Two gas stations sit across the street from one another. On most days, their price signs read the same. Prices go up and down, but the two move together. One station posts a change, and by evening the other has matched it. Neither owner called the other. A higher price costs customers. A lower price costs margin. Whatever the price is that day, both stations end up at it.
Politicians in both parties attack PBMs. Neither party can claim the attack as its own.
Where the position comes from
The position against PBMs starts with something real: a drug needs prior authorization, a plan requires a different drug first, or a product is not covered — and the patient who wanted the drug meets the rule at the pharmacy counter. Whatever the rule’s reason, the patient experiences it as an obstacle to getting the prescribed drug. In a KFF poll in January 2026, 69% of insured adults called prior authorization a burden, and a third named it the biggest burden they face in getting care.
The PBM is the company applying a coverage rule when the pharmacy submits the claim, and its name is on the pharmacy card. The patient encounters the restriction at the counter. Organized interests help supply the name. PhRMA, the drug manufacturers’ trade association, has spent years attaching the PBM’s name to the rule and to the price, in advertising and policy campaigns, and its current campaign puts the case in two sentences: “Your doctor prescribes your medicine. Your insurer and PBM decide if you can get it.” Politicians have picked up this refrain. What constituents bring to it is their own experience at the counter. They can trace the rule to the company applying it, which is what political scientists mean by traceability.
A PBM accounts for only part of the story behind a coverage rule. The rule was adopted by the plan sponsor that pays for the benefit. Some rules also reflect contracts. A drug’s formulary placement and conditions that apply to it can depend on terms negotiated with the manufacturer, and those terms are confidential. Unnecessary or potentially harmful care the rule prevents leaves no patient to describe it. That longer story does not fit in a 30-second ad. And in most congressional districts, few constituents are visibly organized to make the PBM’s case.
What the position is for
Taking a position benefits a politician. In Congress: The Electoral Connection, David Mayhew sorted what a legislator does to get reelected into advertising, claiming credit, and taking positions. “The congressman as position taker is a speaker rather than a doer,” he wrote. “The position itself is the political commodity.” The benefit can grow with each step a politician takes: a press conference, a question at a hearing, a bill introduced, a bill passed, and a law that does what it was intended to do. The first three are position taking. The last two are accomplishments for which a politician can also claim credit.
In Congress, broad support for PBM bills came more than two years before major PBM reforms became law. The Senate Finance Committee approved a PBM bill 26 to 1 in July 2023, and the House passed a broader health package with PBM provisions 320 to 71 that December. PBM provisions were left out of a health package in March 2024 and dropped from a spending bill that December, and major PBM reforms did not become law until February 2026. Agreeing on whom to blame is easier than agreeing on what to do, because a bill has tradeoffs a position does not: premiums, employer costs, pharmacy payment, and who bears the change.
As a political message, letting patients have the medicine their doctors prescribed works as what Donald Stokes called a valence issue. Stokes separated position issues, on which there is disagreement over the preferred outcome, from valence issues, on which everyone favors the same goal and parties compete over who is seen as best able to deliver it. Nobody runs on stricter utilization management. PhRMA’s two sentences about the doctor and the PBM fit on a podium sign, but the case for the rule takes a paragraph. The contest is over who is to blame for the rules that people meet at the counter, and on that question, the two parties have converged. Neither party owns the position.
In May, Democratic Sen. Elizabeth Warren and Republican Sen. Josh Hawley led the Senate reintroduction of a bill to bar PBMs from owning pharmacies. Both portrayed PBMs as “middlemen” driving up costs and harming independent pharmacies. That language is current, but the attack is not new, and it extends beyond Congress. The Federal Trade Commission brought its insulin case involving the largest PBMs under the Biden administration, and the Trump administration settled with two of them. Criticizing insurers has been a familiar position in both parties since the managed care backlash of the 1990s, and a PBM stopping a prescription at the counter looks like an insurer.
Why the position costs so little
Both parties gain from attacking PBMs, and the gain is real. Politicians who name PBMs show that they are listening to a rule people actually meet, and the message reaches an audience the pharmacy counter has already prepared. But the gain is shared. When both parties take the same position on PBMs, the position itself does not set either one apart.
Attacking PBMs also lets a politician avoid a cost. R. Kent Weaver, writing on the politics of blame avoidance in 1986, argued that politicians are motivated more by avoiding blame for unpopular actions than by claiming credit for popular ones because of voters’ “negativity bias” — their tendency to weigh losses more heavily than gains. A politician has three choices. Saying nothing about the rules reads as not listening, and that reading has a cost attached. Speaking up for a PBM costs more. Naming the PBM costs next to nothing, and cosponsoring a PBM bill costs a member one signature. The attack is the cheapest of the three. Few politicians accept the cost of speaking up for a PBM. No coalition has to form for this to happen. Each politician reaches the position alone, by the same arithmetic.
A target with few constituents, shared by both parties, takes the place of targets with more protection. A hospital that is the county’s largest employer, an employer that chose the benefit design, a manufacturer that set the list price, and a pharmacy on the corner all have a hand in what happens at the counter. The hospital, the employer, and the pharmacy have constituents a member can see. The manufacturer has a national association behind it. A PBM has resources of its own and little visible constituency in any one district. Manufacturers and independent pharmacists have pointed the same way, so a politician who names the PBM joins them. Blame avoidance explains why each politician takes the position. When all of them take the same position, the result is deflection. Weaver listed scapegoating among the strategies of blame avoidance. Politicians find it easiest to place blame on the one with the weakest local constituency.
Attacking PBMs sets neither party apart, because the other party is saying much the same thing. It only keeps a politician from being the one who said nothing. Two signs across an intersection read the same for the same reason. A gas station gains no customers by matching the sign across the street. It only avoids being the one whose sign reads differently.