THE CURE HEIST
Ownership Chains, Lobbying, and the Bipartisan Receipt
EP02_03_Follow_the_Money_v1_0 | Updated 2026-04-24
We critique systems and incentives, not individual employees.
Buybacks Beat Cures
14 largest pharma companies, 2016-2020 spending. Source: U.S. House Committee on Oversight and Reform, Majority Staff Report, December 2021
$56 billion more went to Wall Street than to the labs. The argument that high prices fund innovation has receipts. So does the rebuttal.
1. THE THREE PARENTS
CVS HEALTH
Ticker: NYSE: CVS
2023 Revenue: approximately $357 billion
What they own:
- CVS Pharmacy (retail pharmacy, around 9,000 US locations)
- Caremark (PBM, top 3 by prescription volume)
- Aetna (health insurer, acquired 2018 for $69 billion)
- Oak Street Health (primary care, acquired 2023)
- Signify Health (home health, acquired 2023)
Why it matters: CVS Health writes your insurance plan (Aetna), decides which drugs are on your formulary (Caremark), fills your prescription (CVS Pharmacy), and now delivers your primary care (Oak Street). The same parent profits from every step.
When CVS Caremark “negotiates” with drug manufacturers on behalf of Aetna’s members, they’re negotiating with their own corporate parent’s other business units. The referee, the scorekeeper, and the team owner are the same paycheck.
UNITEDHEALTH GROUP
Ticker: NYSE: UNH
2023 Revenue: approximately $371 billion (largest healthcare company by revenue in the world)
What they own:
- UnitedHealthcare (health insurer, around 52 million US members)
- OptumRx (PBM, top 3)
- Optum Health (primary care, surgical centers, physician groups)
- Optum Insight (data analytics, health IT, includes Change Healthcare)
Why it matters: UnitedHealth Group is the most vertically integrated health services company in the US. They insure you, set your formulary, operate your primary care clinic, run the surgical center where you get your procedure, and process the billing data flowing between all of them.
Change Healthcare, acquired by Optum in 2022 for $13 billion, was hit by a ransomware attack in February 2024 that paralyzed US healthcare billing for weeks. A reminder of how concentrated the infrastructure has become.
CIGNA GROUP
Ticker: NYSE: CI
2023 Revenue: approximately $195 billion
What they own:
- Cigna Healthcare (health insurer)
- Express Scripts (PBM, top 3, acquired 2018 for $67 billion)
- Evernorth (Cigna’s healthcare services division)
- Accredo (specialty pharmacy, Express Scripts subsidiary)
Why it matters: Cigna Group acquired Express Scripts in 2018 in a deal that followed the same vertical integration pattern. Cigna now controls the insurance, the PBM, and the specialty pharmacy for its members.
The ProPublica investigation that exposed Dr. Cheryl Dopke’s 121,000 denials in two months documented Cigna’s internal claim-review system. The same parent owns the PBM that sets formulary, the insurer that denies the claim, and the appeals process.
2. THE INSULIN OLIGOPOLY
ELI LILLY AND COMPANY
Ticker: NYSE: LLY
2023 Revenue: approximately $34 billion
Key insulin/GLP-1 products: Humalog, Basaglar, Trulicity, Mounjaro, Zepbound
Lilly launched LillyDirect in 2024. A direct-to-consumer channel that bypasses the PBM chain entirely, selling insulin and other medications direct to patients.
This is a tacit admission by Lilly that their own PBM distribution has become so dysfunctional that going direct is cheaper than going through it.
NOVO NORDISK
Ticker: NYSE: NVO (American Depositary Receipt)
2023 Revenue: approximately $33 billion
Key insulin/GLP-1 products: NovoLog, Levemir, Tresiba, Ozempic, Wegovy
Novo Nordisk’s recent growth is driven heavily by GLP-1 agonists (Ozempic and Wegovy), now with list prices exceeding $1,000 per month. The company has launched NovoCare direct-to-consumer for insulin.
SANOFI
Ticker: NASDAQ: SNY (ADR)
2023 Revenue: approximately $46 billion
Key insulin products: Lantus, Toujeo, Apidra
The third member of the oligopoly. Less aggressive direct-to-consumer pivot than Lilly and Novo. The Lantus patent expired in 2015, but biosimilar competition entered the US market only slowly because of formulary blocking and rebate-driven preferences for the brand.
3. FEDERAL LOBBYING
Health sector lobbying spending in 2024 exceeded $751 million.
Sub-sector breakdown (approximate annual):
- Pharmaceuticals and Health Products: approximately $400 million
- Hospitals and Nursing Homes: approximately $130 million
- Health Services and HMOs: approximately $120 million
- Health Professionals: approximately $100 million
Source: OpenSecrets (Center for Responsive Politics), aggregated from quarterly LD-2 disclosures required by the Lobbying Disclosure Act.
Health sector has been the #1 lobbying sector in America for 10+ years running.
Not finance. Not energy. Not tech. Health.
The industry that benefits from the pricing system above has, by a wide margin, the most-funded lobbying operation in Washington. Every year. For a decade.
That is a structural fact about who has access to the rules being written.
4. PAC DONATIONS (BIPARTISAN)
Health sector PAC donations to federal candidates in the 2024 cycle totaled approximately $52 million.
Split: Roughly even between the two parties. Republicans received slightly more than Democrats in the 2024 cycle, but both received substantial donations.
Historical pattern, Medicare Modernization Act cycle (2003): approximately $29 million to Republicans, approximately $24 million to Democrats. The split varies cycle-to-cycle but remains bipartisan.
That’s not ideology. That’s a subscription to both channels.
What this means in practice:
When the rules of pharmaceutical pricing are debated in Congress, both parties have already received significant donations from the industry being regulated. Neither party arrives at the table empty-handed.
This is not a claim that any specific vote was bought. It is a documented pattern of the industry funding access on both sides of the aisle, every cycle.
Source: OpenSecrets PAC database; FEC disclosures.
5. THE REVOLVING DOOR
The pattern: senior personnel move between government health agencies (HHS, CMS, FDA) and the pharmaceutical and health services industries. Former regulators become industry lobbyists, board members, and advisors. Industry executives become regulators. The same people write the rules and then profit from them.
This pattern is documented across multiple administrations and both parties.
Documented examples:
| Person | Government Role | Industry Role |
|---|---|---|
| Alex Azar | HHS Secretary (2018-2021) | Eli Lilly US President BEFORE; Foresite Capital advisor AFTER |
| Scott Gottlieb | FDA Commissioner (2017-2019) | Pfizer board, New Enterprise Associates venture partner |
| Mark McClellan | FDA Commissioner (2002-2004), CMS (2004-2006) | Duke-Margolis Center; multiple industry boards |
| Seema Verma | CMS Administrator (2017-2021) | Oracle Health EVP/GM; former R1 RCM and Lifestance boards |
| Marilyn Tavenner | CMS Administrator (2013-2015) | AHIP (insurer lobby) CEO |
Sources: ProPublica “Represent” database; OpenSecrets revolving door tracker.
Why this list crosses party lines:
The names above span Democratic and Republican administrations. The pattern is structural, not partisan. Senior government health roles are stepping stones to industry, and industry experience is a credential for the senior government health roles.
The traffic in the revolving door is constant in both directions, regardless of which party holds the White House.
6. THE BUYBACKS RECEIPT
The U.S. House Committee on Oversight and Reform’s 2021 pharmaceutical pricing investigation found:
14 of the largest pharmaceutical companies spent $577 billion on stock buybacks and dividends from 2016-2020, compared to $521 billion on R&D over the same period.
Translation: $56 billion more went to shareholders than to the labs.
The industry’s largest players paid Wall Street more than they invested in finding new medicines. See the chart at the top of this Case File for the visual.
Source: House Oversight Committee Majority Staff Report, December 2021.
The defender’s argument: “High US prices fund the R&D that benefits the world.”
The receipt: The 14 largest pharma companies returned more cash to shareholders than they invested in research over a five-year window.
The aggregate sector-level numbers do not support the “prices fund innovation” framing. Individual companies do invest heavily in R&D. NIH-funded basic science still feeds the pipeline. But the headline defense of US drug pricing is contradicted by the industry’s own filings.
When you hear the innovation argument, ask: whose innovation, funded by whom, and where did the profits actually go?
| Source | Type | Section |
|---|---|---|
| OpenSecrets (Center for Responsive Politics) | Primary | 3, 4 |
| U.S. House Committee on Oversight and Reform Majority Staff Report (Dec 2021) | Primary | 6 |
| FTC Interim Report on Pharmacy Benefit Managers (2024) | Primary | 1 |
| SEC 10-K Filings (CVS, UnitedHealth, Cigna, Lilly, Novo Nordisk, Sanofi) | Primary | 1, 2 |
| ProPublica investigation (Cigna PXDX, 121,000 denials) | Journalism | 1 |
| ProPublica "Represent" database (revolving door tracker) | Journalism | 5 |
| Senate Finance Committee Insulin Pricing Investigation | Primary | 2 |
| FEC Disclosures (PAC contribution detail) | Primary | 4 |