Arkansas – In a bold move against a complex and often unseen part of the American healthcare system, Governor Sarah Huckabee Sanders has placed Arkansas at the forefront of a national fight to rein in the power of pharmacy benefit managers, or PBMs. These third-party companies, once meant to simplify access to prescription drugs and keep costs down, are now being blamed for rising drug prices, dying community pharmacies, and dangerous delays in patient care.
PBMs were originally designed to act as intermediaries between insurance companies, pharmacies, and drug manufacturers. They were supposed to help manage the maze of fluctuating drug prices and coverage plans. However, in an op-ed recently published in The New York Times, Governor Sanders wrote, “P.B.M.s started as a good idea that quickly went sour.” Instead of helping patients, she says many of them have turned into powerful monopolies, exploiting the system for profit and hurting the very people they were meant to serve.
Now, Arkansas has passed what Sanders calls the “first-in-the-nation” legislation banning PBMs from also owning or being affiliated with pharmacies. The goal, she said, is to eliminate conflicts of interest and bring fairness back to the system. “They can still operate in our state; they just can’t continue to mistreat patients and box out other pharmacies,” Sanders said.
The influence of PBMs cannot be overstated. According to Sanders, just three companies control 80 percent of all prescription transactions in the country. These same companies—CVS Caremark, Express Scripts, and OptumRx—also own or are affiliated with the pharmacies that fill the majority of specialty drug prescriptions, bringing in significant profits. Between them, she says, they raked in $1.6 billion in excess revenue from just two cancer medications over a span of less than three years.
For patients in rural areas like many parts of Arkansas, the consequences of this power structure can be life-threatening. Sanders shared the story of a woman from Camden, Arkansas, who developed a severe breathing disorder. Though she had always used her local pharmacy, her PBM—CVS Caremark—denied her refill request, insisting she use one of their pharmacies over an hour away.
Her choices were bleak: drive a three-hour round trip, pay out-of-pocket for a drug she couldn’t afford, or enroll in a frustrating mail-order system. She chose mail-order but faced delays and administrative red tape that left her without an inhaler for weeks. “This red tape isn’t just annoying; it’s also life-threatening,” Sanders said. “And the only purpose it serves is to line the pockets of corporate suits who stand between patients and the care they need.”
Sanders’s new legislation was met with fierce opposition. CVS launched a media campaign filled with what Sanders described as “hair-on-fire ads” trying to sway public opinion. Once the law passed, CVS reportedly threatened to shut down every pharmacy it owns in Arkansas rather than comply with the law’s requirements to separate PBM operations from pharmacy ownership.
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Now, the legal battles are beginning. CVS and Express Scripts are taking the state of Arkansas to court, using what Sanders calls “all the legal firepower their money can buy.” Meanwhile, the lobbying efforts have already begun in other states and in Washington, D.C., as these companies try to stop the spread of Arkansas’s reforms.
But Sanders remains firm. “Arkansas isn’t scared. We won’t sacrifice our veterans, seniors or rural patients in service of P.B.M. stock prices,” she wrote. She believes that this moment is a turning point and that other states and Congress should follow Arkansas’s example before it’s too late.
The governor credited former President Donald Trump for sparking new energy in the fight against PBMs. “With President Trump in office, everything is changing,” she wrote, pointing to his recent executive order targeting these middlemen. During a news conference, Trump said, “We’re going to cut out the middlemen.”
Sanders is calling on other Republican leaders to take the lead while the momentum is building. “My fellow governors and congressional lawmakers should ignore the fear mongering from P.B.M.s and stand up for patients and local pharmacists to end these anti-competitive practices and fix the broken, backward system that has tarnished America’s health care for too long,” she wrote.
Her call to action is gaining attention beyond Arkansas. As Americans continue to face soaring prescription prices and confusing insurance coverage, more eyes are turning to the hidden forces shaping the market—and to the leaders brave enough to challenge them.
The battle against PBMs is far from over, but Arkansas has fired the first shot in what may become a national reckoning with how prescriptions are priced, distributed, and denied. Whether other states will take up the cause remains to be seen, but the message is clear: when it comes to healthcare, transparency and fairness must come before profits.
