on to cosponsor the Improved and Expanded Medicare for All bills that would move the US into the mainstream of healthcare in all wealthy countries by completely covering everyone for everything (see Yes, Rep. Van Drew, there IS a solution!,  Dec 30, 2025)! If that happened, the US would no longer be a standout for bad, paying 2-3 times what other countries pay and having worse health outcomes – and, as described above, moving in the wrong direction.

I don’t think that most Democrats are opposed to your receiving quality healthcare at a reasonable price (not sure about Republicans) but they get lots of money from these insurers, PBMs, and health systems. They need to hear from you!

PBMs, pharmacies, and insurance companies: Three legs of a many-legged stool. Or cabal.

PBMs. What are they? Pharmacy benefit managers. Oh, thanks. That clears up a lot!

Well, they are big and important in the health care industry, which should give you a clue: they are somewhere between “not about helping you” and “evil”. Unfortunately, this describes almost every big corporation (pharmacies, insurers, pharmaceutical and device manufacturers, and large health care “provider” corporations) that is involved in health care, or more realistically, sucking money out of the public (directly from you or your government) that was intended to provide health care.

But, back to PBMs. They are, as the name suggests, “managers”, in this and many other cases another word for “middlemen”, set up to be intermediaries between the pharmaceutical companies and pharmacies and insurance companies and you, the consumer (remember that last, “you the consumer”, the one entity in this calculus that has very little weight?). Much of what PBMs do, and a lot of the things that they do that make them more money (and thus could be called “abuses”, since they are not about the only important thing, maximizing the health of the people) are described in this piece from American Progress, “5 things to know about pharmacy benefit managers”. In addition to receiving payments for their services from insurance companies (presumably a legitimate fee, although perhaps for a service that benefits the insurers and not you, and as we shall see below, another scam as many of them are owned by insurance companies!), they also have other little “tricks”. Pharmaceutical companies (another huge pig at the trough of health care dollars) frequently offer discounts in the form of rebates on the cost of expensive drugs – and often, to be fair, negotiated by the PBM – intended to help the consumer. But the PBMs often keep a portion of that rebate. More insidious is that this rebate is a percentage of the price, so the higher the price, the more the PBM gets to pocket. This may (and often does) lead to their “preferred drug lists” having the most expensive drugs as preferred. While this does not cost the patient more (because it puts it in a lower tier), it does make more money for the PBM.

PBMs also engage in “spread pricing” where the amount they receive from the insurer for a drug is more than they pay the pharmacies. And they keep it. And the cost of your insurance and your co-pays can go up to “repay” the insurer for the payments that they make to the PBM. Most of us are familiar with paying for things at a discount, only to discover that the discount is from an inflated “list price”, which already includes a sizeable profit for the vendor. Nowhere is this as common as in drugs; if you have a drug plan (say, Medicare Part D) you are likely to discover that what you pay for your drugs (your co-pay) doesn’t count to your annual deductible, since the insurance company and PBM (now often one and the same) have decided you are already getting a good deal from the discounts that they have received, even when they are pocketing the spread. In 2018, Ohio discovered its Medicaid program was paying $220 million more to PBMs than the latter were paying to the pharmacies for them! Entrepreneurship? Criminal theft?

In a recent piece on his substack, Health Care Un-Covered, health insurance industry whistleblower Wendell Potter describes how ‘The PBM-insurer mafia comes for community pharmacies’. The first important item is contained in the title – “PBM-insurer mafia” – now these two entities are not in competition but in collaboration as two of the “Big 3” PBMs are now owned by insurance companies (OptumRx by United Health and ExpressScripts by Cigna), and the third (Caremark) by a pharmaceutical chain, CVS. This follow the pattern prevalent in all industries, but particularly in “health care” of increasing consolidation, vertical integration, and monopoly power. As Potter describes, one victim of this has been independent community pharmacies. Why such independents are good and of value is eloquently described by one such pharmacist quoted in his piece, so I  won’t re-quote it here; suffice it to say it is what you can imagine is lacking in corporate chains – personal service to people. The benefit to the PBMs of putting independent pharmacies out of business and shunting prescription business to the chains is obvious for CVS/Caremark, but also true for ExpressScripts since it has a deal with Walgreens. And, of course, for all in insurance companies to their owned mail-order pharmacies (which you may get regular emails urging you to use). As is always the case, the lowest income people (who often have the worst insurance coverage, or have Medicaid) are the worst hit, but increasingly insurers and their PBMs have found ways to screw all of us.

There has been increasing political pushback, finally. ‘Last year, Republican Ohio Attorney General Dave Yost said that “PBMs are modern gangsters.”’ This year, Senate Finance Committee Chairman Ron Wyden (D-Ore.) and Ranking Member Mike Crapo (R-Idaho) tried to get new legislation passed; ‘“The time for PBM reform was yesterday,” Wyden said. “It’s past time to crack down on the shady practices of these pharma middlemen that result in higher drug prices for consumers and threaten pharmacies across Oregon and nationwide. I’ll be working around the clock to get this done as soon as possible.”’ But it hasn’t yet passed; it is hard to get consensus on anything in Congress these days, and the insurance companies and PBMs have very powerful (and generous!) lobbies. ‘In recent months, an independent pharmacy, Osterhaus Pharmacy, in Iowa, sued the major PBMs over DIR* fees. In its lawsuit against UnitedHealth, it stated, “This vertical consolidation has served OptumRx well. It now controls not just the pricing of drugs, not just the selection of the drugs covered by Part D Plans, and not just the selection of pharmacy services providers in each Part D network; OptumRx also controls access to almost a quarter of the Medicare beneficiaries enrolled in PBM‐affiliated Plans.”’

Yup. If you are convinced that such consolidation (monopolization) of our health care system is a good thing for efficiency and effectiveness, you should have a UnitedHealth poster on your wall. They are the largest “health” insurance company, control the largest share of Medicare “Advantage” clients, own the doctors’ network Optum, and, as above, control OptumRx. The last two are very big moneymakers for them, and account for much of their growth and profit. But the others are just as bad and would like to be as big.

On the other hand, perhaps you are not so convinced. In which case you should be calling your senators and representatives and letting them know that they should be supporting legislation to rein in the PBMs. And, while they’re at it, the insurance companies. And all the big profit-making corporations jacking up the cost of health care while limiting the care.

They have the dollars. But we have our voices, and our votes!

 

*DIR: Direct and Indirect Remuneration fees, which are charged to pharmacies by PBMs. A much more detailed description of them is in Potter’s piece, but in brief they are another method for the PBMs to scam more money, and to do so without any meaningful transparency.