CRamnibus, Bad. Solving the PBM Problem? Good.

When it comes to massive pieces of legislation, conservatives have long sounded the alarm about the perils of sprawling, unmanageable bills packed with pork and riddled with hidden provisions. The recent 1,500-plus-page "CRamnibus" was no exception. It was a monstrosity of government overreach—an unreadable, unaccountable juggernaut crammed with unnecessary spending and policies that defy common sense. But even amidst the legislative wreckage, there was one glimmer of hope: long-overdue reform of the Pharmacy Benefit Manager (PBM) system.

While it is good news that the CRamnibus was scuttled, the attention to PBM reform within the proposed bill underscores an issue that policymakers on both sides of the aisle must address—and quickly. Pharmacy Benefit Managers, the so-called "middlemen" in the prescription drug supply chain, have been quietly driving up drug costs for years, enriching themselves at the expense of patients, taxpayers, and even the pharmaceutical industry. Former President Donald Trump has been a vocal critic of PBMs, as evidenced in his recent comments on the subject. Trump’s commitment to eliminating these parasitic entities is a testament to his understanding of the real drivers of America’s healthcare crisis. It’s time for Congress to follow his lead and take decisive action.

The Problem with PBMs

Let’s start with the basics. PBMs were originally conceived as intermediaries to negotiate better drug prices on behalf of insurers and consumers. In theory, they were supposed to bring efficiency to the system. In practice, however, they’ve become a major source of inefficiency, opacity, and skyrocketing costs.

PBMs profit by negotiating rebates from drug manufacturers and pocketing a sizable portion of those savings for themselves. These deals are often hidden from public view, creating a system that lacks transparency and accountability. Worse, PBMs have been known to steer patients toward higher-priced drugs because they yield larger rebates—not because they’re the best or most affordable option for the patient.

In his remarks, President Trump hit the nail on the head: “The middleman... makes more money frankly than the drug companies, and they don’t do anything except they’re a middleman.” This isn’t hyperbole; it’s a fact. PBMs have positioned themselves as toll collectors in a system that should prioritize the well-being of patients, not the bottom lines of bureaucratic middlemen.

Trump’s Push to “Knock Out the Middleman”

President Trump has been unrelenting in his critique of PBMs, and rightly so. During his presidency, he introduced several measures to increase transparency and curb the power of these middlemen, but the entrenched system resisted significant change. Now, as the nation gears up for another election cycle, Trump has doubled down on his commitment to reform.

“We’re going to knock out the middleman,” Trump declared, vowing to bring drug costs down to levels “that nobody has ever seen before.” He is absolutely correct to target PBMs as a key driver of high drug prices. By eliminating or at least severely curbing the influence of PBMs, we can finally address the root causes of price inflation in the pharmaceutical market.

Trump’s willingness to take on PBMs is also emblematic of his broader approach to governance: identify the problem, ignore the lobbyists, and prioritize the needs of the American people. This is the kind of leadership we need in Congress as it grapples with this issue.

The CRamnibus: A Cautionary Tale

The failure of the CRamnibus should serve as a warning to policymakers. Massive, unwieldy bills are no way to govern. They are impossible to scrutinize, rife with wasteful spending, and often serve as vehicles for unrelated pet projects. The American people deserve better.

However, the fact that PBM reform made it into the CRamnibus is a testament to the urgency and importance of this issue. It’s a reminder that even in the midst of legislative chaos, there are opportunities to advance good policy. Moving forward, Congress must ensure that PBM reform is addressed in a more focused and transparent manner. This is not an issue that can wait for the next bloated spending package.

A Path Forward

So, what should PBM reform look like? Here are a few key principles that policymakers should consider:

1. Transparency: PBMs must be required to disclose their rebate structures, pricing models, and any financial incentives that could influence their decision-making. Sunlight is the best disinfectant, and transparency will go a long way toward curbing abuses.

2. Direct-to-Consumer Pricing: Patients should be able to see the real cost of their medications, without the convoluted layers of pricing and rebates that PBMs use to obscure the truth.

3. Accountability: PBMs must be held accountable for their actions. This includes stricter oversight and penalties for practices that harm patients or distort the market.

4. Competition: Policymakers should encourage competition among PBMs and explore alternatives that eliminate the need for middlemen altogether. Free-market competition is the most effective way to drive down costs and improve quality.

   
   

The Stakes Are High

Reforming the PBM system is not just about saving money; it’s about saving lives. High drug costs force too many Americans to choose between their medications and other basic necessities. This is unacceptable in a nation as prosperous as ours.

The enduring importance of solving the PBM problem cannot be overstated. It is a rare issue that unites Americans across political and ideological lines. It is a challenge that demands immediate attention and decisive action. And it is an opportunity for policymakers to prove that they can rise above partisanship to do what is right for the American people.

As President Trump has so aptly put it, the middleman must go. It’s time to knock out the PBMs and restore sanity to our healthcare system. For the sake of patients, taxpayers, and the future of our nation, Congress must make PBM reform a top priority in the coming year. Let’s hope they rise to the occasion.