With 66 percent of U.S. adults, some 131 million people, now taking prescription drugs, and with Medicare drug spending running into the hundreds of billions, it is worth asking how the pharmaceutical industry came to occupy so central a place in American health care. Several recent developments show how the relationship works.

The FDA announced this month that it is hiring more than 2,000 employees, rebuilding after reductions earlier in the year. That hiring is possible in part because industry itself funds a large share of the agency’s drug review work. Under the Prescription Drug User Fee Act (PDUFA), the FDA collected nearly $1.5 billion in prescription drug user fees in fiscal year 2025. The agency that reviews these products is substantially financed by the companies whose products it reviews.

Also this month, Insight Health Systems took over management of Chicago’s shuttered Weiss Memorial Hospital and Oak Park’s West Suburban Medical Center. Insight’s business includes a pharmacy operation oriented toward oncology, rare disease, and other high-cost drug treatments, which is a reminder that hospital ownership and drug revenue are not separate questions.

In Illinois, the governor signed a law requiring public schools to offer annual mental health screenings for students in grades 3 through 12 beginning in 2027, the first state to do so. Universal screening has supporters and critics. Supporters point to unmet need. Critics note that an earlier national school screening program was discontinued years ago amid disputes over its funding and its effect on diagnosis rates, and they ask who benefits when screening expands faster than the treatment capacity behind it.

The rise of pediatric psychopharmacology

Children have been central to the prescription drug market since the field of pediatric psychopharmacology emerged. Conditions now routinely treated with medication in children, including conduct disorder, depression, bipolar disorder, oppositional defiant disorder, mood disorders, obsessive-compulsive disorder, social phobia, anxiety, and autism spectrum conditions, were diagnosed far less often and medicated far less often before that field took shape. Many of these diagnoses rest on clinical judgment rather than a definitive test, which makes the boundaries of each one consequential.

Pediatric psychopharmacology became one of the industry’s largest growth areas before GLP-1 agonists arrived. Whether that growth reflects better recognition of real illness, overdiagnosis, or both remains genuinely contested.

One case that shaped the field

Much of that expansion is associated with the late Harvard child psychiatrist Joseph Biederman, whose work is credited with a roughly 40-fold rise in outpatient visits for pediatric bipolar disorder.

In 2008, Biederman, who published several hundred scientific articles and dozens of book chapters, was investigated by Congress over industry payments he had not disclosed, and he agreed to suspend his industry-related activities. After a three-year review, Harvard required him and two colleagues to refrain from paid industry-sponsored outside activities for one year and to comply with a two-year monitoring period, during which they needed approval from the medical school and Massachusetts General Hospital before taking on paid work.

Arrangements between industry and academic medicine are not new. The 1980 Bayh-Dole Act allowed universities to patent and license federally funded research, which gave institutions a direct financial stake in commercializing it. What is less widely appreciated is how much public money moves through the same institutions. Federal research grants administered by Massachusetts General Hospital totaled $287 million in 2005, the same period in which its researchers were also receiving industry support.

This is worth understanding because of how conflict-of-interest disclosure works in practice. A researcher can accurately report no personal industry conflict while the institution that employs them receives industry funding directly. The disclosure is truthful and the relationship is still there.

The physical geography reflects it too. The Novartis Institutes for BioMedical Research sit near Harvard Medical School and Massachusetts General Hospital, and Pfizer’s research operations sit near MIT and Harvard. Proximity is not proof of anything, but it is not accidental either.

Why children and older adults

The pharmaceutical industry has been called a fourth branch of government, and the comparison is about influence rather than conspiracy. Children and older adults matter disproportionately to it because neither group generally makes its own prescribing decisions, including the decision to stop a medication. That is an argument for more careful prescribing at both ends of life, not for withholding treatment from people who need it.

None of this means the drugs do not work or that the people prescribing them are acting in bad faith. It means the incentives deserve to be visible, and right now much of the structure that shapes American prescribing sits outside public view.

Martha Rosenberg is an investigative reporter whose work has appeared in the British Medical Journal (BMJ), Consumer Reports, Public Citizen, the Center for Health Journalism at USC Annenberg, the Nieman Foundation for Journalism at Harvard University, and other outlets. She studied at Rush Medical School and writes on health care, food, medicine, and public policy.

Rosenberg’s reporting has been cited by Memorial Sloan Kettering Cancer Center, Mayo Clinic Proceedings, Public Library of Science Biology, ScienceDirect, the Journal of Pain & Palliative Care Pharmacotherapy, the Journal of Trauma & Dissociation, Britannica, National Geographic, Hastings Law Journal, and Wikipedia. She is the author of several books, including Multidisciplinary Management of Chronic Pain: A Practical Guide for Clinicians, Born With a Junk Food Deficiency, Big Food, Big Pharma, Big Lies, and Food, Clothes, Men, Gas and Other Problems. She publishes on Substack, OpEdNews, and her Amazon author page.