In a Tennessee household where political divisions run deep, Amye and Charlie Joseph have found something they can agree on. Married for 35 years, Amye identifies as a Republican while Charlie is a Democrat, and the couple describes the current era of American political polarization as an "interesting time" to be living through. Yet their shared frustration with a profit-driven healthcare system has given them a common enemy: pharmacy benefit managers, the little-understood companies known as PBMs.
The Josephs' dissatisfaction centers on CVS Health, a conglomerate that reported $400 billion in revenue last year and operates on several levels of the healthcare industry at once. The company owns Aetna, a major health insurer; CVS Caremark, one of the nation's dominant PBMs; and CVS Pharmacy, the largest retail pharmacy chain in the United States. That combination of businesses across insurance, drug plan management, and retail sales has made the company a lightning rod for patients who feel squeezed at every stage of the prescription process.
Amye Joseph does not mince words about her feelings. She says she and her husband hate CVS, and she points to what she sees as a lack of meaningful face-to-face interaction with pharmacists, drug prices that climb without clear explanation, and pressure from the couple's CVS Caremark drug plan to fill prescriptions at CVS stores rather than at their local pharmacy. In her view, PBMs are not simply intermediaries in the drug supply chain. She describes them instead as a mechanism for extracting money, arguing that the arrangement ultimately benefits CVS itself.
The concept behind PBMs was originally practical. They were created to administer prescription drug benefits and to negotiate lower prices on behalf of employers, insurers, and government programs. By pooling purchasing power, the thinking went, these middlemen could restrain the growth of drug spending. In practice, however, PBMs have become bipartisan punching bags, accused of absorbing profits at the expense of the employers, governments, and patients they are meant to serve. The gap between their stated purpose and their perceived performance is precisely what has turned them into such a potent political target.
What makes the backlash notable is its breadth. Healthcare debates in Washington, D.C., continue to divide Democrats and Republicans on many fronts, but taking on PBMs has emerged as a unifying cause at a moment of widespread public anxiety over rising medical costs. Patients and politicians from both parties, across both chambers of Congress and in statehouses around the country, have voiced similar complaints. The issue appears to cut through ideological lines in a way few healthcare topics now do.
Tennessee and Arkansas have moved ahead with regulating these companies, part of a broader push by states to act where federal legislation has stalled or moved slowly. The source article notes that this wave of state-level activity is unfolding as part of health reporting collaborations between national outlets, KFF Health News, and local member stations, reflecting how closely state policy decisions are being watched nationally. For advocates of stricter oversight, the states serve as laboratories for rules that could eventually inform federal action.
The political dynamics are unusual in several respects. Republicans who typically favor lighter regulation of private industry have joined Democrats who favor stronger consumer protections, both responding to constituents who feel they are paying more for prescriptions while intermediaries profit. The result is a rare coalition that spans party affiliation, geography, and even individual households like the Josephs', where a Republican wife and a Democratic husband reach the same conclusion about who is to blame.
CVS Health's scale illustrates why the company draws so much attention. Reporting $400 billion in revenue in a single year, it operates simultaneously as the entity that decides which drugs are covered, the entity that sells those drugs at retail, and, through its insurance arm, the entity that pays for care. Critics argue that this vertical integration creates conflicts of interest, because the same corporation can influence what patients pay while also capturing revenue at multiple points along the chain. The Josephs' complaint that their drug plan steers them toward CVS stores rather than independent pharmacies is a direct example of that concern.
For patients, the stakes are tangible. Rising out-of-pocket costs, shrinking pharmacy networks, and the disappearance of familiar local pharmacists all shape how people experience the healthcare system day to day. The frustration Amye Joseph describes is not abstract policy disagreement; it is rooted in routine encounters at the counter, in unexplained price changes, and in the sense that decisions about their medications are being made by a distant corporation rather than by a professional they know and trust.
The pressure on PBMs is also unfolding against a backdrop of turmoil in the pharmacy industry more broadly. Retail chains have been restructuring, with Walgreens announcing plans to close 1,200 stores and CVS recently laying off thousands of staff in an effort to cut costs. These developments underscore how consolidation and financial strain have reshaped the business of dispensing medicine, leaving consumers to navigate a landscape with fewer independent options.
Regulation at the state level, as in Tennessee and Arkansas, raises its own set of questions. Supporters say state rules can force greater transparency about how PBMs negotiate rebates and set reimbursement rates, potentially giving independent pharmacies a fairer footing and giving patients clearer information. Opponents worry that a patchwork of state laws could complicate national drug benefit administration and that the underlying drivers of high drug prices lie elsewhere in the system.
Even so, the emergence of PBMs as a shared target signals something important about the current political moment. When partisans agree on little else, the fact that patients and politicians from both parties are directing their anger at the same set of companies suggests the issue carries unusual salience with voters. It also suggests that the healthcare cost debate may increasingly focus not on whether government or markets should dominate, but on who exactly is capturing value in the middle of the transaction.
For the Josephs, the disagreement that matters is not partisan. It is between the promise that PBMs would hold down costs and their experience that the opposite has occurred. Their household, like the broader electorate, has found a rare point of consensus. Whether that consensus translates into durable policy change, in state capitals and eventually in Washington, remains an open question, but the alignment of patients and politicians across party lines has already made pharmacy benefit managers one of the most scrutinized players in American healthcare.
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