Washington, D.C. — Insurance Watchdog Coalition (IWC) today sent a letter to leaders of the Senate Health, Education, Labor, and Pensions (HELP) Committee calling on lawmakers to broaden their approach to lowering prescription drug costs by addressing the role of health insurance companies in determining what patients pay.

In the letter to Chairman Bill Cassidy, Ranking Member Bernie Sanders, and members of the Committee, IWC commended their ongoing efforts to reduce drug prices but warns that current policy discussions risk overlooking a central driver of patient costs: insurance design and insurer-controlled pricing mechanisms. New polling released from IWC reveals that voters nationwide – and across the political spectrum – overwhelming support insurance reform as the top priority in improving health care.

“While policymakers have taken important steps to address drug pricing, insurance barriers remain the greatest threat to affordability,” said Mark Merritt, executive director of IWC. “For most patients, out-of-pocket costs are set by insurers – not drug manufacturers – and often bear little relationship to list prices.”

The letter outlines how rising premiums, restrictive formularies, and high out-of-pocket costs continue to limit access to medications, even as policymakers pursue pharmaceutical pricing reforms.

IWC’s letter also highlights structural concerns within the insurance system, particularly the growing vertical integration of insurers with pharmacy benefit managers (PBMs), specialty pharmacies, and provider groups. According to the Coalition, these arrangements create conflicts of interest and enable insurers to influence pricing and access decisions across the prescription drug supply chain.

The letter raises specific concerns about the use of affiliated PBM group purchasing organizations (PBM GPOs), including those domiciled offshore, which can be used to retain manufacturer rebates and reduce transparency into whether savings are passed on to patients.

Recent federal enforcement activity underscores these risks. The Federal Trade Commission has reached a settlement with Express Scripts, a subsidiary of Cigna, related to aspects of its rebate and PBM GPO arrangements. Similar structures remain in place across other major PBMs affiliated with large insurers.

In addition, IWC points to federal policy opportunities to reduce waste and improve affordability. It highlights the No Unreasonable Payments, Coding, or Diagnoses for the Elderly (No UPCODE) Act as one example, noting that eliminating an estimated $124 billion in excess payments could help lower out-of-pocket costs for Medicare beneficiaries.

“Patients are facing increasing barriers to care – from prior authorization delays to coverage denials – while opaque pricing structures make it harder to understand where healthcare dollars go,” Merritt said. “We urge the Committee to take a comprehensive approach that includes meaningful insurance reform.”

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Insurance Watchdog Coalition’s mission is to educate legislators, regulators, key opinion leaders, the media and the American people about the harmful impacts of vertically integrated insurance monopolies, especially in our healthcare system, which in turn will help create more competition in the marketplace, lower healthcare costs, and ensure that healthcare savings go to patients, not big insurers.

WASHINGTON, DC – A new national survey out today reveals a striking and unified sentiment among American voters: there is strong, bipartisan support to rein in health insurance companies by breaking up existing monopolies and eliminating rampant waste, fraud and abuse.

OnMessage Public Strategies, on behalf of Insurance Watchdog Coalition, conducted the poll of 1,000 likely voters nationwide. The survey found that across the political spectrum, voters are overwhelmingly aligned in their concerns about the health care system. Large majorities place the blame primarily on health insurance companies, support breaking up large insurers and indicate they are more likely to support candidates for public office who champion health insurance reform.

Health Insurance Industry Faces Deep Public Disapproval

Public sentiment toward health insurance companies has deteriorated to strikingly low levels. Just 17% of voters view insurers favorably, while 78% hold unfavorable views, including 47% who say their opinion is “very unfavorable.”

When asked which industry Congress should prioritize, health insurance companies are the overwhelming answer:

• 60% say Congress should focus on health insurance companies — the overwhelming top choice
• 18% pharmaceutical companies
• 8% hospital systems
• 6% pharmacy benefit managers (PBMs)

This concern spans party affiliation, with Democrats, Republicans, and Independents all identifying health insurers as the top priority.

Strong Support for Cutting Waste, Fraud, and Abuse

The survey finds significant backing for President Trump’s efforts to reduce waste, fraud, and abuse in government health care programs, with 81% of likely voters say they would be more likely to vote for a candidate focused on eliminating inefficiencies and holding both government programs and insurance companies accountable.

Broad, Bipartisan Support for Structural Reform

Voters are not only dissatisfied – they support structural change:

• 70% say they are more likely to support a candidate who favors breaking up large health insurance companies
• 90% agree insurers have too much control and should be broken up, including 74% who strongly agree

Key Messages Drive Support Even Higher

Support for reform intensifies when voters are presented with specific information about industry practices. Among the most compelling findings:

• 89% support action after learning insurers have created monopolies in local markets
• 88% support action after hearing about vertical integration across PBMs, pharmacies, and other services
• 87% support action after learning insurers are acquiring large numbers of physician practices
• 87% support action after hearing that a handful of companies control more than half the market

These results highlight strong voter reactions to concerns about consolidation, conflicts of interest and market dominance.

Clear Political Implications

The survey underscores significant electoral consequences tied to this issue:

• 84% say they would support a candidate who takes on insurance companies to lower costs, including 81% of Independents and 80% of undecided voters (44% strongly agree)
• 86% are less likely to vote for a candidate funded by big insurance companies (67% much less likely)

Overall, voters increasingly view health insurance companies as central to rising costs and systemic inefficiencies, and they are calling for meaningful reform. As health care costs continue to climb, this issue is a key factor in voter decision-making, with clear incentives for candidates willing to seek reforms in the industry.

Read the full survey memo.

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Insurance Watchdog Coalition’s mission is to educate legislators, regulators, key opinion leaders, the media and the American people about the harmful impacts of vertically integrated insurance monopolies, especially in our healthcare system, which in turn will help create more competition in the marketplace, lower healthcare costs, and ensure that healthcare savings go to patients, not big insurers.

Congress Made Important Strides on PBM Reform, But More Must Be Done

WASHINGTON, DC – Insurance Watchdog Coalition (IWC) today issued a statement in firm support of the bipartisan inquiry led by the House Committees on Oversight and Reform into the predatory practices of Pharmacy Benefit Managers (PBMs).

We encourage Chairman James Comer (R-KY) of House Committee on Oversight and Government Reform and House Appropriations Subcommittee on Labor, Health and Human Services, Education, and Related Agencies Chairman Robert Aderholt (R-AL) to keep pursuing insurance and PBM reforms that reduce prescription drug costs for patients.

While the recently signed Consolidated Appropriations Act, 2026 (passed February 3, 2026) represents a significant step in the right direction toward reforming PBM “black box” accounting, many PBM profit schemes remain intact.  IWC encourages Congress to take swift action to address these practices and deliver real savings for American employers, taxpayers and healthcare programs.

Insurers and PBMs continue to utilize many predatory tactics identified in the Committee’s 2024 investigation into PBMs such as:

• Prior Authorization Abuse: Administrative hurdles used to override doctors and steer patients to profitable drugs.
• “Fail-First” Mandates: Forcing patients onto ineffective drugs before accessing prescribed, life-saving therapies.
• The Medicaid Gap: The new law fails to ban “spread pricing” in Medicaid, leaving low-income patients vulnerable to hidden PBM markups.
• Patient Steering: Mandating use of PBM-owned mail-order pharmacies, undermining local community access.

IWC hopes that Congress will prioritize addressing these harmful practices that decrease healthcare access and affordability.

Mark Merritt, executive director of the IWC, stated: “We are encouraged by the momentum that exists in Congress to address insurer and PBM predatory practices and are thankful for the Trump Administration’s commitment to addressing the rampant fraud and abuse within the American insurance marketplace. We need reforms now so patients can get their medications without jumping through hoops or paying sky-high insurance co-pays at the pharmacy counter.”

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Insurance Watchdog Coalition’s mission is to educate legislators, regulators, key opinion leaders, the media and the American people about the harmful impacts of vertically integrated insurance monopolies, especially in our healthcare system, which in turn will help create more competition in the marketplace, lower healthcare costs, and ensure that healthcare savings go to patients, not big insurers.

WASHINGTON, DC – Insurance Watchdog Coalition (IWC)commends the U.S. House Energy and Commerce Committee for focusing its hearing today on fraud and abuse in Medicare and Medicaid—areas where the scale of the problem has grown significantly and demands urgent scrutiny.

“Large insurance companies have turned Medicare and Medicaid into giant ATMs—and taxpayers are footing the bill,” said Mark Merritt, executive director of IWC.

As Congress examines fraud in federal health programs, IWC warns that the largest drivers of waste are no longer isolated actors, but large, vertically integrated insurance companies and the intermediaries they control.

Three Major Drivers of Waste and Abuse

PBM Practices Inflating Drug Costs

Vertically integrated pharmacy benefit managers (PBMs), often owned by large insurers, now control most of the prescription drug market and play a key role in determining drug pricing and access.

Key practices driving higher federal spending include:

• Spread pricing, where PBMs charge payers more than they reimburse pharmacies
• Rebate-driven formularies, favoring higher-priced drugs with larger rebates
• Steering to PBM-owned pharmacies, particularly for high-cost specialty drugs

These arrangements allow insurers and their affiliated PBMs to extract additional revenue

from taxpayer-funded programs, while obscuring the true cost of prescription drugs.

Medicare Advantage Upcoding and DOJ Litigation

Medicare Advantage has become one of the largest and fastest-growing components of federal healthcare spending. Its payment system creates strong incentives to maximize reported diagnoses—and therefore federal payments.

These practices are now at the center of federal fraud litigation. In United States ex rel. Poehling v. UnitedHealth Group, the U.S. Department of Justice alleges that UnitedHealth Group identified unsupported diagnoses through internal reviews but failed to delete them before submitting data to Medicare, inflating payments.

Beyond individual cases, the broader fiscal impact is substantial. Analysis from the Committee for a Responsible Federal Budget estimates that current Medicare Advantage payment policies could result in approximately $1.2 trillion in excess federal spending over the next decade.

This is not incidental overpayment—it reflects a system that rewards higher coding intensity and drives higher federal spending, with costs passed on to seniors through increased Medicare Part B premiums.

“This isn’t incidental overpayment—it’s a business model,” Merritt said.

Taken together, these practices reflect a system where the largest financial gains come not from delivering care, but from maximizing payments.

Offshore GPOs: “Ghost PBM Organizations”

PBM-controlled Group Purchasing Organizations (GPOs) operating offshore have emerged as a new mechanism for collecting administrative fees tied to drug rebates.

These entities:

• Operate under a 1987 Anti-Kickback Statute safe harbor never designed for this purpose
• Collect fees tied directly to rebate volume and drug prices
• In some cases operate outside the United States, increasing opacity and limiting oversight

These structures allow PBMs to capture additional revenue tied to higher drug prices, embedding incentives that drive up costs in taxpayer-funded programs.

These entities exist not to lower prices, but to collect fees tied to higher ones—embedding incentives that work directly against taxpayers.

Call for Congressional Action

IWC urges Congress to align oversight with how the healthcare system actually operates today.

This includes:

• Full transparency into PBM pricing and rebate flows
• Stronger auditing and enforcement of Medicare Advantage risk-adjustment practices
• Reform of the GPO safe harbor as applied to PBM-controlled entities

Until Congress addresses these structures, the largest drivers of Medicare and Medicaid waste will remain untouched.

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The Insurance Watchdog Coalition’s mission is to educate legislators, regulators, key opinion leaders, the media and the American people about the harmful impacts of vertically integrated insurance monopolies, especially in our healthcare system, which in turn will help create more competition in the marketplace, lower healthcare costs, and ensure that healthcare savings go to patients, not big insurers.