Scoop: Donald Trump upends PBM debate. Is it “ballgame” or is there more to come?

A bipartisan push to reform PBMs is running into a MAGA buzzsaw...

President Donald Trump upended Congress’s lame duck deliberations about pharmacy benefit managers (PBMs). “We have a thing called the middleman,” Trump said at a press conference. “I don’t know who these middlemen are, but they are rich as hell. And we’re going to knock out the middlemen, we’re going to get drug costs down.”

Multiple people backing PBM reform had the same exact message they conveyed to the Washington Reporter: “Ballgame.” Opponents of PBM reform aren’t so sure, and they are not without powerful allies of their own.

Congress’s fight is pitting various factions of the Republican Party against each other, specifically on attempts to reform PBMs . A bipartisan group of elected officials led by Sens. Bill Cassidy (R., La) and Chuck Grassley (R., Iowa), Speaker Mike Johnson (R., La.), and Reps. Buddy Carter (R., Ga.), Diana Harshbarger (R., Tenn.), and Jake Auchincloss (D., Mass.), are squaring off against some of the most powerful voices in the MAGA universe.

Lawmakers are scrambling to determine what, if anything, a deal would look like. The Reporter reported that over the weekend, a deal emerged that has PBMs panicking — with both Trump and Robert F. Kennedy, Jr. indicating support. Prior authorization, which is strongly opposed by insurance companies, is also in the deal. The deal comes as House Republicans, led by Rep. Jim Jordan (R., Ohio), announced an investigation into CVS Caremark for alleged antitrust violations.

During his press conference, Trump confirmed that he has been working with Kennedy, Dr. Mehmet Oz — his pick to run the Centers for Medicare & Medicaid Services — and with executives. “We spend more time talking about that than anything else,” he said.

Prior to his press conference, a clip of Trump went re-viral among health care policy wonks, in which he attacked PBMs: “We’re going to reduce prices, because the middleman makes more money than the drug companies,” Trump said. “There's a middleman that nobody even knows who they are.”

Some industry groups want a deal before the year ends, believing that some movement on health care policy is preferable, but they are facing a conservative buzzsaw, from some GOP veterans who are objecting to what they view as a singling out of PBMs.

Both Carter and Mark Cuban have taken to the Reporter to make their cases against PBMs. In an op-ed, Carter, a longtime pharmacist, called PBMs “the middlemen who are responsible for making your medicine expensive and inaccessible.”

Cuban, in a Reporter interview, said that he “believe[s] that pass-through PBMs, [which] pass through all rebates, disclose net pricing, let companies own their own claims and more, will replace the biggest PBMs.” The Shark Tank billionaire added that “as self-insured insurers understand they are getting ripped off and move to pass-through PBMs, we will reach an inflection point that disintermediates the big PBMs of today.”

The National Community Pharmacists Association (NCPA), National Federation of Independent Business (NFIB), and other industry groups have argued in support of PBM reforms, highlighting how the unfair practices of PBMs have led to at least one community pharmacy closing per day across the country over the past year. There was a flurry of outreach over the weekend as it appeared the negotiators had been getting close to reaching a deal, although no legislative text had been released as of Monday morning. NCPA has been especially active over the past two years, activating their grassroots network repeatedly to directly engage with members of Congress and hosting pharmacy visits to highlight the role they play in their communities.

One group against the PBM reforms, Conservatives for Lower Health Care Costs, is pushing a study from the Competitive Enterprise Institute (CEI) which argues that PBMs are a core part of the free market’s solution to lower health care costs. PBM regulation, the group claims, “would undermine pharmacy benefit managers’ (PBM’s) freedom to leverage competition in the market to deliver savings — giving big government liberals more control over your health care, and Big Pharma increased profits while Americans would be hit with HIGHER PRESCRIPTION DRUG COSTS.” Joining the group are conservatives such as Joe Grogan, who served as director of the United States Domestic Policy Council and assistant to Trump in his first term.

Grogan posted on X in response to the Reporter’s scoop that “if more plans pull out of part d, it triggers the MMA provision that allows for a gov't run plan. Meaning an RFK Jr. run plan. How would that work out for drug companies? The extra spending in this bill takes 2025 spending leverage from djt, but the anti pbm stuff could really hand him drug pricing leverage. If OPM focuses on clamping down on drug spending in FEHB and RFK Jr. administers his own drug plan, OMB pulls the plug on Biden's illegal part d demo, this could be a very very bad stretch for drug companies.”

Joining Grogan in pushing back against the PBM deal are some of the loudest voices of the online right, and opposition research groups like the American Accountability Foundation (AAF), which is flooding Hill inboxes this week with messaging against it that attacks PHRMA.

Sean Davis, the co-founder of the Federalist, for example, said that the deal is “chock full of Pharma giveaways and big government nonsense. Because apparently Pfizer and Big Pharma didn’t make enough money through the corrupt COVID vaccine mandates. And Congress is trying to cram this all through at the last minute to tie Trump’s hands before he gets into office.”

A PBM industry group, the Pharmaceutical Care Management Association (PCMA), wrote that “‘delinking’ [legislation] would hand a financial windfall totaling up to $32 billion annually to drug companies.” Rep. Greg Murphy (R., N.C.), a longtime doctor, pushed back on that characterization, calling the claim “false” and adding that “PBM’s (Insurance Companies) get a % of drug prices they negotiate. The higher price, the more they get. De-linking takes that relationship away. It also make the rebates go where they should have been going all along. THE PATIENT!”

Proponents of the PBM reform have made the case that these bills pass overwhelmingly, sometimes unanimously, in committees. Opponents have made both substantive and process grounds, arguing that this last-minute change goes against public commitments to a clean continuing resolution.