The Patients Before Monopolies Act and What Actually Lowers Drug Costs

Lower prescription drug prices are a goal shared across the political spectrum, and the debate over how to achieve them is one of the most consequential in American health policy. On May 13, 2026, that debate sharpened. Senators Elizabeth Warren and Josh Hawley, joined by Representatives Diana Harshbarger and Jake Auchincloss, reintroduced the Patients Before Monopolies Act, a bipartisan bill that would prohibit the parent company of a pharmacy benefit manager or an insurer from owning a pharmacy, and require any company in violation to sell its pharmacy business within one year.

The bill addresses a real and widely held concern about conflicts of interest in an integrated drug supply chain. The question worth examining on the evidence is whether forced structural separation is the approach most likely to lower what Americans pay for medicine, particularly when Congress enacted a different, more targeted set of reforms only months earlier. The answer points toward addressing conduct and the true drivers of drug prices rather than dismantling corporate structures.

What the Bill Would Do

The Patients Before Monopolies Act is the narrower successor to the broader Break Up Big Medicine Act, which extended structural separation across insurers, PBMs, wholesalers, and providers and has stalled in committee. The new bill focuses specifically on pharmacy ownership.

Its central provisions prohibit a parent company of a PBM or insurer from owning a pharmacy business, require divestiture of any pharmacy holdings within one year, and impose automatic penalties for noncompliance, including disgorgement of revenue and forced asset sales. It empowers the Federal Trade Commission, the Department of Health and Human Services, the Department of Justice, and state attorneys general to enforce the law, and the 2026 version adds a new private right of action allowing individuals to sue, with treble damages and attorney fees available to prevailing plaintiffs.

Congress Already Chose a Targeted Approach

The structural-separation debate is occurring against a notable backdrop: Congress enacted significant, conduct-based PBM reforms only months ago. The Consolidated Appropriations Act of 2026, signed in February, delinks PBM compensation in Medicare Part D from the price of a drug or the rebates a PBM negotiates, replacing that arrangement with a flat, transparent service fee. It requires PBMs to pass through 100% of rebates and discounts to employer health plans governed by federal law, mandates new disclosure, and authorizes civil penalties for noncompliance.

These reforms target the specific conflict of interest at the center of the criticism: the incentive for a PBM to favor higher-priced drugs because its own compensation rose with the price. The Congressional Budget Office estimated that the enacted PBM provisions would reduce the federal deficit by about $2.1 billion over ten years. This is the evidence-based path in action, a remedy aimed directly at misaligned incentives, scored as a net savings, now becoming operational. The sound course is to let these reforms take effect and measure their results before turning to a far more disruptive structural remedy.

The Real Driver of Drug Prices

Any serious effort to lower drug costs has to begin with how those costs are set. List prices are set by drug manufacturers, not by PBMs or pharmacies. As health policy analysts at Avalere note, rebates negotiated by PBMs do not lower a drug's list price, because the manufacturer sets it; what rebates and discounts do is reduce the net cost of medicines to payers. Plan sponsors then use that rebate revenue to buy down premiums across all enrollees, according to the Congressional Research Service.

This is the function that scale and negotiating leverage perform in the drug supply chain. PBMs negotiate rebates, promote generic substitution, and apply administrative efficiencies that reduce net drug spending for the insurers, employers, and government programs that hire them. Removing a company's pharmacy operations does not change the manufacturer's list price, which is the figure that most directly determines what the system pays. A reform that reorganizes corporate ownership while leaving list-price dynamics untouched risks imposing significant disruption without reaching the principal cause of high prices.

Why Forced Divestiture Is a Blunt Instrument

Structural separation is among the most far-reaching remedies in the regulatory toolkit, and its consequences are correspondingly large. Roughly 77% of commercial and Medicare Part D enrollees are in plans where the insurer and PBM share a parent company, a figure that rises to 88% within Part D. A forced, one-year divestiture mandate would compel the rapid restructuring of companies that administer drug benefits for the large majority of insured Americans, with the integration efficiencies that currently lower net costs and premiums placed at risk in the process.

The newly added private right of action compounds the uncertainty. Authorizing individual lawsuits with treble damages invites extensive litigation, the costs of which tend to find their way back into the price of coverage. A remedy whose consumer benefits are contested and whose disruption is concrete is difficult to justify as the first resort, especially when a targeted alternative has just been enacted and not yet had time to work.

A Fair Hearing for the Other View

The case behind the bill is serious and deserves a fair statement. The Federal Trade Commission has brought enforcement actions against major PBMs, including over insulin pricing. Research from the USC Schaeffer Center has found evidence that PBMs sometimes steer patients toward higher-priced drugs when cheaper alternatives exist, and the same center estimates that delinking PBM compensation from list prices across the supply chain could reduce net drug spending by roughly $95 billion a year. Independent community pharmacies report being squeezed by reimbursement practices, and the concentration is real: three PBMs manage close to 80% of prescription claims, each integrated with one of the largest insurers.

These are legitimate concerns, and they explain why the coalition behind the bill spans both parties and includes physicians and pharmacists. The evidence on remedies, however, is genuinely contested. Notably, the strongest savings estimates attach to delinking, a conduct-based reform of the kind Congress just enacted, rather than to forced divestiture. Economists are not unanimous even on delinking: a University of Chicago analysis cautions that poorly designed compensation rules could raise list prices and reduce appropriate utilization. The honest reading of the literature is that targeted reforms have measurable support, while the case that forced structural separation would lower what patients pay remains unproven.

The Path That Follows the Evidence

The shared objective is lower drug costs and a fair deal for patients and independent pharmacies. The most direct route runs through conduct and list prices: the delinking and transparency reforms now entering force, continued enforcement against demonstrated misconduct, and sustained attention to the manufacturer pricing that sets the starting point for everything downstream. Those tools address the documented problems without dismantling the integrated operations that negotiate discounts, promote generics, and hold net costs and premiums down for tens of millions of enrollees.

A measured policy judges companies by their conduct and their results. The reforms Congress enacted in February reflect that standard. They deserve the chance to work, and their results deserve to be measured, before the country commits to a structural remedy whose benefits are uncertain and whose disruption is not.