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Column: Pharmacy middlemen claim to keep prescription prices low. In fact, they've cost consumers billions

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Column: Pharmacy middlemen claim to keep prescription prices low. In fact, they've cost consumers billions

In 2022, an executive of a big pharmacy middleman firm acknowledged the noxious reality of its business model:

It was designed to massively overcharge customers by steering them to its affiliated or “preferred” pharmacies or its home delivery subsidiary.

Referring to a generic version of Gleevec, a leukemia drug taken by nearly 200,000 patients, the executive noted in an internal memo that “you can get the drug at a non-preferred pharmacy (Costco) for $97, at Walgreens (preferred) for $9000, and at preferred home delivery for $19,200…. We’ve created plan designs to aggressively steer customers to home delivery where the drug cost is ~200 times higher.”

PBMs are not lowering prices for drugs used by patients to treat severe diseases like prostate cancer and leukemia.

— Federal Trade Commission

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The executive concluded, “The optics are not good and must be addressed.”

What that memo described, according to a new report from the Federal Trade Commission, is standard operating procedure among the nation’s largest pharmacy benefit managers, or PBMs.

Originally devised in the 1960s as intermediaries helping health insurers process claims, steering doctors and hospitals to the cheapest drug alternatives and giving insurers greater leverage in negotiations with drug manufacturers, they soon became just another special interest in America’s fragmented healthcare system.

Thanks to a wave of consolidation and growth of healthcare conglomerates, the FTC says, the three largest PBMs manage nearly 80% of all prescriptions filled in the U.S. They have accumulated enough power to profit “by inflating drug costs and squeezing Main Street pharmacies,” driving the independents out of business.

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Once posed as an answer to high drug costs, they’re today at the hub of a system that drives up drug prices for consumers.

Starting in the 1990s, some of the biggest PBMs were acquired by drug companies, creating conflicts of interest that led to federal orders for divestment.

Then came a wave of mergers and acquisitions within the PBM universe, followed by acquisitions by insurers and pharmacy companies — CVS acquired Caremark, then the biggest PBM, in 2007 and UnitedHealth merged CatamaranRx, then the fourth-largest PBM, into OptumRx in 2015.

Between 2000 and 2021, 39 individual healthcare companies — drugstore chains, health insurers, managed care firms and PBMs — all coalesced into three healthcare behemoths, Cigna, CVS and UnitedHealth.

CVS Health Corp. owns not only the Caremark PBM, which controls 34% of the prescription market, but the insurance company Aetna and about 9,000 retail drugstores.

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Cigna Group, which has a prescription market share of 23%, owns the mail-order PBM Express Scripts and the Cigna insurance company. UnitedHealth Group is the largest U.S. health insurer and owns 1,000 walk-in health clinics as well as physician groups; through its OptumRx PBM, its prescription market share is 22%.

Between 2000 and 2021, mergers and acquisitions combined these 39 independent healthcare companies into three huge conglomerates.

(Federal Trade Commission)

Along with Humana, the fourth-ranked PBM with a market share of 7%, those conglomerates produced combined revenue of $456 billion in 2016, 14% of national health spending. Today, they collect more than $1 trillion in revenue, or 22% of U.S. healthcare spending.

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Despite the predictably anticompetitive effects of these mergers and acquisitions, not a single one was challenged by antitrust enforcement agencies, says the FTC — one of the antitrust regulators asleep at the switch.

Among the stratagems employed by PBMs to boost profits, the FTC says, is steering health plans and patients to their own affiliated pharmacy chains.

Some patients have discovered that their drugs won’t be covered by their insurers unless they buy them at specified pharmacies, the result of deals the PBMs have made with insurers, including those with which they share a parent. But the customers may have to pay more out of pocket at the affiliated pharmacies than they would at an independent.

The FTC staff found that for “specialty prescriptions” — a designation the PBMs place on certain drugs, often without explanation — 55% were filled at affiliated pharmacies. The same ratio didn’t occur with prescriptions under Medicare’s Part D prescription coverage, because federal law requires that those prescriptions can be filled at almost any licensed pharmacy. Only 22% of Part D prescriptions were filled at PBM-affiliated pharmacies. That suggests that PBMs may be steering patients to their pharmacies where that’s not forbidden by law.

The statistics were drawn from submissions by two of the three top PBMs, which are unidentified. The third didn’t submit the necessary data.

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The FTC also touches on a relatively new wrinkle in drug pricing — rebates by drugmakers to PBMs in order to gain preferential positions in drug formularies.

The agency says its review of contracts between manufacturers and PBMs shows that some drug companies promise PBMs higher rebates if the latter exclude competing drugs from their formularies — including generic versions that are chemically identical to the brand-name products — or require prior authorization before covering the rival drugs.

Predictably, the big PBMs and their lobbyists find much to dislike in the FTC report, which the agency describes as an interim staff report, part of an investigation launched in 2022.

A spokesperson for Cigna’s Express Scripts criticized the report for “blatant inaccuracies” (but didn’t offer specifics in an email to me). A spokesman for CVS blamed drugmakers for high prescription prices, stating that an FTC effort to “limit the use of PBM negotiating tools would instead reward the pharmaceutical industry.” Optum didn’t reply to my request for comment.

J.C. Scott, president of the Pharmaceutical Care Management Assn., the PBM lobbying arm, accused the FTC of advancing “pre-determined conclusions … irrespective of the facts or the data.”

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Drawing from more than 1,200 comments submitted by stakeholders in healthcare and by other members of the public, the agency outlined a host of methods PBMs are accused of using to benefit their affiliated services, block patient access to inexpensive generics and pocket discounts that should properly go to customers.

The FTC also mined lawsuits, including a 2023 case the state of Ohio filed against Express Scripts, charging that the PBM exploits its knowledge that “Ohioans in need of medication, particularly life-saving medication, will pay the asking price. The choice is binary — pay or suffer.”

Drug manufacturers capitulate to the PBMs’ rebate demands, the lawsuit says, to avoid being dropped from the PBMs’ formularies, the rosters of drugs that they’ll cover. “Patients pay more, manufacturers get less, and the PBMs profit. Handsomely.”

PBMs have been the targets of drug industry participants for years — sometimes fingered by drugmakers or insurers to deflect accusations that they’re responsible for prescription drug inflation.

It may be true that all those entities share the blame for high prices. Over the last couple of decades, however, all have become tentacles of the same octopus. The consolidation of drug chains, physician groups, insurers and PBMs into conglomerates has made it much harder to identify responsibility for drug inflation.

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Contracts between PBMs and unaffiliated pharmacies, the FTC says, are “opaque, complex, and conditional, making it challenging to understand what pharmacies will ultimately be paid for any given drug.” The result is that smaller, nonchain pharmacies may get pushed out of the market, “leading to higher costs and lower quality services for people around the country.”

The FTC report offers two case studies involving generic cancer drugs in which the agency says PBMs reimbursed their affiliated pharmacies more for prescriptions than unaffiliated pharmacies, yielding nearly $1.6 billion in gross profits from 2020 through mid-2022 for those affiliated pharmacies over the national average of those drug costs.

The drugs are a generic version of Zytiga, a treatment for prostate cancer, and a generic for Gleevec, a drug for leukemia. The high reimbursement rates for druggists dispensing those drugs may “translate into high out-of-pocket costs for patients,” the FTC says. In other words, “PBMs are not lowering prices for drugs used by patients to treat severe diseases like prostate cancer and leukemia.”

Magnify the gains on those two drugs by the potential profits the PBMs may be extracting from the entire spectrum of prescription pharmaceuticals, and the toll becomes breathtaking.

reimbursement rates

Prices that PBMs paid affiliated pharmacies for the generic version of prostate cancer drug Zytiga were much higher than they paid independent pharmacies, and much higher than the national average cost. As a result, patients may have been charged much higher co-pays at the affiliates — but may not have had any other option.

(FTC)

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“It appears that PBMs are having the commercial health plans and Medicare Part D prescription drug plans they manage pay their affiliated pharmacies rates that are grossly in excess” of national average prices or prices paid to unaffiliated pharmacies.

No one escapes the consequences of this sort of market manipulation. The internal transactions, largely hidden from the public and regulators, may distort the statistics that health plans submit to the government to show they meet the coverage standards required by the Affordable Care Act, allowing the conglomerates to “game” the rules, the FTC says.

They may drive up healthcare costs for self-insured clients such as large companies, which may pare back health coverage for their employees as a result.

They can raise co-pays for patients, lead to cutbacks in the availability of coverage for some drugs, or prompt patients to ration their prescriptions, risking their health to save money. To the extent they affect Part D, they may drive up government spending.

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To quote the Ohio lawsuit, PBMs were created as a counterweight to perceived profiteering by Big Pharma. But once they “grew powerful enough to themselves extract exorbitant fees … the solution became the problem.”

The FTC says it issued its interim report because several PBMs haven’t provided the agency with the information they’re required to submit, hindering its ability to complete its investigation.

At the very top of the report, the FTC warns that the firms better come across “promptly,” or they’ll be taken to court. The FTC should start suing now, because the PBMs’ apparent code of silence raises a familiar question: What must they be hiding?

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Commentary: Trump Media’s financial report revives doubts for investors

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Commentary: Trump Media’s financial report revives doubts for investors

So much Trump-related news has appeared lately on the airwaves and in web pixels — what with Iran and Epstein and Minnesota and so on — that inevitably a nugget will fall between the cracks.

That seems to have been the fate of the most recent annual financial report of Trump Media and Technology Group, which covered calendar year 2025 and was issued Friday.

Trump Media, which is 52% owned by Donald Trump and trades on Nasdaq with a ticker symbol based on his initials (DJT), is the holding company for Trump’s social media platform, Truth Social.

The value of TMTG’s brand may diminish if the popularity of President Donald J. Trump were to suffer.

— A risk factor disclosed by Trump Media

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The annual financial disclosure has garnered minimal press coverage. That’s a pity, because it makes fascinating reading, though not in a good way.

Here are the top and bottom lines from the 10-k annual report: Trump Media lost $712.1 million last year on revenue of about $3.7 million. That’s quite a bit worse than its performance in 2024, when it lost $409 million on revenue of about $3.6 million. The company attributed most of the flood of red ink to “loss from investments,” of which more in a moment.

Truth Social isn’t an especially strong keystone of this operation. The platform is chiefly an outlet for Trump’s social media ramblings and the occasional official White House statements. But no one has to sign in to Truth Social to see them — they’re almost invariably picked up by the news media or reposted by users on other platforms such as X.

That might explain Truth Social’s relatively scrawny user base. The platform is estimated to have about 2 million active users, according to the analytical firm Search Logistics. By comparison, X has about 450 million monthly active users and Facebook has more than 2.9 billion.

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It’s no mystery, then, why TMTG disdains “traditional performance metrics like average revenue per user, ad impressions and pricing, or active user accounts, including monthly and daily active users,” according to its annual report.

Relying on those metrics, which are used to judge TMTG’s social media rivals, “might not align with the best interests of TMTG or its stockholders, as it could lead to short-term decision-making at the expense of long-term innovation and value creation.”

Instead, the company says it should be evaluated based on “its commitment to a robust business plan that includes introducing innovative features, new products, new technologies.” But it also acknowledges that, at its heart, TMTG is a proxy for “the reputation and popularity of President Donald J. Trump.” The company warns that “the value of TMTG’s brand may diminish if the popularity of President Donald J. Trump were to suffer.”

How has that played out in real time? Trump Media notched its highest closing price as a public company, $66.22, on March 27, 2024, the day after its initial public offering. In midday trading Monday, the shares were quoted at $11.08, for a loss of 83% since the IPO.

One can’t quibble with stock market price quotes; nor can one finagle annual profit and loss statements, at least not without receiving questions, and perhaps lawsuit complaints, from attentive investors and the Securities and Exchange Commission.

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In recent months, TMTG has engaged in a number of baroque financial transactions.

In May, the company announced that it was planning to raise $3.5 billion from institutions to invest in bitcoin, with the money to come from issues of common and preferred shares. The goal was to climb onto the cryptocurrency train, which Trump himself was fueling by, among other things, issuing an executive order promoting the expansion of crypto in the U.S. and denigrating enforcement efforts by the Biden administration as reflecting a “war on cryptocurrency.”

Under Trump, federal regulators have dropped numerous investigations related to cryptocurrencies. Trump has also talked about creating a government crypto strategic reserve, which would entail large government purchases of bitcoin and other cryptocurrencies; a March 3 announcement on that subject briefly sent bitcoin prices soaring by nearly 20%, though they promptly fell back.

Then there’s TMTG’s relationship with Crypto.com, a Singapore-based crypto “service provider” best known to Angelenos unfamiliar with the crypto world as the firm with naming rights to the Los Angeles arena that hosts the NBA Lakers and Clippers, WNBA Sparks and NHL Kings.

In August, Crypto.com and TMTG announced a deal in which TMTG would pursue a crypto treasury strategy consisting mostly of Cronos tokens, a cryptocurrency sponsored by Crypto.com. The initial infusion would consist of 6.4 billion Cronos valued at $1 billion, or about 15.8 cents per Cronos.

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As of Dec. 31, TMTG said in its 10-K, it owned 756.1 million Cronos, acquired at a cost of about $114 million, or 15 cents each. By year’s end, they were worth only about nine cents each, for a paper loss of about $46 million. In trading this week, Cronos was quoted at about 7.6 cents, producing a paper loss for TMTG of about $56.5 million, or roughly half the investment.

The financial maneuvering involved in this trade is a little dizzying. The initial transaction was a 50% stock, 50% cash trade in which Crypto.com bought $50 million in TMTG stock and TMTG bought $105 million in Cronos. Who gained in this deal? It’s almost impossible to say.

Crypto.com did gain, if not purely in cash, then arguably through the Trump administration’s good graces.

On March 27, the SEC formally closed an investigation of the company that it had launched during the Biden administration, when the agency was headed by a known crypto skeptic, Gary Gensler. Trump appointed a crypto-friendly regulator, Paul Atkins, as Gensler’s successor.

It’s reasonable to note that as a business model, crypto treasuries have been in vogue over the last year or so, allowing investors to play the crypto market without all the complexities of actually buying and holding the digital assets by buying shares in treasury companies.

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I asked Crypto.com whether the steady decline in Cronos’ price suggested that the hookup with TMTG wasn’t bearing fruit. “The fluctuation in value during this time period is consistent with the entire crypto market, which is typical in a bear market,” company spokeswoman Victoria Davis told me by email.

Davis also asserted that the SEC’s investigation of the company had been closed by Gensler, “not the current administration” (i.e., Trump). That’s misleading, at best. Gensler put the investigation on hold after the 2024 election, when it became clear that Trump was going to be in charge.

Crypto.com’s March 27 announcement of the formal end of the case attributed the action to “the current SEC leadership” and blamed the case on “the previous administration.” I asked Davis to explain the discrepancy but got no reply.

TMTG, like Crypto.com, attributed the decline in Cronos’ value to the secular bear market raging in the entire cryptocurrency space, a reflection of “temporary price swings across the crypto market,” said TMTG spokeswoman Shannon Devine. She said the price decline “will not diminish our enthusiasm for the enormous potential of the [CRONOS] ecosystem.”

Trump’s coziness with crypto companies hasn’t gone unnoticed by Democrats on the House Judiciary Committee, who issued a scathing report on the topic in November. (The White House scoffed at the report, saying in response to the report that Trump “only acts in the best interests of the American public.”)

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In mid-December, TMTG launched yet another remaking — this time, plunging into the business of fusion power. The instrument is TAE Technologies, a Foothill Ranch-based company working to develop the technology of nuclear fusion as a clean energy source. According to a Dec. 18 announcement, TMTG and TAE will merge, creating what they say is a $6-billion company.

According to the announcement, TMTG will contribute $200 million to the merged company when the deal closes in mid-2026, and an additional $100 million subsequently. Following the merger, TMTG said last month, it will consider spinning off Truth Social into a new publicly traded company.

These arrangements are murky. TAE is privately held and the value of Truth Social is conjectural at best, so TMTG shareholders could be hard-pressed to assess their gains or losses from the merger and spin-off.

What makes them even murkier is the speculative nature of fusion as an electrical power source. Although numerous companies have leaped into the field — and TAE, which has been backed by Alphabet, the parent of Google, is among the oldest — none has shown the capability of generating electrical power at commercial scale with the elusive technology.

Although some researchers say that fusion could become a technically and economically feasible power source within 10 years, only in 2022 did fusion researchers (at Lawrence Livermore National Laboratory) achieve the goal of using fusion to produce more energy than is required to sustain a reaction. They were able to do so only for less than a billionth of a second.

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Others working on the technology have expressed doubts that fusion could become a viable power source before the 2040s. The technical challenges, including how to convert the energy produced by a fusion reactor into electricity, remain daunting.

All this points to the fundamental question of what TMTG is supposed to be. TMTG’s original mission, according to its own publicity statements, was to build Truth Social into an alternative social media platform “to end Big Tech’s assault on free speech by opening up the Internet.”

Spinning off Truth Social would place that goal on the side. TMTG is on its way too becoming a hodgepodge of crypto, fusion and other investments selected without regard to whether they fit together or are even achievable. The only constant is Trump himself.

If you want to invest in him, TMTG may be the best way to do it. But judging from its latest financial disclosure, that’s not the same as being a good way to do it.

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California gas is pricey already. The Iran war could cost you even more

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California gas is pricey already. The Iran war could cost you even more

The U.S. attack on Iran is expected to have an unwelcome impact on California drivers — a jump in gas prices that could be felt at the pump in a week or two.

The outbreak of war in the Middle East, which virtually closed a key Persian Gulf shipping lane, spiked the price of a barrel of Brent crude oil by as much as $10, with prices rising as high as $82.37 on Monday before settling down.

The price of the international standard dictates what motorists pay for gas globally, including in California, with every dollar increase translating to 2.5 cents at the pump, said Severin Borenstein, faculty director of the Energy Institute at UC Berkeley’s Haas School of Business.

That would mean drivers could pay at least 20 cents more per gallon, though how much damage the conflict will do to wallets remains to be seen.

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“The real issue though is the oil markets are just guessing right now at what is going to happen. It’s a time of extreme volatility,” Borenstein said. “We don’t know whether the war will widen or end quickly, and all of those things will drive the price of crude.”

President Trump has lauded the reduction of nationwide gas prices as a validation of his economic agenda despite worries about a weak job market and concerns of persistent inflation.

The upheaval in the Middle East could be more acutely felt in the state.

Californians already pay far more for gas than the rest of the country, with the average cost of a gallon of regular at $4.66, up 3 cents from a week ago and 30 cents from a month ago, according to AAA. The current nationwide average is about $3 per gallon.

The disruption in international crude markets also comes as refiners are switching to producing California’s summer-blend gas, which is less volatile during the state’s hot summers. The switch can drive up the price of a gallon of gas at least 15 cents.

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The prices in California are largely driven by higher taxes and a cleaner, less polluting blend required year-round by regulators to combat pollution — and it’s long been a hot-button issue.

The politics were only exacerbated by recent refinery closures, including the Phillips 66 refinery in Wilmington in October and the idling and planned closure of the Valero refinery in Benicia, Calif., which reduced refining capacity in the state by about 18%.

California also has seen a steady reduction in its crude oil production, making it more reliant on international imports of oil and gasoline.

In 2024, only 23.3% of the crude oil refined in the state was pumped in California, with 13% from Alaska and 63% from elsewhere in the world, including about 30% from the Middle East, said Jim Stanley, a spokesperson for the Western States Petroleum Assn.

“We could see a supply crunch and real price volatility” if the Middle East supply is interrupted, he said.

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The Strait of Hormuz in the Persian Gulf, through which about 20% of the world’s oil passes, was virtually closed Monday, according to reports. Though it produces only about 3% of global oil, Iran has considerable sway over energy markets because it controls the strait.

Also, in response to the U.S. attack, Iran has fired a barrage of missiles at neighboring Persian Gulf states. Saudi Arabia said it intercepted Iranian drones targeting one of its refinery complexes.

California Republicans and the California Fuels & Convenience Alliance, a trade group representing fuel marketers, gas station owners and others, have blamed Gov. Gavin Newsom’s policies for driving up the price of gas.

A landmark climate change law calls for California to become carbon neutral by 2045, and Newsom told regulators in 2021 to stop issuing fracking permits and to phase out oil extraction by 2045. He also signed a bill allowing local governments to block construction of oil and gas wells.

However, last year Newsom changed his stance and signed a bill that will allow up to 2,000 new oil wells per year through 2036 in Kern County despite legal challenges by environmental groups. The county produces about three-fourths of the state’s crude oil.

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Borenstein said he didn’t expect that the new state oil production would do much to lower gas prices because it is only marginally cheaper than oil imported by ocean tankers.

Stanley said the aim of the law was to support the Kern County oil industry, which was facing pipeline closures without additional supplies to ship to state refineries.

Statewide, the industry supports more than 535,000 jobs, $166 billion in economic activity and $48 billion in local and state taxes, according to a report last year by the Los Angeles County Economic Development Corp.

Bloomberg News and the Associated Press contributed to this report.

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Block to cut more than 4,000 jobs amid AI disruption of the workplace

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Block to cut more than 4,000 jobs amid AI disruption of the workplace

Fintech company Block said Thursday that it’s cutting more than 4,000 workers or nearly half of its workforce as artificial intelligence disrupts the way people work.

The Oakland parent company of payment services Square and Cash App saw its stock surge by more than 23% in after-hours trading after making the layoff announcement.

Jack Dorsey, the co-founder and head of Block, said in a post on social media site X that the company didn’t make the decision because the company is in financial trouble.

“We’re already seeing that the intelligence tools we’re creating and using, paired with smaller and flatter teams, are enabling a new way of working which fundamentally changes what it means to build and run a company,” he said.

Block is the latest tech company to announce massive cuts as employers push workers to use more AI tools to do more with fewer people. Amazon in January said it was laying off 16,000 people as part of effort to remove layers within the company.

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Block has laid off workers in previous years. In 2025, Block said it planned to slash 931 jobs, or 8% of its workforce, citing performance and strategic issues but Dorsey said at the time that the company wasn’t trying to replace workers with AI.

As tech companies embrace AI tools that can code, generate text and do other tasks, worker anxiety about whether their jobs will be automated have heightened.

In his note to employees Dorsey said that he was weighing whether to make cuts gradually throughout months or years but chose to act immediately.

“Repeated rounds of cuts are destructive to morale, to focus, and to the trust that customers and shareholders place in our ability to lead,” he told workers. “I’d rather take a hard, clear action now and build from a position we believe in than manage a slow reduction of people toward the same outcome.”

Dorsey is also the co-founder of Twitter, which was later renamed to X after billionaire Elon Musk purchased the company in 2022.

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As of December, Block had 10,205 full-time employees globally, according to the company’s annual report. The company said it plans to reduce its workforce by the end of the second quarter of fiscal year 2026.

The company’s gross profit in 2025 reached more than $10 billion, up 17% compared to the previous year.

Dorsey said he plans to address employees in a live video session and noted that their emails and Slack will remain open until Thursday evening so they can say goodbye to colleagues.

“I know doing it this way might feel awkward,” he said. “I’d rather it feel awkward and human than efficient and cold.”

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