Matt dives into a specific healthcare topic to help those in the industry, and those outside of it, better understand the market drivers causing today’s healthcare challenges.

A class action firm just filed a RICO lawsuit against Express Scripts and Cigna. RICO. The Racketeer Influenced and Corrupt Organizations Act. The legal framework was originally built to dismantle organized crime.

Federal litigators at Bernstein Litowitz Berger & Grossmann chose that word deliberately. They allege that Express Scripts created a shell company in Switzerland called Ascent to divert billions in drug rebates away from employers, unions, and patients. Not a billing error. Not a contract dispute. A pattern of organized activity designed to capture money that belonged to the people paying for healthcare.

Cigna's own former chief medical officer admitted that Ascent's creation enabled the company to "double, triple dip on fees" without customers ever knowing.

That quote alone should keep every pharma executive awake tonight. Because the company on which your patient access strategy depends just got called a racketeer by a federal court filing.

And it gets worse. Express Scripts settled with the FTC in February 2026 over allegations it artificially inflated insulin prices through anticompetitive rebating practices. CVS Caremark reached its own proposed settlement with the FTC in late March 2026. Optum Rx has not settled. All three of the largest PBMs now face active federal scrutiny simultaneously.

Let me say that again. Every single dominant PBM in the United States has a federal case file open right now.

Here is how the model works. Employers and patients hand money to an intermediary. That intermediary promises to negotiate discounts with drug manufacturers and pass the savings along. The intermediary controls the formulary, the claims adjudication, the pharmacy network, and the rebate flow.

The intermediary has every structural incentive to keep margins hidden. Offshore entities. Layered affiliates. Opaque fee arrangements. The people paying the bills never see the math.

The numbers tell the story. The three largest PBMs processed 80% of all equivalent prescription claims in 2025, according to Drug Channels Institute. Express Scripts, CVS Caremark, and Optum Rx collectively manage pharmacy benefits for the vast majority of Americans with prescription drug coverage. This is a $638 billion industry built on a relationship of trust that federal regulators now say was violated.

The structural pressure goes beyond Washington. Tennessee lawmakers introduced bipartisan legislation (SB 2040/HB 1959) to ban pharmacy companies from simultaneously owning a PBM. The bill targets CVS directly because it owns Aetna, CVS Caremark, and retail pharmacies under one roof. CVS responded by threatening to close all 134 Tennessee locations and eliminate 2,000 jobs. The bill's sponsor, Senator Bobby Harshbarger, called it "fearmongering." He is right.

Arkansas passed a similar law in 2025. CVS sued to block it. The stores are still open while the litigation plays out. The pattern is consistent: PBMs fight transparency with threats. And the threats are losing credibility.

Here is what advocacy leaders inside pharma companies need to understand. ELAVAY data consistently shows that advocacy organizations rank transparency in pricing and access pathways as a top-three factor when evaluating pharmaceutical company partnerships. The PBM layer sits between those partnerships and the patient. Your advocacy strategy runs through an intermediary that federal courts now allege operated as a racketeering enterprise.

That should change the way you evaluate risk.

Every rebate arrangement your company negotiates assumes a distribution chain that now faces federal enforcement on multiple fronts. Copay programs. Hub services. Patient assistance programs. All of it runs through PBM infrastructure.

Think about what that means operationally.

Copay accumulator and maximizer programs depend on PBM claims adjudication systems. If structural reform forces those systems to change, the economics of copay support change with them. Your carefully modeled patient affordability programs may not survive the transition.

Hub services route patients through pharmacy networks controlled by entities facing federal enforcement. When the Plumbers' Welfare Fund alleges that Express Scripts funneled kickbacks through a Swiss shell company rather than passing rebates to plan sponsors, the entire network that those hub services rely on becomes a liability question.

Patient assistance programs structured for insured patients with cost-sharing problems assume a stable formulary environment. But formularies built on rebate-driven placements are exactly what the FTC and RICO lawsuits target. If those placements unwind, patients lose access to medications they already depend on.

Now layer in the coverage gap that keeps widening. A KFF survey published in March 2026 found that roughly 1 in 10 ACA Marketplace enrollees from 2025 dropped their coverage entirely in 2026. Another 17% say they cannot afford their premiums and may drop later this year. More than half of returning enrollees report cutting spending on food and basic household items to cover healthcare costs.

Those are the patients already struggling under the current system. Add PBM structural disruption to the mix, and the patient access gap becomes a canyon.

The companies that score highest in ELAVAY's annual benchmarking study share a common trait. They do not build their advocacy infrastructure on a single intermediary layer.

Leaders invest in direct relationships with advocacy organizations and patient communities. They build navigation programs that connect patients to support resources without routing everything through PBM-controlled channels. They communicate transparently about pricing. They plan for disruption before disruption arrives.

Specific behavior: the top ELAVAY performers audit their patient access pathway dependencies annually. They model scenarios where a major intermediary exists, restructures, or faces enforcement action. Companies that scored highest in ELAVAY's responsiveness dimension did this proactively, before this enforcement wave hit.

The organizations that treated advocacy as a strategic function, with real internal authority and budget, built resilience into their access models. The ones that treated advocacy as a communications project, a nice slide in the corporate deck, are now scrambling.

I have watched this pattern repeat for more than 15 years across every major disruption in pharma's relationship with patients. The companies that invest in advocacy infrastructure before the crisis always outperform the ones that panic-hire consultants after the headline drops.

Your PBM is not your partner. Your PBM is your counterparty. Partners share risk. Counterparties transfer it. The RICO lawsuit just made that distinction impossible to ignore.

Here is what you do this quarter.

Contact [email protected] for a 30-minute strategy session on preparedness for PBM disruption. No pitch deck. No sales funnel. A direct conversation about what your patient access model looks like if the intermediary you depend on gets restructured by a federal court.

The companies that move now will navigate this. The ones that wait for the next headline will spend the next two years explaining to patients why their medication access disappeared.

I know which side of that line I would rather be on. You should too.