In an era defined by deep political polarization, a Tennessee couple offers a snapshot of an emerging consensus. Amye and Charlie Joseph have been married for 35 years, but they sit on opposite ends of the political spectrum—Amye is a Republican, Charlie is a Democrat. Yet inside their Elizabethton, Tennessee, home, they have discovered a rare point of agreement: a shared frustration with pharmacy benefit managers, the controversial middlemen of the prescription drug supply chain.
Their common ground reflects a broader shift across the United States. While Democrats and Republicans in Washington remain divided on many healthcare issues, the desire to rein in pharmacy benefit managers—commonly known as PBMs—has become a rare unifying force. Patients, politicians, and employers alike are increasingly pointing fingers at these companies, accusing them of prioritizing profits over patient care.
At the heart of the Josephs' frustration is CVS Health, a corporate giant that reported $400 billion in revenue last year. The conglomerate operates on multiple levels of the healthcare industry: it owns Aetna, a major health insurer; CVS Caremark, one of the nation's dominant PBMs; and CVS Pharmacy, the largest retail pharmacy chain in the country. For critics, this vertical integration represents a troubling concentration of power.
"They're not even a middleman," Amye Joseph said of the company. "They're a money grab for CVS." She describes a system where face-to-face interaction with pharmacists has dwindled, drug prices seem to rise without clear explanation, and patients are pressured by their CVS Caremark drug plan to use CVS stores rather than local pharmacies. "We hate CVS. I'm going to be straight-up," she added.
PBMs were originally designed to serve a practical purpose: managing prescription benefits and negotiating lower drug costs on behalf of employers, insurers, and government programs. In theory, their role was to create efficiency and leverage volume to secure discounts. However, over time, these intermediaries have morphed into powerful entities that critics say absorb profits at the expense of the very parties they were meant to serve.
The list of aggrieved stakeholders is remarkably diverse. Employers who sponsor health plans complain that they cannot see the true cost of drugs. Independent pharmacists argue that PBMs reimburse them below the cost of dispensing medications, driving them out of business. Patients face rising out-of-pocket expenses and confusing formularies. Even state governments, which foot the bill for Medicaid and public employee health plans, are struggling to contain costs.
What makes the PBM issue particularly potent is its bipartisan appeal. In Tennessee and Arkansas, state lawmakers have moved forward with regulations targeting these companies—an unusual development in an otherwise gridlocked healthcare policy landscape. The fact that both conservative and liberal states are taking action underscores how widespread the dissatisfaction has become.
The political dynamic is striking. While debates over the Affordable Care Act, Medicaid expansion, and other major health policies continue to divide the parties, taking on PBMs has become a rare shared cause. Republicans see it as a matter of reining in corporate power and protecting free-market competition. Democrats view it as a necessary step to lower drug prices and protect consumers. Both sides can point to tangible harm inflicted on their constituents.
The Josephs' household illustrates how this issue cuts across ideological lines. For Amye, the Republican, the problem is one of accountability and transparency. For Charlie, the Democrat, it is about fairness for working families. Their shared disdain for PBMs has become a topic of conversation that transcends their political differences, a phenomenon repeating in households across the country.
The stakes are enormous. PBMs control access to prescription drugs for millions of Americans. They determine which medications are covered, how much patients pay, and which pharmacies can dispense them. Their decisions can mean the difference between a patient affording a life-saving drug or going without. When those decisions appear to be driven by profit rather than health, public anger intensifies.
CVS Health is hardly alone. Other major PBMs, including Express Scripts and OptumRX, operate with similar market dominance. Together, the largest PBMs handle the vast majority of prescriptions in the United States. This concentration of power has raised antitrust concerns and prompted calls for greater oversight at both the state and federal levels.
In Tennessee and Arkansas, new regulations represent the first waves of a broader regulatory push. These laws aim to increase transparency, restrict certain business practices, and give state officials more authority to scrutinize PBM operations. While the specifics vary, the underlying message is the same: states are no longer willing to wait for federal action.
The federal government has also taken notice. Lawmakers from both parties have introduced bills targeting PBM practices, though comprehensive reform remains elusive. The complexity of the healthcare system, combined with intense lobbying from industry groups, makes legislative change difficult. Still, the growing bipartisan pressure suggests that the status quo may not hold indefinitely.
For patients like the Josephs, the debate is not abstract. It plays out in every trip to the pharmacy counter, every explanation of benefits, and every difficult conversation about which medications they can afford. Their experience reflects a healthcare system that often feels stacked against the very people it is meant to help.
As the 2026 election season approaches, PBMs are emerging as an unexpected campaign issue. Candidates from both parties are likely to face questions about what they plan to do. The issue's bipartisan appeal makes it a safe talking point, but translating that rhetoric into meaningful reform will require overcoming powerful vested interests.
The Josephs may disagree on many things, but on this issue, they are aligned. Their marriage has survived 35 years of political differences, and they now find themselves on the same side of a fight that is reshaping American healthcare politics. In their view, the enemy is not each other—it is a system that seems designed to extract profit rather than provide care.
That sentiment, echoed in red states and blue states alike, is why pharmacy benefit managers have become such a potent political target. When a Republican and a Democrat in rural Tennessee can agree on something, it signals a shift that policymakers in Washington and state capitals would be wise not to ignore. The question is no longer whether PBMs will face scrutiny, but how far that scrutiny will go—and what it will mean for the cost of prescription drugs in America.
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