Here is a fact that should make your blood boil:
Three companies - CVS Caremark, Express Scripts, and OptumRx - manage 79% of all prescription drug claims in the United States. That’s coverage for roughly 270 million people. Not three hundred companies. Not a competitive marketplace humming with innovation and consumer choice. Three. And according to a 2024 Federal Trade Commission staff report, those three companies are wholly owned subsidiaries of three insurance behemoths: CVS Health, Cigna, and UnitedHealth Group, respectively.
Read that again. The same corporation that sells you your insurance plan also decides which drugs get covered, at what price, and whether your pharmacy can stock them. This is called vertical integration. In another era, and when it comes to other, ahem “industries” we called it what it is: a cartel.
Now hold that thought, because I want to talk about estradiol patches.
What the New York Times Got (Partly) Wrong
A recent New York Times piece addressed the ongoing estradiol patch shortage. The framing, at least in part, leaned on a familiar and deeply disturbing narrative: women have been told that hormone therapy will “fix everything,” demand has surged, and — well, supply chain things happen.
Some experts quoted in that piece, including a leading medical research authority and recognized expert in both gender differences in disease and menopause - a physician who should absolutely know better - suggested the shortage was substantially driven by increased patient demand. The implication being that women, newly educated (or perhaps newly manipulated?) about menopause care, have flooded the market and created a scarcity problem through sheer enthusiasm.
I have two words for that analysis: intellectually lazy.
And I’ll add a few more: willfully ignorant, or worse.
Let’s Name What’s Actually Happening
Estradiol is not a new drug. The patch formulation has existed for decades. Generic versions are widely manufactured. There is no exotic ingredient, no rare supply chain dependency, no Act of God that explains why women are being told their pharmacy is out of stock - month after month, refill after refill. And make no mistake, these shortages may seem more evident now, post FDA boxed warning removal, but have gone on for many years prior to the recent “surge” in interest.
What there is: a system in which three PBMs function as gatekeepers between drug manufacturers and the patients who need medication. These entities negotiate (read: dictate) reimbursement rates with pharmacies, decide which drugs land on formularies, and influence which manufacturers get contracts worth filling. When a low-cost generic like estradiol - a medication with no blockbuster profit margins and no patent protection - runs into friction in this system, the friction is not random. It is structural.
PBMs profit, in significant part, from the spread between what they pay manufacturers and what they charge insurers. A generic commodity like estradiol is not particularly lucrative to move through that machinery. There is little financial incentive to ensure smooth, consistent access. There is, however, significant financial incentive to steer patients toward branded alternatives, or simply to let supply tighten without urgency.
This is not a conspiracy theory. The FTC said as much in their 2024 report, which documented how PBM practices inflate costs, reduce competition, and harm patient access - particularly for independent pharmacies and for generic drugs.
On Blaming Women for Their Own Healthcare Crisis
The suggestion that the estradiol shortage is meaningfully caused by women demanding too much - because they’ve been convinced menopause treatment is a panacea - is a rhetorical move I want to examine carefully, because it is doing a lot of work.
It centers women’s behavior as the problem. It positions demand as somehow illegitimate or manufactured. It implies that the solution involves women tempering their expectations rather than a broken system providing adequate supply. And it conveniently avoids mentioning the three corporations controlling nearly 80% of drug claims, the reimbursement structures that disincentivize stocking certain generics, or the vertical integration that creates conflicts of interest at every level of the supply chain. (I’m not even addressing the fact that only 4% of eligible US women are currently prescribed menopausal hormone therapy)
If an expert is quoted suggesting that women wanting appropriate hormone therapy is the root cause of this shortage - without a single mention of PBM market concentration or pharmacy reimbursement economics - one of two things is true: either they have not done the intellectual work required to speak credibly on drug access in America, or they have, and they’re choosing not to say it out loud.
I will let you draw your own conclusions about which is more forgivable.
What Vertical Integration Means for Your Prescription
When an insurance company owns the PBM that processes your claim, which owns or contracts exclusively with a pharmacy that fills your prescription, you are not in a healthcare system. You are in a vertically integrated revenue extraction model that happens to, occasionally, also provide healthcare.
Every decision in that chain - what’s covered, what’s reimbursed, what’s stocked, what’s preferred - is filtered through the same corporate profit motive. And when the drug in question is an off-patent estradiol patch that costs pennies to manufacture but requires logistical investment to keep consistently in stock? The math on “how much does this company care about ensuring access” is not complicated.
The FTC report is damning and worth reading in full. It documents the ways PBMs have used their market position to squeeze independent pharmacies, create perverse incentive structures, and limit competition in ways that directly harm patients. This is not the shadowy speculation of fringe critics. This is the federal government’s consumer protection agency saying, in bureaucratic but unambiguous language: this system is hurting people.
What You Can Do
Knowing the structural reality doesn’t resolve your immediate problem of not being able to fill your prescription, so let me offer some practical guidance alongside the outrage:
Ask your prescriber about alternatives. Estradiol is available in multiple formulations - gel, spray, cream, oral tablet, vaginal ring, and the weekly transdermal patch, which is a different product from the twice-weekly patch and may be more consistently available depending on manufacturer and region. If the patch is unavailable, a transdermal gel (or compounded estradiol cream) delivers the same molecule through a similar route. These may be more consistently available.
Consider a compounding pharmacy. A reputable compounding pharmacy can prepare bioidentical estradiol in standardized doses. This is a legitimate option when commercially manufactured products are inaccessible, and the hormones used are the same FDA-regulated bulk ingredients.
Consider on online pharmacy: HRT Club, Mark Cuban Cost Plus and others are doing a good job locating and filling these prescriptions from outside the PBM system.
Call ahead. Patch shortages are inconsistent across regions and distributors. A 15-minute call to pharmacies in your area - or a broader geographic radius if you’re able - can locate stock that your regular pharmacy doesn’t have.
Contact your representatives. The FTC report exists partly because Congress asked for it. Bipartisan pressure for PBM reform is growing. The more constituents who contact their representatives about drug access - and specifically name PBM market concentration as the issue -the more political will accumulates.
Keep naming the system. When you share this with a friend, don’t say “there’s a shortage.” Say: “three corporations control 79% of drug claims in this country, and one of the drugs they’re not ensuring access to is the estradiol patch.”
The Bottom Line
The estradiol patch shortage is not a story about women wanting too much. It is a story about market concentration, perverse incentives, and the consequences of allowing insurance companies to also own the pharmacy benefit managers who also effectively control drug access for the majority of Americans.
When experts - particularly physicians who work within or adjacent to this system - explain away drug shortages without naming these structural realities, we should ask why. Intellectual curiosity demands it. Our patients deserve it.
And for what it’s worth: I’m judging.
Sources: FTC Pharmacy Benefit Managers Staff Report, 2024. ftc.gov ; JAMA Health Forum Sept 27,2024 Jamanetwork.com
Wow, great article! It is absolutely criminal. What if people ran out of insulin? Or blood pressure medication, or god forbid, Viagra😱. ( oh butthere are multiple Other ED drugs to choose from, all which are very inexpensive!!!)
Great article elucidating the corruption in our for profit healthcare system. As a PharmD on the twice weekly patch, one solution is to dose those every 4 days v twice a week, since one patch can last 4 days. Of course even with the reminder on my phone, I can forget, but most times i dont have symptoms unless Im 2 days late.
But..yes there are other delivery methods! And no Viagra crisis 😡