You wonder what went wrong with young people who leave college without a clue about how the world works and then run to HR with endless complaints. In the old days, 60% of 16-19 year olds held jobs. Now only a third do. This is a disaster.

My wife and I own a pharmacy. Last month we spent days trying to pry one prescription loose from a company that did everything it could to hold onto it. The drug was everolimus. A generic. It treats cancer and protects transplant patients from rejecting their new organ. Not exotic. Not rare. A pill. The patient wanted it filled with us because we're cash-pay and cost-plus. No insurance. No PBM. No secret markups, no games. Our price was $318. That's not cheap by our standards — most of what we fill runs under $20 — but it was honest. Here's what that same prescription looked like on the other side of the counter. In 2023, Medicare was paying about $6,645 for it. That's roughly 21 times our price for the identical medication. Medicare spent around $240 million on everolimus alone that year. If they'd paid our price, they'd have saved roughly $230 million. On one generic drug. So how does an insurance company profit off a drug that expensive? Don't they pay for it? No. You pay for it. In your premiums. Their job isn't to spend less — it's to keep your healthcare dollars circulating inside their own companies. And the tool they use is called spread pricing. Spread pricing works like this: the middleman bills the health plan one price, pays the pharmacy a lower one, and keeps the difference. You never see it. On TRICARE, they pay an independent pharmacy like mine about $311 to fill everolimus. That barely covers our cost of the drug. Meanwhile the plan gets billed thousands. That gap — north of $6,000 on a single fill — is pure margin the middleman pockets. Now here's the part they'd rather you not think about. The pharmacy we were fighting was Accredo. Accredo is owned by Express Scripts. Express Scripts is the pharmacy benefit manager owned by Cigna. Same company, three masks. That nesting-doll structure isn't an accident — it's the whole design. When the pharmacy, the PBM, and the insurer are all one entity, they can shuffle money between their own pockets and call it whatever they want. The confusion is the product. And this isn't a story about one weird drug. It's the business model. The FTC has been digging into exactly this. In its January 2025 report on the three biggest PBMs — CVS Caremark, Express Scripts, and OptumRx — staff found those companies marked up specialty generic drugs by hundreds and thousands of percent when dispensing through their own affiliated pharmacies. Just those markups generated more than $7.3 billion above what the drugs actually cost to acquire, from 2017 to 2022. One in five of the specialty generics they studied was marked up over 1,000%. Some cancer generics: over 3,000%. On top of that, the FTC pegged spread pricing on those same drugs at another $1.4 billion. One example straight from the FTC's files: dimethyl fumarate, a multiple sclerosis drug. Costs about $177 to acquire. The PBMs paid their own pharmacies close to $4,000 for a 30-day supply. Same trick. Different drug. And they steer the profitable ones to themselves on purpose. Pharmacies affiliated with the big three took in 68% of specialty dispensing revenue in 2023 — up from 54% in 2016. The prescriptions marked up more than $1,000 disproportionately end up at their own pharmacies, not independents like mine. So when we called to transfer this patient's everolimus to be filled without insurance, it landed like we were asking them to set $6,000 on fire. Of course they stonewalled us. That's why we fired them. No insurance means no invisible $6,000 charge buried in a premium you can't itemize. It means the price you see is the price. Ours was $318. Theirs was thousands. Same pill.

The story of 'not being allowed to merge' as the cause of Spirit's failure isn't quite right, although a different Biden administration antitrust action is a better fit. 1. JetBlue needed Spirit in order to grow in Boston, New York and Fort Lauderdale at the same time. They had a partnership with American Airlines that gave them slots to finally expand in New York, but they didn't have the planes and pilots to take advantage of that without ceding ground elsewhere. 2. The Biden administration sued to break up the American Airlines-JetBlue partnership that had previously been approved under the first Trump administration. That was legal (DOT entered into a settlement with the airlines, but that wasn't binding on DOJ) but a rule of law problem. And it was a bad antitrust theory that treated jointly deciding who would fly where as per se illegal, rather than looking at consumer benefit or total competition in the market (the JetBlue-American partnership created a 3rd viable competitor to United and Delta in New York). 3. When the Biden administration killed the American-JetBLue deal, JetBlue-Spirit no longer made sense. JetBlue management was committed though and stuck with it. Losing that deal in court helped JetBlue. 4. JetBlue hasn't made money in six years. They are shrinking to stem losses. If they'd completed the Spirit deal they would've been financially worse off, with a lot more to shrink. The deal would've gotten Spirit shareholders paid, but wouldn't have meant those planes and pilots would still be flying for JetBlue. The Biden administration went after JetBlue-American and *that* is what killed the chance for Spirit, as much as killing JetBlue's deal to buy them. And the JetBlue-American antitrust action was worse because it wasn't just an example of government trying to mold the market the way they wanted to see it and failing (they wanted Spirit's 200 planes all flying in an ultra-low cost model, even Spirit's optimistic plan now has 60% of those planes gone). And it wasn't just an example of bad antitrust law that shifted away from the consumer. It was a shot against the rule of law, where government signoff in one administration can no longer be relied upon in the next. That was the airline antitrust case that brought us here, not the simple story everyone tells.