In
February,
Congress
finally
took
action
to
rein
in
PBMs
via
the
Consolidated
Appropriations
Act
of
2026.
It
included
reforms
like
the
delinking
of
PBM
compensation
from
the
price
of
a
drug
in
Medicare
Part
D
and
more
detailed
reporting
to
plan
sponsors.
But
this
is
only
the
tip
of
the
iceberg
when
it
comes
to
the
PBM
reform
that
advocates
are
calling
for.
Many
would
like
to
see
Congress
address
vertical
integration
with
insurers
and
pharmacies.
The
three
biggest
PBMs
are
owned
by
large
insurance
companies:
CVS
Health’s
Caremark,
UnitedHealth
Group’s
Optum
Rx
and
Cigna’s
Express
Scripts.
A
bill
introduced
in
February
by
Senators
Elizabeth
Warren
(D-Massachusetts)
and
Josh
Hawley
(R-Missouri)
would
take
on
this
issue.
The
Break
Up
Big
Medicine
bill
would
“prohibit
a
parent
company
from
owning
a
medical
provider
or
management
services
organization
and
a
PBM
or
an
insurer.”
It
also
takes
action
beyond
PBMs,
such
as
banning
a
parent
company
of
a
prescription
drug
or
medical
device
wholesaler
from
owning
a
medical
provider
or
management
services
organization.
However,
according
to
several
healthcare
policy
experts,
it’s
not
likely
that
this
will
pass.
“I
think
the
chances
of
it
passing
are
slim
to
none.
I
think
the
chances
of
it
getting
attention
and
actually
starting
conversations
and
possibly
additional
hearings
might
be
likely,
but
I
would
be
shocked
if
this
got
passed,”
said
Chris
Deacon,
principal
and
founder
of
VerSan
Consulting.
One
only
needs
to
look
at
how
long
it
took
for
the
first
set
of
PBM
reforms
to
pass
to
know
that
the
path
ahead
for
this
bill
is
rocky.
While
it’s
difficult
to
put
a
number
on
just
how
many
bills
have
been
introduced
or
reintroduced
that
involve
PBMs,
one
of
the
early
bills
can
be
traced
back
to
2011:
the
Pharmacy
Competition
and
Consumer
Choice
Act.
This
bill
would
have
increased
transparency
of
PBMs.
Bipartisan
congressional
efforts
to
control
PBMs
really
started
to
ramp
up
in
the
last
decade,
first
with
the
introduction
of
the
Prescription
Drug
Pricing
Reduction
Act
of
2019,
which
would
have
required
more
PBM
reporting
of
rebates
and
discounts,
according
to
Meredith
Freed,
senior
policy
manager
with
KFF’s
Program
on
Medicare
Policy.
Since
then,
numerous
other
bills
involving
PBMs
have
been
introduced
or
reintroduced,
most
not
even
making
it
past
being
referred
to
committee
(at
least
20
were
introduced
during
the
2023-2024
congressional
session).
However,
a
few
have
gotten
out
of
committee,
notably
the
Pharmacy
Benefit
Manager
Transparency
Act
of
2023
and
the
Modernizing
and
Ensuring
PBM
Accountability
Act
of
2023.
The
closest
the
U.S.
got
to
federal
PBM
reform
(prior
to
the
Consolidated
Appropriations
Act
of
2026)
was
in
December
2024
when
Congress
attempted
to
pass
a
spending
bill
that
included
changes
to
PBMs,
like
disconnecting
PBM
revenue
from
drug
prices
in
Medicare
Part
D.
But
Elon
Musk
argued
that
the
bill
included
too
much
government
waste,
and
President
Joe
Biden
later
signed
a
narrower
spending
bill
that
left
out
PBM
reform.
“There
have
been
a
fair
number
of
bipartisan
efforts
over
the
years.
…
Depending
how
you
view
it,
I
think
some
people
from
the
pharmacy
side
might
have
said
this
is
a
multi-decade
effort
to
address
PBM
reform.
But
in
Congress,
the
momentum
has
really
picked
up
in
the
last
decade,”
Freed
said.
It’s
worth
noting
that
some
states
have
enacted
PBM
reform,
most
recently
California.
Its
law
bans
spread
pricing,
the
practice
of
when
a
PBM
charges
a
health
plan
more
for
a
drug
than
it
pays
the
pharmacy
and
keeps
the
difference
as
profit.
Arkansas
also
passed
a
law
that
would
prevent
PBMs
from
owning
pharmacies,
but
a
federal
judge
blocked
it
from
being
implemented.
Arkansas
appealed
this
decision.
Could
the
Break
Up
Big
Medicine
bill
pass?
It’s
highly
unlikely
that
the
Break
Up
Big
Medicine
bill
will
pass,
particularly
after
the
Consolidated
Appropriations
Act
of
2026
passed,
according
to
Deacon
of
VerSan
Consulting.
The
Department
of
Labor
also
recently
proposed
a
rule
that
included
additional
PBM
reforms,
and
Congress
may
be
waiting
to
see
how
these
initial
reforms
pan
out.
The
bill
also
includes
broader
reforms
preventing
parent
companies
of
a
prescription
drug
or
medical
device
wholesaler
from
owning
a
medical
provider.
Deacon
noted
that
while
Warren
isn’t
wrong
when
she
says
companies
have
manipulated
the
healthcare
system
to
enrich
themselves,
this
“didn’t
happen
in
the
dark.”
It
happened
in
plain
sight
and
often
with
the
support
of
lawmakers
to
enable
better
coordination
and
more
efficiency.
And
undoing
this
will
be
extremely
difficult
and
unrealistic
in
the
near
term,
Deacon
said.
She
added
that
there
are
economic
factors
to
consider
as
well.
“The
profits
of
these
large
insurers
and
healthcare
conglomerates
don’t
just
go
to
corporate
executives
or
‘greedy
shareholders.’
They
are
deeply
embedded
in
public
pension
funds,
retirement
accounts,
and
401(k)s
held
by
millions
of
Americans.
…
So
while
the
concerns
about
consolidation
are
real,
reversing
decades
of
structural
integration
across
the
healthcare
system
is
far
more
complicated
than
simply
passing
a
bill;
simply
a
bridge
too
far
for
politicians
today,”
she
said.
On
an
episode
of
MedCity
Debunked,
Samir
Batra,
managing
partner
of
Health
Innovation
Pitch,
echoed
these
comments,
stating
that
this
bill
—
while
appealing
—
would
cause
“epic
destruction”
of
existing
industry
structures.
That’s
because
it
goes
beyond
just
aiming
to
break
up
the
legacy
PBMs
that
dominate
the
market.
It
also
seeks
to
break
up
companies
like
Cardinal
Health
and
McKesson
—
companies
that
aren’t
even
PBMs.
“Epic
destruction”
aside,
the
political
and
legal
hurdles
would
make
it
highly
unlikely
to
succeed,
especially
considering
the
lobbying
power
companies
like
UnitedHealthcare,
CVS
Health
and
Cigna
have,
he
said.
A.J.
Barbarito,
associate
attorney
at
Frier
Levitt,
agreed
that
this
bill
is
unlikely
to
pass,
especially
as
a
standalone
bill.
“Congress
is
not
famous
these
days
for
passing
many
laws,”
he
said.
“The
PBM
bill
that
did
finally
get
through
was
[part
of]
a
larger
budgeting
act.
That’s
the
kind
of
law
that
typically
gets
through
when
we’re
seeing
any
major
reform
or
any
major
law
being
passed,
it
is
with
an
appropriations
bill.
A
standalone
bill
like
this,
I
don’t
see
a
great
deal
of
potential
for
passing.”
The
fact
that
it
is
a
bipartisan
bill
sponsored
by
one
of
the
most
liberal
members
of
Congress
(Warren)
along
with
one
of
the
most
conservative
members
of
Congress
(Hawley)
may
work
in
its
favor,
Barbarito
noted.
Still,
this
bill
is
likely
too
extreme
for
most
Republicans
and
even
some
“middle-of-the-road”
Democrats,
he
said.
Meanwhile,
Patients
for
Affordable
Drugs,
an
advocacy
organization,
believes
the
bill
could
go
either
way.
Some
lawmakers
may
argue
that
they’ve
already
enacted
PBM
reform,
so
why
bother
going
even
further?
However,
Americans
want
prescription
drug
reform,
with
9
out
of
10
urging
Congress
to
do
more
to
lower
drug
prices.
“I
think
there
will
be
a
continued
appetite
to
go
after
insurance
and
vertical
integration,”
said
Merith
Basey,
CEO
of
the
organization.
Patients
for
Affordable
Drugs’
first
priority,
however,
is
patent
reform
with
pharma
companies,
she
noted.
While
most
PBM
reform
bills
have
stalled
before
gaining
meaningful
traction,
their
introduction
still
serves
an
important
purpose,
according
to
Barbarito.
“I
do
find
there
to
be
value
in
putting
forth
bills
like
this.
…
I
think
that
it
is
very
important
for
people
to
start
discussing
the
problem
of
consolidation
and
vertical
integration.
…
It
is
very
obvious
that
there
is
a
profound
conflict
of
interest
with
a
PBM
that
contracts
with
pharmacies
setting
rates
for
the
pharmacy
that
it
itself
owns,
and
setting
rates
for
its
own
competitors.
It’s
viscerally
disturbing
to
see
a
system
that
currently
permits
that,”
he
said.
“What
I
really
like
about
this
bill
is
that
it
brings
that
to
light,
and
it
opens
up
a
conversation
for
folks.”
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bong
hyunjung,
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