The Fuse That Could Finally Blow Up The PBM System

A couple days ago, Mark Cuban posted something on LinkedIn that should keep every Fortune 500 CEO awake at night.

“ERISA attorneys are salivating to sue you!”

That’s a direct quote.

Why? The full post is below — and you should read it. Because what Cuban is talking about is one of the most quietly corrosive practices in American healthcare. And if the mechanics of it feel confusing, don’t worry. I’m going to translate the whole thing for you in plain English.

Let’s walk through it…

During the deductible phase, when an employee pays the full list price for a brand-name medication, that “list price” is really two numbers glued together:

So that inhaler an employee pays two weeks salary for out of pocket?

Here’s where the money actually goes:

Cuban spells it out with unflinching clarity:

“YOUR SICKEST EMPLOYEES ARE THE ONES PAYING THE REBATE TO YOU.”

And then he ends with a warning CEOs should take very seriously:

“When you sit in the inevitable deposition… remember you are under oath.”

For months, I’ve tried to show you the inner wiring of the American healthcare system — the PBM rebate walls, the spread pricing, the pharmacy closures, the sham formularies. And through all of it, I’ve been asking myself the same question:

What finally blows up the PBM system?

Congress knows what’s happening and does nothing.
The FTC can try, but PBMs always find a side door.
Drug companies complain, but they still play the game.

But Cuban’s post made something click for me.

This might just be the spark.

A patient fills a $600 brand medication in January. Their deductible isn’t met, so they pay the full list price at the counter.

They think they’ve paid $600 because that’s what the drug “costs.”

Here’s what really happens:

This isn’t some conspiracy.
It's a documented fact.

Back in 2021, my favorite data team at 46Brooklyn Research published a forensic analysis titled “Money From Sick People.” The title wasn’t creative. It was literal.

Their conclusion, based on real claims data:

“The sickest employees fund a disproportionate share of the employer’s pharmacy benefit.”

Most employers had no idea this was happening.

But in a lawsuit?
Ignorance isn’t a defense.
It’s an exhibit.

Whenever you raise this with a corporation, they offer the same defense:

“Rebates keep premiums lower for everyone.”

That’s the HR-approved, feel-good justification. In fact, many comments under Cuban’s post repeated it verbatim. These people claim that the rebate payments are put right back into their health plans to contribute to the company costs as a whole.

Here’s the truth:

This isn’t “lowering premiums.”

It’s wealth transfer from the sick to the healthy, engineered through pharmacy claims.

And legally?

It’s indefensible.

ERISA (Employee Retirement Income Security Act of 1974) — the law governing employer health plans — requires two things:

Rebates are plan assets.

Meaning:
If an employer receives rebate dollars generated by sick employees — and employees were never told — that is a clean, textbook fiduciary breach.

Every employer in America is sitting on this liability.

Which is why Cuban’s post isn’t hyperbole. It’s essentially the script for the first question an ERISA attorney will ask in discovery:

“Were you aware that rebate dollars were paid by your own employees directly to your company?”

There is no good answer to this question.
Not for a CEO.
Not under oath.

PBMs aren’t afraid of patients.
They aren’t afraid of pharmacists.
They aren’t afraid of drug companies or bad headlines.
They aren’t afraid of Congress.

But they are afraid of their corporate clients waking up.

Because PBMs only survive as long as employers blindly sign their contracts — trusting benefit consultants who don’t understand PBM incentives and PBMs who absolutely do.

ERISA litigation flips the incentive structure overnight.

The moment one major employer gets sued by its own workers — even if it settles quietly — every other employer in the country will ask the same question:

“Are we exposed too?”

And the answer is yes.
Every single time.
Because the Big Three PBMs all use the same playbook.

This is the moment PBMs lose their greatest weapon:

Employer complacency.

Once that’s gone, their empire starts to shake.

Here’s how the collapse unfolds:

Step 1: Corporations realize PBM rebate structures expose them to ERISA liability.

Step 2: They refuse to sign opaque, rebate-driven PBM contracts.

Step 3: They migrate to pass-through PBMs and true net-cost models.

Step 4: They begin sourcing drugs from transparent platforms like Cost Plus, or emerging players like Andel — companies that don’t touch rebates at all.

Step 5: The Big Three PBMs lose market share and negotiating leverage.

Step 6: The rebate economy collapses because the participants stop showing up.

PBMs don’t fear regulators — regulators can be lobbied.
They don’t fear journalists — opacity absorbs criticism.

But if their own customers stop trusting them?

That’s the one variable PBMs can’t control.
That’s the real detonation.

This isn’t a theoretical debate about benefit design.
This is what you see at the pharmacy counter:

When the PBM model falls, the consequences are simple:

Drugs get cheaper.
Access gets easier.
Pharmacies stop closing.
Patients stop being punished for getting sick.

This is what PBMs have spent two decades trying to prevent.

I’ve wondered for a long time what finally forces change.

Not another hearing.
Not another FTC report.
Not another pharmacist yelling into the void.

It was always going to take something structural — something that hurts the right people’s bottom line.

Now it’s here.

A viral LinkedIn post just told America’s CEOs the truth:

Your PBM made you a beneficiary of your employees’ illness.
And if you knew — or should have known — ERISA will come for you.

If even one company gets dragged into court, the fuse is lit.
If a handful switch to transparent PBMs, the dominoes fall.
If the rebate game collapses, so does the PBM empire.

The spark we’ve been waiting for may have just landed in plain sight.

And judging by the smoke, the fuse is burning.

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