Reporter: Michael McAuliff
Lawmakers who came within days of passing new restrictions on pharmacy benefit managers are trying to revive those measures as part of major funding bills Congress is rushing to complete.
It was unclear if the specific provisions from December's package would be the same, but lawmakers said it was vital to move PBM legislation after the last Congress advanced numerous bipartisan measures, but failed at the last minute to include them in the year-end government funding bill.
That attempt failed when President Donald Trump and his adviser, billionaire Elon Musk, objected to other parts of the budget package, forcing Congress to adopt a narrower bill that funds the government until March 14. If the Republican-led Congress and Trump don't enact federal appropriations for the remainder of fiscal 2025 by that date, a partial government shutdown would commence.
Proponents of reining in PBMs see an opportunity in the March funding bill, which is expected to attract bipartisan support, or to legislation that Republicans are drafting to extend expiring tax cuts, likely without consulting Democrats. Because the Congressional Budget Office predicts some PBM legislation would reduce federal spending, it would fit into either package.
"We're trying to decide whether we use it for a 'pay-for' in reconciliation or what we're going to do about it," said Rep. Buddy Carter (R-Ga.), the chair of the Energy and Commerce Committee's Health Subcommittee.
The previous bills would have instituted significant new transparency requirements on drug industry middlemen such as Cigna unit Express Scripts, CVS Health subsidiary CVS Caremark and UnitedHealth Group division OptumRx, and would have drastically changed how they get paid.
The legislation would have "de-linked" compensation that PBMs earn based on pharmaceutical list prices and banned spread pricing — or charging more for medicines than the prices negotiated with drugmakers — in Medicare and Medicaid. Compensation could no longer be linked to how large of a discount a PBM negotiates from a high list price. Nor could a PBM keep a portion of the savings, or a spread, for itself. They also would have to charge fixed administrative fees.
Another provision in the abandoned package would have instituted similar changes for employer-sponsored health plans, including transparency rules and requirements to pass on negotiated drug price savings to plan sponsors.
The Pharmaceutical Care Management Association, which represents PBMs, is adamantly opposed to all of it.
“More government control in the private market exacerbates the high prices consumers are facing and would be disastrous for employers trying to provide affordable healthcare to working families," PCMA said in a statement. "It would only increase Big Pharma’s profits. Employers should get to make the call on how they design the healthcare benefits for their employees — not the government. If Congress wants to lower drug costs, they need to get Big Pharma to lower the prices and rein in patent abuses."
But that's not how most members of Congress see it.
"We're going to continue to push for PBM reform. It's extremely important," said Rep. Dr. Marianette Miller-Meeks (R-Iowa), a member of the Energy and Commerce Committee. That panel has jurisdiction over a huge swath of the healthcare system, including Medicaid, Medicare and programs from the Affordable Care Act of 2010.
"We've got to. We've got to make that happen," said Rep. Rick Allen (R-Ga.), another committee member who said he is "absolutely" pushing to add the previous package to one of the big spending bills.
Rep. Diana Harshbarger (R-Tenn.), an Energy and Commerce Committee member who was a pharmacist before entering Congress, said the panel is still discussing how to proceed. She was as adamant as her colleagues that PBM measures be included in the mix... CONTINUE READING
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