Let's Unite Against PBMs' Pennsylvania Monopoly

The healthcare industry’s most covert scheme might finally be unraveling. This week, the New York Times debuted a series of investigative reports on pharmacy benefit managers (PBMs) and their role in overcharging state Medicaid programs, Medicare, and employer-sponsored health plans for specialty prescription drugs. As consumers, especially seniors, struggle to pay for medication in Pennsylvania and across the nation, these findings strike me as particularly egregious.

This longstanding practice has been robbing consumers for some time but the blame for the high costs has never managed to be aimed at its rightful provocateur: PBMs.

Three dominant PBMs—CVS Caremark, OptumRX, Express Scripts—are owned by three of the largest healthcare conglomerates in the country—Aetna, United Healthcare, Cigna—that have cornered over 80% of the prescription drug pharmacy benefit market. This environment has bred greed, and that greed has led to patients being deprived of critical care. This monopolistic practice has long been hidden. But not anymore.

Thanks to the New York Times and numerous studies that have been released based on real pharmaceutical claims data, we now know better. Pennsylvania is moving forward with legislation to restore market forces by rebalancing the leverage of middlemen in the pharmaceutical industry, and thus rescuing patients from predatory price gouging. Senate Bill 1000, introduced by state Sen. Judy Ward, and HB 1993, introduced by state Sen. Jessica Benham (I’m a co-sponsor and strong advocate), are primed for consideration in either chamber. Moreover, Gov. Shapiro has pledged his support for serious PBM reform, even galvanizing his support during his February budget address.

Bipartisan wins are rather rare to come by these days, but they’re not altogether impossible. The PBMs have drawn equal ire from both major parties. We’ve united against the clear manipulation of the marketplace, the simply unaffordable prices that our constituents are forking out to get life-changing treatment, and the monopolistic stranglehold that threatens to crowd out our community pharmacies. I commend the governor and Republican and Democratic members of the Senate and House in Pennsylvania for coming together to reform this long overdue practice. The good news is that it seems the jig is up for PBMs. It would be even better news if we can move on either SB 1000 or HB 1993, for the good of our Commonwealth and the millions of Pennsylvanians overpaying for their prescription drugs.

Joe D’Orsie represents the 47th Legislative District in the Pennsylvania House of Representatives.