I spoke with GOP Rep. Buddy Carter. He thinks Republicans and Democrats can find common ground on PBMs, high out-of-pocket costs

Buddy Carter produced a report, “Pulling Back the Curtains on PBMs,” which is centered on interviews with nine patients who spoke candidly about their experiences with PBMs.

It has been nine years since Yuri Cárdenas was handed a difficult medical diagnosis. Since then, the agony of dealing with prescription managers and insurance companies has often caused as much or more anguish than the physical condition Cárdenas suffers from.

“I’ve tried hundreds of medications and so much more, like hospital stays,” Cárdenas said. “But each treatment is a hurdle. Getting insurance to cover my medications, treatments or specialists is an endless series of phone calls between multiple insurance companies, PBMs (prescription benefit managers), providers – and round and round.”

Recently, a PBM denied – without a warning or explanation – approval for a medication Cárdenas had been taking for seven years. That was on top of other gaps in coverage such as high out-of-pocket charges that force many patients to ration drugs prescribed by their doctor because that is all they can afford. Each denial, said Cárdenas, "chips away at a hope for a fruitful career or forever getting [my] life back." 

Cárdenas is one of the millions of Americans who are covered by health insurance yet still struggle with getting the health care they need – either because of high-out-of-pocket costs or because they can’t get approval for the proper medications that would improve their quality of life. Cárdena’s biggest obstacles – and the roadblock for many patients – are the PBMs, one of the “middlemen” in America’s balkanized health care system. These powerful yet obscure players have added an extra layer of profit for big healthcare companies while making inscrutable decisions about paying for patients’ often life-saving medications.

GOP Rep. Buddy Carter, a Georgia pharmacist who owned three drug stores by the time he was elected to Congress in 2014, has a truly unique perspective on this crisis. Carter is one of just two pharmacists in the House of Representatives, and his personal experiences have motivated his work in seeking to curb the influence of PBMs, with the goal of reducing costs to patients.

Yuri Cárdenas and Elisa Comer are featured in Rep. Buddy Carter’s report,“Pulling Back the Curtains on PBMs.”

“I tell people that I’m the one who was on the other side of the counter who had to tell the senior citizens the price of their medication – and … I’m the one who watched them as they tried to decide between whether they were going to buy medications or buy groceries,” Carter said in a phone interview. “I’m the one who had to tell the mother how much the prescription was for her child and watch while she cried because she didn't have the money to pay for it.”

Recently reelected to his fifth term, Carter is now a leader in drafting legislation and pushing federal regulators to curtail the influence of large PBMs through a variety of means, including breaking up the vertical integration that allows large healthcare players to control not just the PBM middlemen but the insurance companies above them and the pharmacies below them. His legislation would force PBMs to pass the cost of rebates back to consumers while demanding transparency in pricing.

Carter’s efforts may not seem surprising given his pharmacist background, but what is unusual about this congressman’s crusade against corporate greed in health care is that the South Georgian is a staunchly conservative Republican. Indeed, Carter has been a consistent foe of many of the Democrats’ big-ticket, taxpayer-funded solutions – including support for repealing the Affordable Care Act – while arguing for market-based policies. But he says the pain that high out-of-pocket drug costs impose on patients calls out for answers he thinks both parties could rally behind.

“I never once went to the counter and asked, ‘Are you a Republican or a Democrat?’” Carter recalled of his pharmacy days. “High drug prices impact everybody. They don’t just impact one certain group and there’s no reason why this should be a partisan issue at all.”

Carter is absolutely right. Regardless of one’s ideology, the basic facts are pretty clear that monopolistic practices and lax regulatory oversight of PBMs have been a raw deal for patients, paying out-of-pocket dollars to an actor that adds next to nothing in the way of medical relief. 

Currently, three PBMs control nearly 80% of the market, and all are now owned by giant corporations–UnitedHealth Group, CVS Health (Aetna), and Cigna–that own and operate health insurance plans and administer many other plans for large employers and federal and state governments. 

The trend accelerated after Carter left the pharmacy business to become a congressman – Cigna bought Express Scripts in 2018 while CVS Health merged with Aetna in 2017– and these behemoths have used their clout to raise deductibles or deny certain medications. Some patients go into debt to stay healthy, while others don’t get the meds they need. Some die – despite having insurance.

The congressman said he watched over the years as PBMs went from simply processing claims to establishing proprietary formularies – a list of approved drugs – to demand rebates that typically are not passed on to patients. This has led to insidious practices that tend to raise prices – listing higher-cost drugs, for example, to boost the rebate. 

“The solution is quite simple – you should break up this vertical integration,” Carter said. “Insurance companies should not be allowed to own a PBM or a pharmacy, that’s the way you do it. You create competition in the marketplace.”

This fall, Carter produced a report, “Pulling Back the Curtains on PBMs,” which is centered on interviews with nine patients who spoke candidly about their experiences with PBMs. The congressman said he hopes that amplifying these voices will rally bipartisan support. “What I wanted to do is take it to the streets, if you will.”

Rep. Buddy Carter’s report, “Pulling Back the Curtain on BMS: A Path Towards Affordable Prescription Drugs.”

Elisa Comer, a businesswoman, is quoted in the report as saying she’s come to view fighting with her PBMs over prescriptions as akin to a second job, often taking up as much as 15-20 hours a week. 

"I've actually had to go in and out of medications for anxiety," Comer said, because "the system is running your healthcare, not you and your doctor … I don't know any other industry that gets to run their books this way. People are dying."

Currently, three big PBMs – Aetna's Caremark, Cigna's Express Scripts, and UnitedHealth's Optum – contribute large and growing percentages to the revenues and profits of these healthcare giants. The critical role of these middlemen in raising prices has not received nearly enough scrutiny.

Carter has been lobbying the Federal Trade Commission, or FTC, to investigate PBMs and the role of vertical integration since he arrived on Capitol Hill. After years of dithering, the FTC finally announced such a probe in early June, acknowledging the critique that PBM business practices “depend on highly complicated, opaque contractual relationships that are difficult or impossible to understand for patients and independent businesses across the prescription drug system.”

But Carter said he continues to work on forging a bipartisan coalition that could also enact legislation to rein in PBMs and lower drug costs. He said he recently attended a dinner with two Republican House members and two Democrats who were upbeat about the prospects for such bills in the next Congress.

The measures that Carter is currently pushing for include the Drug Price Transparency in Medicaid Act, which would curb some of the powers of PBMs while forcing them to be more transparent about their pricing strategies. He also backs legislation aimed at lowering the out-of-pocket drug costs for seniors by reforming the fee system for the Medicare Part D program. He said he’s already spoken with Rep. Kevin McCarthy, who may be the next House Speaker, about making these bills a priority.

Despite their sharp ideological and philosophical differences, the veteran GOP lawmaker believes the financial costs and the stress on ailing people are so great that Democrats and Republicans both should – and can – find common ground to solve the problems. In fact, he believes bipartisanship is ultimately the answer not only for runaway out-of-pocket expenses but for the broader crisis of high healthcare costs.

“I get that we’re going to have different approaches and we’re going to have different thoughts on the way that we should solve it,” Carter said. “But health care costs impact everybody.”

That’s exactly right. It’s no secret that many of us fighting to lower out-of-pocket medical expenses aren’t going to see eye-to-eye with this Georgia congressman on every issue, including his recent vote against the Inflation Reduction Act, which aims to lower some prescription drug pricing. But his track record shows we share a common goal: Making health care more affordable and more accessible for more Americans.