In February, Congress finally took action to curb PBMs through the Consolidated Appropriations Act of 2026. It included reforms such as decoupling PBM compensation from the price of a drug in Medicare Part D and more detailed reporting to plan sponsors.
But this is just the tip of the iceberg when it comes to the PBM reform called for by its supporters. Many would like Congress to address vertical integration with insurers and pharmacies. The three largest PBMs are owned by large insurance companies: CVS Health’s Caremark, UnitedHealth Group’s Optum Rx and Cigna’s Express Scripts.
An invoice introduced in February, Senators Elizabeth Warren (D-Massachusetts) and Josh Hawley (Republican-Missouri) would tackle 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 insurer.” It also takes steps beyond PBMs, such as prohibiting the parent company of a prescription drug or medical device wholesaler from owning a medical provider or management services organization.
However, according to several health policy experts, this is unlikely to be adopted.
“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 audiences might be likely, but I would be shocked if it passed,” said Chris Deacon, principal and founder of VerSan Consulting.
You only have to look at how long it took for the first round of PBM reforms to pass to know that the road ahead for this bill is fraught with challenges.
Although it is difficult to quantify the number of bills introduced or reintroduced involving PBMs, one of the first bills dates back to 2011: the Pharmacy Competition and Consumer Choice Act. This bill would have increased transparency for PBMs.
Bipartisan efforts in Congress to control PBMs really began to ramp up over the past decade, first with the introduction of the Prescription Drug Price Reduction Act of 2019, which would have required more PBM reporting on rebates and rebates, according to Meredith Freed, senior policy manager for KFF’s Medicare Policy Program.
Since then, numerous other bills involving PBMs have been introduced or reintroduced, with most failing to even make it out of committee (at least 20 were introduced during the 2023-2024 Congressional session). However, a few made it out of committee, including the Pharmacy Benefit Manager Transparency Act of 2023 and the PBM Modernization and Accountability Ensuring Act of 2023.
The closest the United States came 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, such as 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 who left aside the reform of the PBM.
“There have been quite a few bipartisan efforts over the years. … Depending on how you look at it, I think some people in the pharmaceutical industry might have said this is a decades-long effort to address PBM reform. But in Congress, the momentum has really picked up over the last decade,” Freed said.
It should be noted that some states have adopted PBM reform more recently. California. Its law prohibits spread pricing, the practice in which 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 the federal judge blocked it to be implemented. Arkansas appealed this decision.
Could the Break Up Big Medicine bill pass?
The Break Up Big Medicine bill is highly unlikely to pass, especially after passage of the Consolidated Appropriations Act of 2026, according to Deacon of VerSan Consulting. The Department of Labor also recently proposed a rule providing for additional PBM reforms, and Congress may be waiting to see how these initial reforms play 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 is not wrong when she says corporations manipulated the health care system to enrich themselves, it “didn’t happen in the dark.” This happened in plain sight and often with the support of legislators to allow for better coordination and efficiency. And undoing that will be extremely difficult and unrealistic in the short term, Deacon said.
She added that there are also economic factors to consider.
“The profits of these large insurers and health care conglomerates do not go only 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 concerns about consolidation are real, reversing decades of structural integration across the health care system is far more complicated than simply passing a bill; simply a bridge too far for today’s politicians,” she said.
In an episode of MedCity demystifiedSamir Batra, managing partner of Health Innovation Pitch, echoed these comments, stating that this bill – while attractive – would cause “epic destruction” of existing industrial structures. Indeed, this goes beyond simply breaking up the legacy PBMs that dominate the market. He also seeks to break up companies like Cardinal Health and McKesson – companies that aren’t even PBMs.
“Epic destruction” aside, political and legal hurdles would make the project very unlikely to succeed, especially given the lobbying power that companies like UnitedHealthcare, CVS Health and Cigna have, he said.
AJ Barbarito, associate attorney at Frier Levitt, agreed that this bill is unlikely to pass, especially as a standalone bill.
“Congress is not known these days for passing a lot of legislation,” he said. “The PBM bill that ultimately passed was [part of] a broader budget law. This is the kind of legislation that typically gets passed when we see a major reform or a major piece of legislation passed, it’s with an appropriations bill. I don’t see much potential for a standalone bill like this to pass.”
The fact that this is a bipartisan bill sponsored by one of the most liberal members of Congress (Warren) and one of the most conservative members of Congress (Hawley) could work in its favor, Barbarito noted. Still, this bill is probably 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 might argue that they have already passed PBM reform, so why go even further? However, Americans want prescription drug reform, with 9 in 10 urging Congress to do more to lower drug prices.
“I think there will be a continued appetite for insurance and vertical integration,” said Merith Basey, the organization’s CEO. However, Patients for Affordable Drugs’ first priority is patent reform with pharmaceutical companies, she stressed.
Although most PBM reform projects have stalled before gaining traction, their introduction continues to serve an important purpose, according to Barbarito.
“I think it’s helpful to introduce bills like this. … I think it’s very important that people start talking about the problem of consolidation and vertical integration. … It’s very obvious that there is a deep conflict of interest with a PBM that contracts with pharmacies by setting the prices of the pharmacy it owns and setting the prices of its own competitors. It’s viscerally troubling to see a system that currently allows this,” he said. “What I really like about this bill is that it brings this to light and it opens up a conversation for people. »
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