A Turning Point in Health Policy: PBM Reform, Integration, and the Rise of DTC Drugs

Affordability—particularly the rising cost of health care—is front and center heading into the 2026 midterms. Elected officials ushered in significant health policy changes in 2025 and promised more action to ease patients’ financial burdens. Three key issues will drive the health policy agenda in the year ahead: reactions to the long-awaited passage of pharmacy benefit manager (PBM) reform; growing concern around vertical integration in health care; and the rise of direct-to-consumer (DTC) prescription drug sales. Here’s a rundown of what that might look like—and the potential impact on the marketplace. 

After prolonged debate, PBM reform was signed into law on February 3, 2026.¹ It delivered substantive changes, though less sweeping than many expected. To briefly recap, the bill:

• Mandates a flat-dollar fee structure for PBMs in all Part D plans, including through Medicare Advantage, regardless of drug price (aka “delinking”);
• Imposes an any-willing-pharmacy requirement for Part D plans, with Centers for Medicare & Medicaid Services (CMS) to publish standards for “reasonable and relevant” contract terms;
• Creates new reporting and transparency requirements in Part D and commercial PBM contracts; and
• Mandates that PBMs pass through 100 percent of rebates to Employee Retirement Income Security Act (ERISA) plan sponsors.

Notably absent from the law were a Medicaid spread pricing ban and the mandatory National Average Drug Acquisition Cost (NADAC) survey. They were part of the PBM reform package that almost passed in December 2024, but appear to have fallen out because the Congressional Budget Office (CBO)—responsible for estimating the costs of pending legislation—revised its analysis or “score” on spread pricing. It had previously been scored as saving $200 million over 10 years, but was revised to be a net expenditure, up to $7 billion over the same period.² The original score was paired with the NADAC survey, but I haven’t yet confirmed if they were still connected in the latest score or if it evaluated spread pricing separately.

Moving on to what became law, I was surprised by the regulation of commercial plans under ERISA. Traditionally, Republicans have held broad views on the freedom of contract; reluctant to dictate terms to private entities. This marks a change, although both parties have become more populist recently, especially on health care. This suggests Republicans may be willing to go further on regulating commercial activity than in the past.

Given that there are other PBM reform proposals still floating around, they may revisit this subject soon.

The jury is still out on how much change this reform will bring. Supporters heralded it as a watershed moment, and opponents were sharply critical of its impact on patient costs, especially premiums. I’m somewhere in the middle. It will certainly induce some change; I think the Part D any-willing-pharmacy provision is the most significant reform and may be a bellwether for future commercial changes. The transparency requirements may lead to more savvy contracting, but much of the information covered may not be actionable. Further, the market anticipated reform and made advanced preparations, so the impact of delinking and rebate pass-throughs is likely to be muted. Rebates make up a much smaller share of PBM revenue than they did 10 years ago, with many plans and PBMs moving to fee-based contracts. Some changes will be introduced, but the ceiling for change is low, and it’s unclear if patients will notice an impact on their pocketbooks.

Vertical integration is a longstanding topic of debate around managed care policy. But after successful PBM reforms, it has become a focus for critics of the US health care system. Congressional scrutiny on vertical integration this year has largely been on PBM- and health plan-owned group purchasing organizations (GPOs). In some ways, this makes sense; GPOs stand to grow in importance in an administrative fee-based environment. On the other hand, it’s a niche topic that doesn’t lend itself to easy description.

GPOs negotiate drug prices on behalf of multiple health care purchasers. Those purchasers could be groups of small businesses, groups of smaller regional health plans or PBMs, you name it, but the goal is to use their combined market power to achieve greater discounts than they could individually. While there are some independent GPOs, most are owned by large PBMs. Supporters contend that the combined market power benefits smaller actors with fewer resources, but critics argue that GPO fees are opaque and used to retain rebate revenue that should be passed along to plan sponsors.

At hearings in January and February, members of Congress pressed PBMs and their trade association representatives on the role of GPOs in drug pricing, questioning whether they were truly lowering costs for patients.³ Also in February, the Federal Trade Commission (FTC) reached a settlement with ExpressScripts—the PBM owned by Cigna—over their use of rebates in insulin coverage. As part of this settlement, ExpressScripts agreed to relocate its GPO, Ascent Health Services, from Switzerland to the United States. While unlikely to have a big impact on costs, it does mean that Ascent is fully governed by US transparency and antitrust laws.

Stakeholders should also keep a close eye on the Break Up Big Medicine Act (S. 3822), introduced on February 10 by Senators Josh Hawley (R-MO) and Elizabeth Warren (D-MA).⁴ This bill, which may be more about messaging than legislating, would go far in restricting vertical integration in health care. It would prohibit a parent company from simultaneously owning a health plan or PBM, an administrative services company (payroll processing and claims, for example), and a health care provider, such as a hospital, primary care practice, or outpatient pharmacy. Companies owning both would be required to divest conflicting interests within one year of enactment or have a portion of their revenue placed in escrow until compliance is met. Passage would have massive repercussions for the US health system, affecting virtually every major insurer. 

How would this affect integrated delivery networks (IDNs)? The language plainly covers IDNs, but I have a hard time imagining that was intentional on the part of the sponsors. Entities like Kaiser Permanente and UPMC are not typically the targets when policymakers express concern about vertical integration in health care. 

I would be remiss if I didn’t mention one of this year’s splashiest issues: TrumpRx and the rise of DTC drug sales. TrumpRx launched on February 5, 2026, with 43 drugs listed and no integration with insurance benefits. While there are a couple of drugs with TrumpRx-exclusive prices, most drugs listed simply repackage discounts available elsewhere, either through manufacturer direct programs or GoodRx coupons.⁵ In fact, the TrumpRx coupons have the same BINs and PCNs as GoodRx. Further, 22 of the 43 drugs listed have lower-cost generics available elsewhere. Given that the site does not integrate with users’ insurance benefits, there’s an extra hurdle for patients who want to compare prices. The TrumpRx site even notes that lower prices may be available through health insurance. 

As a pessimist, TrumpRx has yet to win me over. With few exceptions, these are almost certainly not the most-favored-nation (MFN) prices we heard so much about. Unless the MFN prices are somehow coincidentally the exact prices that already existed in other DTC channels, which seems unlikely. For now, we’ll have to wait and see how this develops. President Trump has called for Congress to codify his MFN deals, which I understand to mean that Congress should make MFN pricing mandatory in perpetuity. One interesting piece of this puzzle is the recent settlement between the FTC and ExpressScripts, where ExpressScripts agreed to count TrumpRx out-of-pocket costs towards enrollees’ deductibles. We’ll have to wait and see how this looks in practice, but it may help motivate benefit integration—which could improve the user experience, at least.

Affordability will dominate political conversation this year, especially in health care. The first wave of PBM reform is now law, vertical integration is under scrutiny, and DTC models are testing the benefit system’s boundaries. Each promises disruption. However, whether these developments will result in meaningful reductions in patient costs remains uncertain. 

1. Congress Unveils Minibus Funding Bill with Health Extenders. AMCP. Published January 22, 2026. Accessed March 25, 2026. https://www.amcp.org/sites/default/files/2026-02/fedupdate_jan_26_hhs_approps_proposal.pdf
2. Lim D. Congress targets PBs in bipartisan deal. Politico. Published January 21, 2026. Accessed March 25, 2026. https://www.politico.com/newsletters/prescription-pulse/2026/01/21/congress-targets-pbms-in-bipartisan-deal-00737795
3. House Health Committees Hold Hearings with Health Insurer CEOs. AMCP. Published January 22, 2026. Accessed March 25, 2026. https://www.amcp.org/sites/default/files/2026-02/legupdate_jan26_insurer_hearings.pdf
4. Warren, Hawley Introduce Bipartisan Bill to Break Up Big Medicine. Press release. Elizabeth Warren.  Published February 10, 2026. Accessed March 25, 2026. https://www.warren.senate.gov/newsroom/press-releases/warren-hawley-introduce-bipartisan-bill-to-break-up-big-medicine
5. Wilkerson J, Parker JE, Cirruzzo C, Chen E, Payne D. TrumpRx claims to offer the lowest prices. But many drugs have cheaper generics. Stat News. Published February 6, 2025. Accessed March 25, 2026. https://www.statnews.com/2026/02/06/trumprx-discount-drug-website-undercut-by-cheaper-generics/ 

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