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**DECEMBER 5, 2025**

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Apart from some high-profile examples like real estate agents or financial brokers, the middleman economy is all but invisible. They hide within business transactions; it’s unclear how much they make and what, exactly, they do. This story is about intermediaries of all kinds, and I start with one of the most powerful and secretive, one that decides whether your insurance will pay for a drug you need, say, for asthma. As a family in Wisconsin can attest, this type of middleman is so powerful that it’s reasonable to say they decide whether someone lives or dies.

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**–Whitney Wimbish, staff writer**

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Illustration by Richard Borge

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Cole William Schmidtknecht was about to turn 23 last year, when he went to Walgreens on a cold January day in Appleton, Wisconsin, to pick up some medicine. He expected his Advair Diskus inhaler to cost what it always had under his prescription drug plan, between $35 and $66.86 [link removed]. But when he got to the counter that day, the pharmacist told him insurance no longer covered it and that there was no alternative. His options were to pay $539.19, a 700 percent increase, or leave. So he left.

For the next 120 hours, Cole suffered slow, constant torture. He repeatedly struggled to draw breath. He tried to use an outdated “rescue” inhaler. It didn’t work. He began to asphyxiate. By the time his roommate drove him to the emergency room, Cole was “unconscious, pulseless, and appeared blue.” Medical staff gave him two rounds of adrenaline and performed two rounds of CPR, a four-minute race against time to wake him up. They lost. Cole was pronounced dead 11 days after his trip to Walgreens. The immediate cause of death: asthma.

“Cole was forced to choose between his medication and his rent. He chose to pay his rent,” Rep. Jake Auchincloss (D-MA) told Congress almost a year later [link removed]. But who forced him? Who decided his inhaler was no longer covered? Not UnitedHealthcare, his $448 billion insurance company, nor the drug company. Cole’s grieving parents pieced it together: The decider was Optum Rx, a UnitedHealthcare subsidiary.

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