Just before President Trump pushed her out at the behest of his corporate donors, former Federal Trade Commission chairwoman Lina Khan released a damning report about the most rapacious and anti-competitive actors in the entire healthcare system: pharmacy benefit managers.
These middlemen in the drug supply chain don’t discover new medicines. They don’t manufacture them. They don’t even physically dispense most prescriptions. Yet they rake in tens of billions of dollars each year by driving up costs for everyone else — especially patients battling cancer, HIV, heart disease, and autoimmune conditions.
In their report, FTC investigators documented how the PBM industry — which is dominated by just three firms, CVS Caremark, Express Scripts, and OptumRx, that collectively oversee roughly 80% of all prescriptions dispensed nationwide — imposed eye-popping markups on generic drugs used to treat deadly diseases. The PBMs’ affiliated pharmacies charged hundreds — even thousands — of percent more than they paid to acquire drugs like the cancer treatment Gleevec and multiple sclerosis medication Ampyra.
This isn’t just a case of corporations being greedy. It’s the result of a rigged market structure.
In theory, pharmacy benefit managers could play a valuable role by negotiating with drug manufacturers for lower prices. Since they haggle on behalf of health plans that collectively enroll hundreds of millions of Americans, these PBMs have considerable leverage, and should theoretically drive a hard bargain and win enormous discounts. And in fact, they do.
The problem is that those savings rarely flow to patients at the pharmacy.
Instead, PBMs have made the supply chain so convoluted that almost nobody on the outside — whether the patient filling the prescription, the pharmacist dispensing it, the doctor writing it, or even the employer sponsoring the health plan — can easily tell how much a drug will cost after discounts, rebates, and various fees and clawbacks are applied.
This opacity isn’t an accident. It’s by design. The lack of transparency enables PBMs to overcharge patients and health plans.
Congressional investigations have revealed numerous instances in which PBMs steered patients towards more expensive drugs — which come with bigger discounts and rebates for the PBM — “even when there are lower-cost and equally safe and effective competing options” available. Some of the largest PBMs have even created offshore shell corporations to help pocket negotiated rebates — instead of passing them off to patients.
Patients don’t even realize when they’re being ripped off.
PBMs almost never disclose the total discounts they negotiate on specific drugs. So patients’ cost-sharing obligations are calculated based on a drug’s unnegotiated, inflated “list price,” rather than its true discounted price. As a result, patients spend billions more out-of-pocket than they otherwise would if the discounts were publicized.
These inflated costs are a key reason that 21% of American adults have skipped filling a prescription in the past year due to affordability concerns, while 12% have skipped doses or cut pills in half.
The FTC also found clear patterns of self-dealing, where PBMs steered the most profitable prescriptions to their own affiliated pharmacies while boxing out independent community pharmacies. Thousands of independent pharmacies have closed in recent years, leaving entire counties without a single brick-and-mortar store where patients can fill a prescription.
Finally, PBMs use their consolidated power to keep drugs off of health plan formularies — unless manufacturers pay exorbitant fees.
This is a policy failure. But it’s also a political opportunity.
Congress has previously considered two bipartisan bills that would rein in PBMs’ worst abuses. If reintroduced and passed, one bill would eliminate the perverse incentive for PBMs to favor expensive drugs by delinking PBMs’ compensation from list prices. Another would require that negotiated discounts be passed directly to patients at the pharmacy. And just last month, FTC Chair Andrew Ferguson reignited an FTC lawsuit against pharmacy benefit managers (PBMs) that accuses them of anticompetitive behavior.
Democrats have a chance to lead — and win — on this issue. Taking on PBMs doesn’t just lower drug costs. It shows voters that we’re willing to fight the entrenched interests hurting their families and their finances. It shows that we’re the party that puts patients ahead of profiteers.
We don’t need to wait for the next election. We just need the political will to act.
