E=CUP: price

Let’s talk about P.

Price is the variable where the most money is being extracted from your health plan. It’s also the variable you have the least visibility into.

Here’s why: the largest carriers in the U.S. have spent the last decade buying their supply chains.

Your insurer likely owns the PBM that manages your prescription drug benefits.
That PBM likely owns (or steers to) a specialty pharmacy.
And there’s often a rebate aggregator in the middle collecting manufacturer payments before they reach the plan.

This is vertical integration.

And it means P gets set inside a closed system. You’re not negotiating price. You’re accepting it.

Here’s the mechanic that makes it worse.

The ACA’s Minimum Loss Ratio requires insurers to spend 80–85 cents of every premium dollar on claims.

That sounds like a protection for you. It isn’t.

If an insurer pays a higher claim to a physician practice it owns, that money moves from one pocket to another. It counts toward MLR.

It grows the premium base.

And you pay more.

The good news: P just got a lot harder to hide.

The CAA 2026 (signed into law in February) now requires PBMs to disclose direct and indirect compensation to your plan. Rebates default to 100% pass-through. And you have a statutory right to audit your PBM annually with an auditor of your choosing.

The system that inflated P for decades is now required to show you the receipts.

The CFOs who move first on this will have a real advantage.

Question: When you hear “pharmacy savings,” what’s the first thing you ask for: rebate terms, spread detail, or audit rights?