In a small household in Elizabethton, Tennessee, a Republican and a Democrat have found something they can finally agree on. Amye Joseph, a Republican, and her husband, Charlie, a Democrat, have been married for 35 years. Like many American couples, they have learned to navigate their political differences. But when the conversation turns to the healthcare industry, the partisan divide disappears. Their shared frustration centers on pharmacy benefit managers, the controversial middlemen who sit between drugmakers, insurers, pharmacies, and patients.
Pharmacy benefit managers, commonly known as PBMs, were originally created to serve a practical purpose: managing prescription drug plans and negotiating lower prices on behalf of employers and insurers. In theory, their role was to use the combined purchasing power of millions of patients to extract discounts from drug manufacturers and pharmacies. Over time, however, critics argue that these companies have morphed into powerful profit centers that drive up costs rather than hold them down.
Amye Joseph's ire is directed specifically at CVS Health, a conglomerate that reported $400 billion in revenue last year. CVS Health owns a major health insurer, Aetna; one of the nation's dominant PBMs, CVS Caremark; and the largest retail pharmacy chain in the country, CVS Pharmacy. That vertical integration means the same company can decide which drugs are covered, how much patients pay, and where they must go to fill their prescriptions. "We hate CVS," Joseph said bluntly, describing a system she believes prioritizes corporate profit over patient care.
One of her chief complaints is the disappearance of face-to-face interaction with pharmacists. She also points to drug prices that seem to rise without clear explanation, and pressure from the couple's CVS Caremark plan to use CVS stores rather than their local pharmacy. In her view, PBMs are not genuine middlemen negotiating on behalf of consumers. "They're not even a middleman," she said. "They're a money grab for CVS."
That sentiment is not isolated. Across the country, patients, employers, and government officials have grown increasingly frustrated with PBMs, accusing them of absorbing profits at the expense of everyone else in the healthcare chain. The companies are now facing a rare wave of bipartisan backlash. While Democrats and Republicans in Washington remain deeply divided on most healthcare issues, taking on PBMs has become a unifying cause.
The appeal of PBM reform crosses party lines because the problem touches nearly every American who relies on prescription medication. Employers who sponsor health plans complain that they cannot see the true cost of drugs or understand how much of their spending ends up with the PBM. Independent pharmacists say they are being reimbursed below their costs while being forced into restrictive contracts. Patients, meanwhile, often discover that their copays are higher than the cash price of a drug, a phenomenon that has fueled public outrage.
State lawmakers are stepping into the void left by federal inaction. Tennessee and Arkansas are among the states now regulating PBMs, passing laws designed to curb some of the industry's most criticized practices. These state-level efforts reflect growing pressure from constituents who want action, regardless of which party controls the legislature. The measures vary, but they generally aim to increase transparency in PBM contracts, protect independent pharmacies, and ensure that patients are not overcharged at the counter.
The push for regulation comes amid broader turmoil in the pharmacy sector. Walgreens announced it would close 1,200 stores, and CVS recently laid off thousands of staff in a bid to cut costs. These developments have raised questions about the sustainability of the retail pharmacy model and the role PBMs play in squeezing margins for local drugstores. When a community loses its pharmacy, patients may have to travel farther to fill prescriptions, a particular burden for rural residents and the elderly.
Critics of PBMs argue that the industry's business model is built on opacity. The rebates and discounts that PBMs negotiate with drugmakers are often confidential, making it difficult for employers and regulators to assess whether savings are being passed along to patients. In some cases, PBMs are accused of favoring more expensive drugs because higher list prices generate larger rebates, which can benefit the PBM's bottom line even as patients pay more out of pocket.
The industry counters that PBMs are a necessary counterweight to pharmaceutical companies that set high list prices. Without PBMs, they argue, drug costs would be even higher, and employers would have no leverage in negotiations. But that defense has done little to quell the anger among consumers and policymakers who see the system as rigged in favor of large corporations.
The Josephs' story illustrates how healthcare has become a rare point of convergence in an otherwise polarized political landscape. Amye Joseph describes the current moment as an "interesting time" in her household, a wry acknowledgment of the odd bedfellows that PBM reform has created. She and her husband may disagree on candidates and policies, but they share a conviction that the current system is failing patients.
That conviction is echoing in statehouses and on Capitol Hill. Lawmakers from both parties have introduced bills to rein in PBM practices, and federal agencies have begun scrutinizing the industry more closely. The debate is no longer about whether PBMs should be regulated, but about how far the regulation should go and who should enforce it.
For patients like the Josephs, the stakes are personal. Every trip to the pharmacy is a reminder that the system they depend on often feels stacked against them. Their frustration is not abstract ideology but lived experience, and it is shared by millions of Americans who find themselves paying more for care while feeling less in control.
As the 2026 midterm elections approach, PBM reform could become a rare issue that candidates from both parties champion. Whether that translates into meaningful change remains uncertain, but the bipartisan anger is real. In a country where Republicans and Democrats seem to agree on almost nothing, pharmacy benefit managers have managed to unite them in disdain.
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