Opinion by: Angie Carraway, Democratic candidate for Texas House District 89
Most of us have stood behind someone at the pharmacy counter doing quiet math, deciding which prescription to fill this month and which one can wait.
About one in four adults say they haven’t filled a prescription in the past year because of cost. Older Americans aren’t insulated from it. Many take several medications a month, so even small increases add up fast. We talk about that problem often. We rarely ask who sets the price.
The Middleman
There’s a middleman in the prescription system. It’s called a pharmacy benefit manager, or PBM. Most families have never heard the term. But three of these companies now process nearly 80 percent of the prescriptions filled in this country.
They decide which drugs your plan covers. They decide what your pharmacy is paid. They decide what you owe at the counter. And increasingly, they own the pharmacies they’re supposed to be bargaining with.
Markets work when the rules are clear and the players are visible. This system has neither.
What the Investigators Found
Federal investigators have spent two years examining how these companies operate. The three largest PBMs marked up specialty generic drugs—including medicines for cancer, HIV and transplant patients—by hundreds and sometimes thousands of percent at their own affiliated pharmacies.
Those markups brought in more than $7.3 billion above what the drugs cost to acquire in just six years. The same companies collected an estimated $1.4 billion more through spread pricing, where they bill a plan one price, pay the pharmacy less and pocket the difference.
Last year, the Federal Trade Commission sued the three largest PBMs over insulin. Regulators say the way these companies negotiated rebates helped inflate the list price of a drug people need to stay alive.
Where the Line Actually Is
I want to be fair. PBMs aren’t the only reason prescriptions cost too much. Manufacturers set list prices. Insurers and federal policy shape them, too. Anyone who tells you there’s a single villain is selling something.
But this much isn’t in dispute. A few companies control the pipeline between you and your medicine. They operate with almost no transparency. And they’re under active federal investigation for practices that appear to raise costs and push out local pharmacies.
Why It Matters Here
That last part matters here at home. When a PBM pays an independent pharmacy less than it pays its own, the independent one struggles. In much of this district, the neighborhood pharmacy is where people get their care and their questions answered from someone who knows their name. A billing scheme in a distant boardroom shouldn’t decide whether that pharmacy survives.
What I’d Do
So my position is simple: cut out the middleman. Remove the layer that adds cost, hides the price and steers business to itself. Let pharmacists serve patients. Let families see what they pay and why.
This isn’t a partisan idea. No one at any kitchen table in Collin County is defending a hidden markup on their child’s medicine. The real question is whether the people writing the rules in Austin work for the families paying the bills or for the companies that profit from the confusion.
I’m running because leadership should be grounded in the lives people are actually living. There’s no better example than the pharmacy counter, where the math is real and the choices are personal. We can make the price of medicine honest again. That’s work worth doing.