In a rare moment of bipartisan cooperation, U.S. lawmakers have struck an unexpected health care agreement — but whether the deal survives the political battlefield remains uncertain.
After months of stalled negotiations to renew Affordable Care Act (ACA) subsidies — which expired late last year — congressional leaders unveiled a health reform package attached to a broader government funding bill. The proposal targets long-standing concerns about pharmacy benefit managers (PBMs), expands public health programs, and boosts funding for community health centers.
However, despite support across party lines, the agreement now faces fierce lobbying pressure, ideological resistance within the Republican Party, and procedural risks in the House, all of which could derail the legislation in the coming days.
PBM Reform at the Center of the Deal
A cornerstone of the package is a proposal to reform pharmacy benefit managers — intermediaries that negotiate drug prices between pharmaceutical companies, insurers, and employers.
The bill includes a high-profile measure backed by Bill Cassidy and Bernie Sanders, which would ban PBMs from earning revenue through drug rebate arrangements — a practice critics argue inflates prescription drug prices and lacks transparency.
PBMs negotiate confidential discounts with drug manufacturers, but critics say these savings often fail to reach consumers and instead increase corporate profits. Pharmaceutical companies, facing political pressure over high drug prices, have increasingly blamed PBMs for the cost burden.
Yet, the reform has provoked intense backlash from the PBM industry, which has successfully blocked similar proposals in the past.
“Especially at a time when health insurance premiums are rising, this proposal could make costs worse,” said Eric Burlison, criticizing the Cassidy-led measure.
“I think this goes too far.”
Political Tightrope in Congress
While the deal has bipartisan appeal, it faces political landmines, particularly in the House of Representatives, where Republicans hold a narrow and fragile majority.
Conservative hard-liners could attempt to block the procedural rule required to bring the funding package to the floor — a tactic that could effectively sink the entire bill.
Lawmakers must also navigate powerful lobbying groups, including the Pharmaceutical Care Management Association (PCMA), which has spent tens of millions of dollars opposing PBM regulations over the past several years.
Since calls for reform intensified in 2023, PCMA has reportedly spent $47 million lobbying against PBM restrictions — roughly double its previous spending levels.
Democrats Weigh Policy Gains Against Political Risks
If the bill passes, it could hand Republicans a major health policy victory, even as Democrats campaign against the GOP over rising insurance premiums following the expiration of ACA subsidies.
Democrats have made health care affordability a central issue ahead of upcoming elections, criticizing Republicans for failing to extend enhanced Obamacare premium credits.
Negotiations over subsidy renewal continue in the Senate, but talks stalled before lawmakers left for a 10-day recess, with disputes over abortion policy and minimum premium payments standing in the way of a deal.
Despite these unresolved issues, some Democrats argue the PBM reforms are too important to delay.
“We’ve wanted to clean up PBMs for a long time,” said Don Beyer.
“We have to accept that not everything they do is wrong — but reform is necessary.”
Meanwhile, Kathy Castor warned that passing the bill won’t shield Republicans from voter backlash.
“Do they get credit for finally doing what they should have done all year? Maybe,” she said.
“But health care will remain a major election issue.”
White House Pressure and Trump’s Health Agenda
For many Republicans, the legislation aligns with Donald Trump’s push to end PBM kickbacks and increase transparency in insurance pricing — priorities outlined in the president’s recent health policy proposal.
By advancing the bill, GOP leaders see an opportunity to claim progress on lowering drug prices, an issue with broad public appeal.
Senator Cassidy described the package as delivering “real conservative reforms that rein in healthcare middlemen, make prescription drugs more affordable, and expand access to lifesaving treatments for children.”
However, some conservative lawmakers remain skeptical.
Chip Roy said insurers that own PBMs may simply shift tactics to preserve profits:
“They’re just going to shuffle the deck chairs and keep doing what they want.”
A Shift in GOP Free-Market Philosophy
Political observers note that Republican support for PBM regulation marks a departure from traditional free-market ideology.
“This is Congress telling private companies how they can structure contracts,” said one insurance lobbyist, speaking anonymously.
“Historically, Republicans resist that kind of interference.”
Yet rising drug costs and voter frustration appear to be reshaping party priorities.
How the Deal Came Together
The current package revives efforts that collapsed in December 2024, when a previous government funding bill — containing similar PBM provisions — was torpedoed after Elon Musk publicly criticized it.
Lawmakers are eager not to repeat that failure.
“These reforms should have passed last year,” Castor said.
“They were ready — until outside pressure derailed them.”
The groundwork for the bill has been years in the making. Committee hearings, policy markups, and stakeholder consultations throughout 2025 ensured most lawmakers are already familiar with the reforms.
One Senate aide described the PBM reforms as “baked into the system for years — sitting in a deep freezer, waiting for the right moment.”
Industry Pushback and Strategic Evasion
Despite growing political pressure, PBMs and their allies continue to wield enormous influence.
Industry groups argue that PBMs are already evolving business models to reduce costs — and warn that Congress risks raising prices by restricting flexibility.
Brendan Buck, communications chief for PCMA, argued:
“PBMs are innovating far faster than Congress could legislate. Limiting flexibility will lead to higher drug costs.”
Meanwhile, pharmaceutical companies and PBMs continue to blame each other for high prescription prices, flooding Washington with ad campaigns and lobbying efforts.
Notably, companies like Cigna, UnitedHealth, and CVS Health have already announced voluntary pricing reforms, a move analysts interpret as an attempt to get ahead of federal regulation.
Still, some lobbyists remain skeptical the bill will meaningfully change the system.
“This isn’t going to be a game changer,” said one pharmaceutical industry insider.
“It’s a small step, not a transformation.”
What Comes Next: The First Shot in a Longer War
Experts predict that even if the bill passes, it will only mark the beginning of broader health sector reform.
“This is the opening salvo in what will be a long fight to reshape health care economics,” said Sujith Ramachandran, a professor at the University of Mississippi School of Pharmacy.
With drug prices, insurance premiums, and health affordability likely to dominate election-year politics, lawmakers are expected to increase scrutiny of health care middlemen and pricing models in the months ahead.
