Meet the Connectors

[Celerity]

Middlemen, our economy’s most shadowy characters, sit in between buyers and sellers and get rich in the process. It can even be a matter of life or death.

https://prospect.org/2025/12/05/meet-the-connectors-middlemen/



Cole William Schmidtknecht was about to turn 23 last year, when he went to Walgreens on a cold January day in Appleton, Wisconsin, to pick up some medicine. He expected his Advair Diskus inhaler to cost what it always had under his prescription drug plan, between $35 and $66.86. But when he got to the counter that day, the pharmacist told him insurance no longer covered it and that there was no alternative, though the lawsuit his parents brought showed a generic version should have been covered. His options were to pay $539.19, a 700 percent increase, or leave. So he left.

For the next 120 hours, Cole suffered slow, constant torture. He repeatedly struggled to draw breath. He tried to use an outdated “rescue” inhaler. It didn’t work. He texted his dad Bil, a fellow asthmatic, saying he couldn’t breathe. He began to asphyxiate. By the time his roommate drove him to the emergency room, Cole was “unconscious, pulseless, and appeared blue.” Medical staff gave him two rounds of adrenaline and performed two rounds of CPR, a four-minute race against time to wake him up. They lost.

Cole remained unconscious, his throat so constricted that workers strained to intubate him, his brain starved of oxygen. For six days, he lingered on a ventilator in the intensive care unit “until doctors finally informed his parents … that he was beyond help.” Cole was pronounced dead 11 days after his trip to Walgreens. The immediate cause of death: asthma. “Cole was forced to choose between his medication and his rent. He chose to pay his rent,” Rep. Jake Auchincloss (D-MA) told Congress almost a year later.

But who forced him? Who decided his inhaler was no longer covered? Not UnitedHealthcare, his $448 billion insurance company, nor the drug company. Cole’s grieving parents pieced it together: The decider was Optum Rx, a UnitedHealthcare subsidiary. Optum is less well known than UnitedHealth but enormously powerful; it’s one of just three pharmacy benefit managers (PBMs) that control almost 80 percent of about 6.6 billion prescriptions nationwide. It manages drug transactions for insurance plans, negotiating prices with drug manufacturers and reimbursing pharmacists. And it controls the formulary, the list of drugs that get covered. When Optum drops a drug for whatever reason, people like Cole Schmidtknecht suffer.

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[erronis]

1. I had to deal with PBMs as a state agency regulator. They are only motivated by profit.

Last edited Mon Dec 29, 2025, 05:11 PM - Edit history (1)

You'll hear words like "working to assure optimal use of healthcare resources..." but it's all about corporate greed (again.)

[canetoad]

2. You may remember the late 90s

When many pet animals died from powdered melamine being substitued in dog food made in China. This was at the time when the Chinese economy was really opening up and middle-men made a literal killing by substituting cheap poisons to make their profits go further.