“But I’ve heard the term “middlemen” for a long time. They are so wealthy. They are so wealthy. Nobody has any idea who the hell they are or what they do. They make more money than the drug companies.”
Who are the Middlemen?
Pharmacy benefit manager (PBM) is a third-party administrator of prescription drug programs. In 2016 there were fewer than 30 major PBM companies in this category in the US, and three major PBMs (Express Scripts, CVS Health, and OptumRx of UnitedHealth Group) comprise 78% of the market and cover 180 million enrollees.
Wholesale drug distributors purchase medications directly from manufacturers. The wholesale drug distributor in turn sells the medications to pharmacies. Behemoths Cardinal Health Inc., McKesson Corp. and AmerisourceBergen Corp. have a virtual lock on the wholesale drug market with at least 90% and as much as 95% of all revenue.
The top seven dispensing pharmacies—CVS Health, Walgreens Boots Alliance, Cigna, UnitedHealth Group, Walmart, Kroger, and Rite Aid—accounted for about 70% of U.S. prescription dispensing revenues in 2019.
The 10 largest health insurers collectively wrote 51.8 percent of premiums in the total U.S. market: UnitedHealth Group, Kaiser Foundation, Anthem, Humana, CVS Health, Health Care Service Corp., Centene Corp., Cigna, WellCare Health Plans (Centene) and Molina Healthcare.
The worldwide pharmaceutical market was worth about $1.3 trillion in 2019.
The 10 largest pharmaceutical companies accounted for about a third of that, worth a collective $392.5 billion in revenue. The top 10 pharmaceutical companies, ranked by revenue: Pfizer, Roche, Novartis, Merck, GlaxoSmithKline, Johnson & Johnson, AbbVie, Sanofi, Bristol-Myers Squibb and AstraZeneca
Almost all of these US corporations are dominated by just three giant American asset managers: BlackRock, Vanguard and State Street. The Big Three has entailed a massive concentration of corporate ownership. Together they have nearly US$11 trillion in assets under management. That’s more than all sovereign wealth funds combined and over three times the global hedge fund industry. The largest 14 largest firms control US$28.9 trillion assets under management.
“So I have a lot of enemies out there. This may be the last time you’ll see me for a while. A lot of very, very rich enemies, but they are not happy with what I’m doing.”
The people that control these companies are the very, very rich enemies that Trump is talking about.