In a modest household in Elizabethton, Tennessee, Amye and Charlie Joseph embody the kind of political divide that has come to define modern American life. She is a Republican; he is a Democrat. They have been married for 35 years, and like many couples navigating today's polarized landscape, they have learned to live with their differences. But there is one issue on which they stand shoulder to shoulder: their shared contempt for the healthcare companies known as pharmacy benefit managers, or PBMs.
"We hate CVS. I'm going to be straight-up," Amye Joseph said, directing her frustration at the healthcare conglomerate that dominates multiple corners of the American drug supply chain.
That sentiment, once confined to policy wonks and industry insiders, has now burst into the mainstream. Across the country, patients, politicians, and employers are increasingly pointing fingers at PBMs, the little-understood intermediaries that sit between drug manufacturers, insurers, pharmacies, and the people who actually need medication. What was once a niche bureaucratic function has become a rare point of agreement in a divided nation.
PBMs were originally designed with a straightforward mission: manage prescription drug plans and use their negotiating power to keep costs down for insurers and employers. The idea was that by pooling purchasing power, these middlemen could extract discounts from drugmakers and pass savings along to consumers. For a time, that logic held. But as the industry consolidated, critics argue that the original purpose has been warped beyond recognition.
Today, the three largest PBMs control the vast majority of prescription drug claims in the United States. That concentration of power has raised alarms across the political spectrum. Accusations abound that these companies are siphoning off profits at the expense of employers, government programs, and patients, all while operating with minimal transparency about how they set prices or where the money actually goes.
The Josephs' frustration centers on CVS Health, a company that reported $400 billion in revenue last year. CVS is not just one business; it is a vertically integrated empire. It owns Aetna, a major health insurer. It owns CVS Caremark, one of the nation's dominant PBMs. And it owns CVS Pharmacy, the largest retail pharmacy chain in the country. That combination means the same corporate parent can decide which drugs are covered, how much they cost, and where patients must go to pick them up.
For Amye Joseph, the arrangement feels less like a service and more like a trap. She misses the days when she could speak face-to-face with a pharmacist who knew her by name. She is troubled by drug prices that seem to climb without clear explanation. And she resents pressure from the couple's CVS Caremark drug plan to fill prescriptions at CVS stores rather than at their local pharmacy.
"They're not even a middleman," she said. "They're a money grab for CVS."
That kind of blunt assessment is becoming surprisingly common in statehouses and on Capitol Hill alike. While Democrats and Republicans in Washington remain bitterly divided on issues like immigration, climate policy, and tax reform, taking on PBMs has emerged as a unifying cause. The reason is simple: rising healthcare costs affect everyone, regardless of party affiliation.
Lawmakers in Tennessee and Arkansas have moved ahead with new regulations targeting PBM practices, part of a broader state-level pushback that has gained momentum in recent years. These efforts reflect growing frustration that federal action has stalled, leaving states to fill the void. The measures vary, but many aim to increase transparency around PBM pricing, restrict certain business practices deemed anti-competitive, and protect independent pharmacies from being squeezed out of the market.
The bipartisan nature of this fight is striking. It is not often that patient advocacy groups, small business owners, and politicians from both parties find themselves on the same side of an issue. But PBMs have managed to unite an unlikely coalition. Employers who sponsor health plans complain that they cannot get straight answers about how their money is being spent. Independent pharmacists say they are being reimbursed below cost while being forced into restrictive contracts. Patients describe a system that feels rigged against them.
The stakes go beyond individual wallets. Healthcare spending in the United States continues to outpace inflation and wage growth, placing enormous strain on family budgets, state Medicaid programs, and the federal treasury. If PBMs are indeed capturing a larger share of the healthcare dollar than their services warrant, then reining them in could free up resources for actual care. That argument resonates across ideological lines.
Critics of the industry point to a lack of transparency as a central problem. PBMs negotiate rebates and discounts with drugmakers, but the details of those deals are rarely disclosed. Some analysts argue that rather than lowering prices, PBMs may actually prefer higher list prices because their fees are often tied to a percentage of the drug's cost. The higher the sticker price, the more room there is for the PBM to claim a slice.
The industry disputes this characterization, maintaining that its role is essential to holding down costs and that its critics misunderstand the complexity of drug pricing. But public opinion appears to be shifting against them. The Josephs' story is just one example of how personal experience is driving political engagement. Amye and Charlie may disagree on many things, but when it comes to CVS and the broader PBM system, they are of one mind.
As state legislatures across the country consider new restrictions and Congress weighs federal reforms, the pressure on PBMs is only likely to grow. What remains to be seen is whether this rare bipartisan unity will translate into meaningful change, or whether the industry's lobbying power and the sheer complexity of healthcare policy will blunt the momentum.
For now, the Josephs and millions of Americans like them are watching closely. In a country where common ground can feel impossibly scarce, the fight against pharmacy benefit managers has become an unexpected rallying point — a reminder that some frustrations transcend party lines.
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