Republicans and Democrats Unite Against Drug Middlemen

Republicans and Democrats, deeply divided over much of American healthcare, have found a rare shared target: pharmacy benefit managers, the little-known middlemen who negotiate prescription drug prices but are increasingly accused of inflating them. In Republican-led states such as Tennessee and Arkansas, lawmakers have advanced measures that would bar a single company from simultaneously owning a PBM, a health insurer, and a retail pharmacy — a structure exemplified by CVS Health.

The push, reported by NPR in partnership with WPLN News and KFF Health News, reflects broad public frustration over rising healthcare costs that is cutting across party lines even as Washington remains gridlocked on other health issues.

What Are PBMs?

Pharmacy benefit managers were conceived as intermediaries that manage prescriptions and hold down costs. They negotiate rebates and discounts with drug manufacturers, process claims, reimburse pharmacies, structure pharmacy networks, and design the drug benefits offered by insurers and employers.

Critics argue the model has been warped by size and vertical integration. The three largest PBMs — CVS Caremark, Express Scripts, and OptumRx — dominate the market for managing U.S. prescription drug claims, and each is tied to a major insurer: OptumRx to UnitedHealth, Express Scripts to Cigna, and CVS Caremark to CVS Health, which also owns insurer Aetna and the nation’s largest retail pharmacy chain. A 2024 interim staff report from the Federal Trade Commission highlighted the significant harm to patients and independent pharmacists that it attributed to PBMs’ vertically integrated and concentrated market structure.

CVS Health, which reported about $400 billion in revenue last year, embodies the conflict that critics describe: one company that sets pharmacy reimbursement rates while also owning the pharmacies that collect them.

A Household Divided, United on This

The debate is personal in places like Elizabethton, Tennessee, where Amye and Charlie Joseph have been married 35 years. She is a Republican; he is a Democrat. Their shared frustration with the healthcare system has produced an unusual unity.

“We hate CVS. I’m going to be straight-up,” Amye Joseph said, lamenting the loss of face-to-face contact with pharmacists and prices that seem to rise without explanation. “They’re not even a middleman. They’re a money grab for CVS.”

Charlie Joseph, a retired fire captain who now works as a custodian, discovered he could save money on blood pressure medication by paying cash at a local pharmacy instead of using his CVS Caremark drug plan — buying a 90-day supply for what a 30-day supply would have cost through the plan.

“Right now, it’s more of an inconvenience than anything else as far as it goes, but there’s no consistency,” he said. “The whole healthcare thing is just frustrating, on a good day.”

Tennessee’s Bipartisan Break

In April 2026, Tennessee’s Republican-controlled legislature passed the Freedom, Access and Integrity in Registered Pharmacy (FAIR Rx) Act, which prohibits a single company from operating a health plan, a PBM, and a pharmacy at once. The Senate approved it 24-9 and the House 86-7, with Democrats joining the GOP supermajority that did not need their votes. Governor Bill Lee signed the measure into law on May 22, 2026, making Tennessee the second state, after Arkansas, to bar joint PBM-pharmacy ownership. Under the law, a company may not hold more than a 5 percent ownership interest in both a PBM and a health insurer while also operating a pharmacy in the state. The measure takes effect July 1, 2028, with PBMs and insurers given until that date to divest any pharmacy holdings.

The law’s sponsor, State Sen. Bobby Harshbarger (R), is a pharmacist — as is his mother, U.S. Rep. Diana Harshbarger (R-Tenn.), who sponsors a similar federal bill.

“If a corporation argues that its pharmacy cannot survive unless it is owned by the same entity that sets the reimbursement rate, then we’re not talking about a free market,” Harshbarger said at a February legislative hearing. “We’re talking about control.”

State Rep. Antonio Parkinson (D-Memphis) said he felt he was voting for lower drug prices and for “ma and pa” pharmacies. “If there’s a benefit to my people, I’m supporting it,” he said.

The bipartisan appeal is not accidental, argues Antonio Ciaccia, CEO of the nonprofit drug-pricing think tank 46brooklyn Research. “Republicans are looking at this issue, saying, We know what competition is supposed to do, and it isn’t happening,” he said. “This is not a free market.”

Barak Richman, a lawyer and economist at George Washington University who studies healthcare competition, noted that not every health fight breaks along partisan lines. “We have wildly passionate partisan divides on a lot of healthcare,” he said. “But there’s a lot of healthcare policy that I don’t think is obviously partisan.”

Pushback and a Legal Fight

The industry disputes the characterization. “PBMs are the only part of the prescription drug supply chain working to lower drug costs, which makes PBMs the target of powerful groups, Big Pharma and pharmacists,” said Greg Lopes, a spokesperson for the Pharmaceutical Care Management Association, the PBM trade group.

CVS spokesperson Phil Blando said single-drug prices can be misleading. “Looking at the price of a single prescription does not reflect the value of a comprehensive pharmacy benefit,” he said, adding that any reform should be judged by whether it improves access, simplifies the patient experience, and enhances affordability.

To fight the Tennessee bill, CVS launched a $7 million television campaign claiming it would have to close all 134 of its Tennessee pharmacies, and sent text messages urging customers to contact lawmakers. Tennessee Attorney General Jonathan Skrmetti warned the company to stop. Sponsors countered that CVS could instead divest either its stores or its PBM.

The law has not yet taken effect and is already tangled in court. According to an analysis by The Source on HealthCare Price and Competition at UC Law San Francisco, CVS sued the Tennessee Board of Pharmacy the same day the law was signed, arguing it violates the Dormant Commerce Clause, the Supremacy Clause, and the Takings Clause. CVS contends the law is protectionist, preempted by federal statutes such as ERISA, and forces an unconstitutional taking by requiring divestiture. Express Scripts and the PBM trade group filed separate suits. The Source notes that the three suits parallel the challenge to an earlier Arkansas law.

The legal stakes extend well beyond Tennessee. In 2025, Arkansas passed a similar ban, only to have a federal judge block it, finding it likely violated the Dormant Commerce Clause — in part because a Wal-Mart exception favored an in-state company. That ruling does not bind other courts, but it offers a roadmap for challengers.

Tennessee’s own legislative researchers have cautioned that the ownership ban could raise healthcare costs in the short term. And an industry-friendly critique warns that forcing closures could create “pharmacy deserts” in communities that lose their only drugstore.

Momentum Beyond the States

The state-level activity is part of a broader wave. Every state has imposed some restrictions on PBMs in recent years, and the National Association of Chain Drug Stores celebrated the Tennessee signing as a “landmark victory” for pharmacies and patients.

At the federal level, the bipartisan Patients Before Monopolies Act, reintroduced in May 2026, would prohibit common ownership of PBMs, insurers, and pharmacies and require divestiture within three years. Its sponsors include a striking pairing: Senator Elizabeth Warren (D-Mass.) and Senator Josh Hawley (R-Mo.). A federal law would sidestep the Dormant Commerce Clause and Supremacy Clause challenges facing state statutes, though Takings and Due Process concerns could remain. Congress also enacted narrower PBM provisions earlier in 2026, including rules to “delink” PBM compensation in Medicare Part D and require fuller rebate pass-throughs.

What to Watch

The Tennessee and Arkansas cases are testing a question that reaches far beyond the pharmacy counter: whether states can use structural remedies — forced breakups — to address vertical integration in healthcare, rather than merely regulating conduct. If the laws survive, they give other states a template for curbing consolidation. If they fall, the effort likely shifts to narrower conduct rules such as banning spread pricing or requiring full rebate pass-throughs.

For now, the unusual political alliance holds. As Tennessee Sen. Rusty Crowe (R) told colleagues before the vote, channeling his Vietnam War service: “When you start taking on flak, you know you’re over the damn target.”