In a small household in Elizabethton, Tennessee, political differences have long been a topic of gentle ribbing. Amye Joseph is a Republican; her husband, Charlie, is a Democrat. They have been married for 35 years, and like many American couples, they have learned to navigate their ideological divides. But there is one issue on which they stand shoulder to shoulder: a shared frustration with the healthcare companies known as pharmacy benefit managers, or PBMs. Their mutual discontent, according to Amye Joseph, has given them a unifying target in an era of deep political polarization.
The Josephs' ire is directed squarely at CVS Health. The conglomerate is a giant in the American healthcare landscape, reporting $400 billion in revenue last year. Its reach extends across multiple sectors: it owns Aetna, a major health insurer; CVS Caremark, one of the country's dominant PBMs; and CVS Pharmacy, the largest retail pharmacy chain in the United States. For the Josephs, this vertical integration represents everything that is wrong with the current system. Amye Joseph does not mince words. "We hate CVS," she said, describing what she sees as a money grab that prioritizes corporate profit over patient care.
Her specific complaints echo those of countless Americans. She misses the face-to-face interaction with local pharmacists, a personal connection that she feels has been eroded by the rise of large chain pharmacies. She is exasperated by drug prices that seem to climb without clear explanation. And she feels pressured by the couple's CVS Caremark drug plan to fill prescriptions at CVS stores rather than at their preferred local pharmacy—a practice known as steering, which critics say limits patient choice and undermines community pharmacies.
PBMs were originally conceived with a straightforward mission: to manage prescription drug benefits for insurers and employers, using their bargaining power to negotiate lower prices from drug manufacturers. In theory, this middleman role was meant to hold down costs for everyone. In practice, however, PBMs have become a lightning rod for criticism. They are accused of prioritizing their own profits at the expense of employers, government programs, and patients. The complexity of the drug supply chain—where PBMs negotiate rebates, set formularies, and determine reimbursement rates—has made them a target for those seeking to explain why Americans pay so much for their medications.
What makes the backlash against PBMs particularly notable is its bipartisan nature. In Washington, D.C., healthcare debates often fall along predictable party lines, with Democrats and Republicans clashing over the role of government, the future of the Affordable Care Act, and the best way to lower costs. But taking on PBMs has emerged as a rare unifying cause. Lawmakers from both parties, as well as patients across the political spectrum, seem to agree that these middlemen have grown too powerful and too opaque.
The sentiments expressed by the Josephs are not isolated. They reflect a growing chorus of voices—both patients and politicians—who are united in their disdain for the PBM industry. This shared anger has begun to translate into action at the state level. Tennessee and Arkansas are among the states now moving to regulate PBMs, signaling that the issue is no longer confined to Washington. State legislators are examining ways to increase transparency, limit steering practices, and ensure that community pharmacies can compete on a more level playing field.
The partnership behind this reporting—a collaboration between NPR, KFF Health News, and member stations—highlights the local angles of a national story. Health reporting in the states has brought attention to how PBM practices affect real people in their communities, from rural towns where the local pharmacy may be the only accessible source of medications to suburban households like the Josephs' in Elizabethton. These local stories add texture and urgency to a policy debate that can often feel abstract.
The regulatory push in Tennessee and Arkansas is part of a broader trend. As frustration with healthcare costs mounts, state lawmakers are increasingly unwilling to wait for federal action. They are drafting bills that target PBM business practices, such as spread pricing—where a PBM charges a health plan more for a drug than it reimburses the pharmacy, pocketing the difference—and clawback fees that can surprise pharmacies after the fact. These measures aim to shed light on the financial mechanics of the drug supply chain and to protect both patients and independent pharmacists.
For the Josephs, the issue is deeply personal. Amye Joseph describes a system that feels rigged against consumers. The lack of transparency around pricing, the pressure to use certain pharmacies, and the sense that decisions are made in boardrooms far removed from patient care have left her feeling powerless. Yet she and her husband have found common ground in their frustration. In a time when political divisions often seem insurmountable, their shared disdain for PBMs is a reminder that some problems cut across party lines.
The healthcare industry is watching these developments closely. PBMs argue that they play a vital role in negotiating discounts and that without them, drug prices would be even higher. They contend that their critics misunderstand the complexities of the pharmaceutical market and that reforms could inadvertently raise costs. But the bipartisan nature of the backlash suggests that these arguments are facing increased scrutiny. As more states consider legislation and as patients continue to share their experiences, the pressure on PBMs is likely to grow.
The story of the Josephs is a microcosm of a larger national conversation. It illustrates how healthcare costs have become a kitchen-table issue that transcends political identity. Republicans and Democrats may disagree on many things, but they seem increasingly united in their belief that the current system, with PBMs at its center, is not working for them. Whether that unity will lead to meaningful change—at the state level, in Congress, or in the marketplace—remains to be seen. But for now, the shared frustration is a powerful force, and it is one that the healthcare industry cannot afford to ignore.
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