Congress’ health deal still has hurdles

After months of fruitless negotiations to extend Affordable Care Act subsidies that have since expired, congressional leaders announced Tuesday they’d notched a rare bipartisan win to overhaul other parts of the health care system.

Now they just have to hold onto it.

The agreement, attached to a government spending bill, would implement long-sought changes to the way pharmacy benefit managers operate, as well as extensions of public health programs and increased funding for community health centers. But even with strong support in both chambers, the bill faces significant hurdles.

Lawmakers must navigate around the powerful lobbyists for pharmacy benefit managers, or PBMs — the intermediaries who negotiate drug prices on the behalf of employers and insurers — who have handily defeated similar proposals in the past.

They also must reckon with conservative hard-liners who don’t like some of the provisions and could be prepared to weaponize the House GOP’s perilously slim margins to tank the effort by opposing a party-line procedural rule that would bring the funding measure to the floor.

One such provision in the health care package, championed by Sen. Bill Cassidy (R-La) and Bernie Sanders (I-Vt.) — the chair and ranking member of the Senate HELP Committee, respectively — would prevent PBMs from getting revenue from drug rebates. This proposal, which has buy-in from Senate and House GOP leadership, has infuriated the industry and its allies.

“Especially in the time in which we’re seeing health insurance premiums go up, this is just going to make it worse,” said Rep. Eric Burlison (R-Mo.) in an interview Wednesday. “What Senator Cassidy has done has gone, I think, way too far over the line.”

PBMs negotiate rebates, or discounts, with drugmakers for employer health plans and other payers in an opaque process that has drawn scrutiny over whether discounts are passed on to consumers or retained to boost profits. Drugmakers, under pressure to reduce high prescription drug prices, have been pointing the finger at PBMs as the culprit.

A spokesperson for Cassidy declined to comment.

If the health care package passes as part of the government funding measure, Democrats will have helped Republicans with a major health victory at a time when the GOP is particularly vulnerable on the issue.

Democrats have been hammering Republicans for months over their inaction on extending the enhanced Obamacare subsidies that lapsed at the end of last year. They have made the premiums that have skyrocketed as a result the centerpiece of a nascent midterm campaign assailing Republicans on “affordability.”

Talks for a subsidy extension remain ongoing in the Senate, but lawmakers left last week for a 10-day recess without reaching a deal. Abortion restrictions and minimum premium payments are the biggest impediments to landing a compromise.

For many Republicans, the health care bill they want to pass now as part of legislation to fund several government agencies —including Health and Human Services — also answers President Donald Trump’s demands that Congress end kickbacks to PBMs and require more transparency from insurers. Those elements were included in the president’s health care proposal released last week.

Some Democrats said the policy goal was too important to pass up, even though the deal did not include an extension of the ACA subsidies. A similar effort at the end of 2024 was torpedoed when billionaire Elon Musk blasted government funding legislation that contained the PBM measures, and there’s a desire not to squander the same opportunity this time around.

“We’ve wanted to clean up PBMs. We have to believe that not everything they do is wrong,” said Rep. Don Beyer (D-Va.) Wednesday.

Rep. Kathy Castor (D-Fla.), meanwhile, warned that while Republicans did the right thing on PBMs, it doesn’t mean healthcare will not be a major issue in the midterms.

“Do they get credit for doing the right thing [that] they should have been doing all year long? Okay,” she said.

The GOP and free-market healthcare 

Cassidy, in a statement, said the health package delivers “real, conservative reforms that rein in healthcare middlemen, make prescription drugs more affordable and increase access to lifesaving treatments for children.”

The rebate provision in the bill he authored with Sanders does have support from traditional GOP allies in the business sector. The ERISA Industry Committee, which represents self-funded large employer health plans, has repeatedly pushed for targeting PBM rebates among other reforms.

Rep. Chip Roy (R-Texas) said earlier this week he is still reviewing the package, but mainly wanted more transformational overhauls as insurers who own PBMs could potentially negate any changes.

“I am for the reforms, but at the end of the day insurers own the PBMs and they are just going to shuffle the deck chairs around and keep doing what they want to do,” he said.

For Washington’s influence sector, Republican support for the PBM changes mark a shift within the party away from its free market orthodoxy.

“It’s really like Congress dictating how two private companies can contract … From a historical context, Republicans are not big on interfering with the present marketplace,” said one insurance lobbyist granted anonymity to speak candidly.

Making a deal 

Lawmakers have pushed to return to PBM overhaul legislation since the Dec. 2024 package’s collapse.

“These should have been passed, a lot of them, last year,” said Castor. “They were poised to pass until Elon Musk got involved.”

House Republicans have also been eager to make up for failed attempts to include several health care provisions in their sweeping tax and spending megabill last summer, but they were stripped out in the Senate for not complying with the rules governing the budget reconciliation process.

January offered an enticing opportunity for lawmakers to try again as efforts to craft full-year appropriations bills picked up steam. Normally a health package runs as part of a larger, must-pass government funding measure to help ensure its success.

But the government has been running on stopgap spending bills since March 2024. House Republican leadership has been reluctant to add policy riders to such bills to ensure enough support from fiscal hawks.

This health care package came together relatively quickly this month as most of the items had already been considered – and vetted – previously, chiefly in the scrapped Dec. 2024 government funding legislation. There also were markups and committee hearings on the package’s contents, including regarding PBMs, throughout 2025, giving lawmakers a chance to become familiar with the policies. including on PBM reform, according to a Senate aide familiar with the negotiations.

Pharmacy benefit managers “hate” the reforms “but they … should not be surprised, because it's been baked,” said another Senate GOP aide familiar with the health care package, granted anonymity to speak candidly of the PBM provisions. “And the cake has been sitting on a shelf in a deep freezer, perfectly maintained for like three years.”

Industry evasion 

Even with the latest proposed changes designed to bring accountability to PBMs and how they operate, lobbyists representing insurers, pharmaceutical companies and pharmacies say that PBMs have still largely outmaneuvered Congress.

The industry has spent years evading bipartisan congressional scrutiny, even as state legislatures moved in to reign in the sector. Since calls for reform took off in 2023, the Pharmaceutical Care Management Association, a major trade group, spent $47 million lobbying elected officials against placing guardrails on PBMs — about twice its spending from the prior three-year period.

“The market has outpaced Congress on this by a pretty wide margin,” said Adam Colborn, associate vice president at the Academy of Managed Care Pharmacy, which counts UnitedHealth, CVS Health, and Express Scripts as members. “There’s been a lot of emotion on both sides of the debate, but getting down to the nuts and bolts, there’s a relatively low ceiling for change.”

In October, Cigna announced that it would overhaul its pricing model and remove its system based on rebates, following a commitment from UnitedHealth to pass through 100 percent of rebates in January and a decision from CVS to do so in 2019 — a move analysts view as an effort by industry to get ahead of reform efforts on Capitol Hill.

“I don't think anybody's gonna be shooting off fireworks here … It’s not going to be a game changer,” said one pharmaceutical lobbyist, granted anonymity to share internal discussions of the health care deal currently pending before lawmakers.

On Tuesday, PCMA slammed the Cassidy-Sanders PBM provision, warning that such a proposal would limit companies’ ability to use alternative payment models and raise prices and urging Congress to shift its scrutiny on the pharmaceutical industry instead.

“PBMs are innovating business models to lower costs and meet employer demands far more quickly than Congress could ever implement,” Brendan Buck, PCMA’s chief communications officer, said in a statement. “It makes no sense to ban flexibility and choice and lock employers into a single system that will lead to higher drug costs.”

In September, PCMA launched a six-figure ad campaign in Washington accusing pharmaceutical companies of keeping prices high, following a similar campaign targeting PBMs from the Pharmaceutical Research and Manufacturers of America, which represents brand-name drugmakers in May.

Lobbyists and experts predict the PBM overhauls proposed by Congress are likely only the beginning as lawmakers ramp up scrutiny of the health care sector over high prices – and seek more opportunities to show voters in an election year they care about lowering health care costs.

“This is the opening salvo in what is going to be a long battle for reform,” said Sujith Ramachandran, an assistant professor at the University of Mississippi School of Pharmacy.