Ali–Frazier: Pharma Edition

Earlier this month, Cost Plus Drugs CEO Mark Cuban and Optum CEO Dr Patrick Conway sat down for a long, dense, high-level discussion about healthcare at Johns Hopkins Carey Business School. It was thoughtful, technical, and clearly geared towards executives, policymakers, and people who spend their days thinking about healthcare from 30,000 feet. This was not a conversation I could fully break down here even if I wanted to — and that’s fine, because that’s not what Drugstore Cowboy is for.

This newsletter exists to give everyday people a working understanding of how the healthcare system actually functions in five minutes or less, not to recreate a graduate seminar. So instead of attempting a full recap, I want to focus on a few big-picture takeaways from that debate — specifically the parts that reveal how American healthcare really thinks about money, consumers, and accountability. If you’re looking for a deeper dive, I strongly encourage you to watch the full discussion. But if you want to understand why two brilliant pharma power-players can talk past each other for an hour without ever really disagreeing on the facts, this is my five-minute translation.

One takeaway stood out to me as I watched the discussion — not because either man said it explicitly, but because it explained almost everything that followed.

Mark Cuban consistently spoke as if the patient is the consumer of healthcare.
Patrick Conway consistently spoke as if the employer is.

That distinction isn’t semantic. It’s foundational.

When Cuban talks about healthcare, his arguments orbit a clear moral center: doing right by the person who is sick, confused, or financially exposed. He talks about prices the way consumers understand prices. He talks about transparency as a prerequisite for trust. His worldview assumes that healthcare should function like any other market where the end user deserves to know what something costs before they commit to it.

Conway, by contrast, approaches healthcare through the lens of an executive selling services to large organizations. In his framing, the “customer” is the employer paying Optum to manage benefits, control utilization, and deliver aggregate savings. Patients exist downstream of that relationship. They matter, but they are not the party writing the check.

If you strip morality out of the equation, you can understand where each is coming from. Cuban doesn’t need more money; he’s operating from a public-good mindset. Conway’s responsibility is to shareholders. Those obligations are not symmetric, and they produce very different systems.

When you imagine the consumer as a patient, opacity feels predatory.
When you imagine the consumer as an employer, opacity can feel efficient.

It is far easier to morally justify extracting dollars from the system when you picture those dollars coming from a large, profitable corporation rather than from a sick, working human being. Once that mental shift happens, harm becomes abstract. It gets averaged. It gets buried in metrics. And eventually, it stops looking like harm at all.

One of the most important things to understand about this debate is that it was not a clash between truth and lies (well, not really). Both men made claims that were internally coherent. Both cited data. Both could point to outcomes that look successful on paper.

Healthcare systems can be internally rational and externally destructive at the same time. A model can reduce costs in aggregate while increasing pain, confusion, and risk at the individual level. Those two statements are not mutually exclusive, even though we often pretend they are.

Conway’s defense of the system relies heavily on scale. If something lowers total spend for large employers and raises his stock price, it is framed as a success, even if the mechanism for achieving that reduction involves complexity, delayed access, or cost-shifting that patients feel acutely. The suffering doesn’t disappear; it’s just clouded. It becomes statistical noise.

Cuban’s critique cuts in the opposite direction. He starts with lived experience and works backward. If a patient can’t understand a bill, can’t predict a cost, or can’t tell who is getting paid, the system has already failed regardless of how it performs in a spreadsheet.

This is why the two men often sound like they’re answering different questions. They are.

Conway is defending a system that works for institutions.
Cuban is attacking a system that fails people.

Both can technically be “right,” which is precisely why the system never fixes itself.

If there is one idea Mr. Cuban is absolutely consistent about in healthcare, it is transparency. He returns to it again and again. Not as a moral flourish, but as a structural requirement. Show people the real price. Show them where the money goes. Remove the smoke.

What struck me most during this debate was not the disagreement over outcomes, but the asymmetry of proof.

Cuban makes provable claims. His prices are public. So are his margins. If he’s wrong, you can check. Conway, by contrast, repeatedly made claims that conveniently could not be proven because the proof is private. Contracts are confidential. Deal terms are proprietary. Savings exist, maybe, but only behind closed doors.

This isn’t a rhetorical dodge. It’s the business model.

In no other sector that touches every American’s life are the core pricing mechanisms allowed to remain almost entirely hidden. And yet, in healthcare, we’ve normalized it.

When a system depends on secrecy to function, transparency doesn’t just challenge it — it threatens it. It collapses the moral distance. It forces everyone to confront who is actually paying and who is actually benefiting.

That is why transparency is so often dismissed as unrealistic, dangerous, or overly simplistic. Not because it wouldn’t work. But because it would work too well.

A central point of contention between Cuban and Conway was the classic pharma chicken-or-the-egg question: are drug prices high because of rebates, or do rebates exist because drug prices are high?

Reasonable people can debate the historical origin. But from where I sit, the more important question is what rebates do now.

Even if high prices predated rebates, rebates now require prices to stay high.

Once rebates become central to the system, lowering list prices becomes impossible. Transparency becomes dangerous. The connection between price and value breaks entirely. Patients are shown one number. Employers see another. Middlemen extract a third.

At that point, it no longer matters which came first. The incentive structure is locked in.

This is why we can’t talk about drug pricing without talking about rebates, and why any defense of the current system that treats rebates as incidental misses the point. They are no longer a response to the market. They are the market.

Cuban understands this intuitively. His entire model is built around removing that distortion. Conway, operating inside the existing structure, must defend it. The system he runs cannot survive without it.

One final observation from watching this debate: its very density is evidence of the system it’s defending.

Healthcare conversations stay abstract because abstraction protects incumbents. Complexity diffuses accountability. When no one can clearly explain how money moves, no one can be held responsible for where it ends up. This is literally the reason I started Drugstore Cowboy.

This is also why executive-level healthcare debates rarely resolve patient-facing pain. They are optimized to discuss systems, not experiences. Aggregates, not outcomes. Models, not moments.

Cuban’s greatest “sin” in healthcare — at least from the legacy system’s perspective — is that he keeps dragging the conversation back to first principles. What does it cost? Who pays? Who benefits? Those questions sound naive only because the system has spent decades training us not to ask them.

He keeps asking because somehow, even after all this time, we still don’t have clear answers.

As complicated as this all seems, it really is that simple!!!

This debate will not be “won” on a stage or settled by a single policy proposal. It will be resolved when we decide who healthcare is actually for.

If patients are the consumer and health outcomes are the priority, transparency becomes non-negotiable.

If employers are the consumer and shareholder value is the priority, opacity will always find a defense.

Healthcare does not need more sophisticated arguments. It needs fewer places to hide — and more people who understand what they’re looking at.

Until next time…

Alec Wade Ginsberg, PharmD, RPh
4th-Gen Pharmacist | Owner & COO, C.O. Bigelow
Founder, Drugstore Cowboy