Even though pharmacy benefit manager (PBM) reforms are broadly popular with voters, pharmacists, and even many patient groups, the politics of large-scale reform are far more complicated. In many states, PBM legislation does not fail because lawmakers oppose patient choice — it fails because it competes with dozens of other legislative pressures and navigates partisan divides that make complex healthcare bills difficult to move forward.

Here’s how political dynamics limit big structural reforms and push states toward more modest, incremental steps like transparency requirements or audit rules.

1. PBM reform rarely rises to a “top priority” in many statehouses

Large-scale PBM reform — especially laws involving ownership bans, delinking, rebate pass-through, or strict anti-steering — is technically complex and not easily summarized. Governors and leadership often prioritize issues that are:
✔ simple to message,
✔ highly visible to voters, and
✔ tied to major budget items (schools, taxes, infrastructure, etc.).

PBM reform, by contrast, sits deep inside the machinery of the healthcare system, making it harder to communicate politically. Many lawmakers know PBM issues matter, but they often rank behind:

• education funding

• crime/policing reforms

• workforce and economic development

• Medicaid and budget negotiations

• housing or energy issues

• reproductive health or behavioral health legislation

When legislative sessions are short (as in many states) and political capital is limited, leadership often deprioritizes complex healthcare market reforms.

2. Partisan divisions stall bills that require bipartisan cooperation

PBM reform can be bipartisan — and often is — but it touches multiple ideological nerves that vary by state.

In left-leaning legislatures:

Lawmakers may prioritize:

• Medicaid expansion, childcare, labor rights, mental health funding.
  
  Because PBM reforms often intersect with big insurer and employer interests, some Democratic caucuses hesitate to push bills that may be seen as increasing healthcare costs for unions or self-funded public employee plans.

In right-leaning legislatures:

Conservative lawmakers may hesitate when reform resembles:

• increased regulation of private markets

• state intervention in business models

• expanded state enforcement or new bureaucratic oversight
  
  This makes sweeping structural reforms harder to unify within GOP caucuses — even when many individual Republican lawmakers champion rural pharmacy access.

In divided legislatures:

When chambers or leadership are split (one party in the House, another in the Senate), bills that require technical negotiation — like PBM reforms — often die simply because neither side wants to give the other a political victory.

Result: Only reforms that are “easy wins” (transparency rules, audits, or clarifying definitions) tend to survive divided-government environments.

3. Big reforms create political risk — small ones do not

Sweeping PBM reform comes with uncertain fiscal outcomes:

• Will employer healthcare premiums increase?

• Will insurers or large chain pharmacies threaten service cutbacks?

• Could Medicaid costs rise?

• Will PBMs sue the state and delay implementation for years?

Legislators worry about being blamed for:

• increases in drug premiums,

• network disruption,

• pharmacy desertification if chains close stores in retaliation, or

• million-dollar legal battles with national corporations.

Transparency laws, on the other hand:

• cost little money,

• create no major market disruption,

• and have limited political downside.

So political calculus leads many lawmakers to advance only low-risk incremental reforms, even if those do not meaningfully change PBM behavior.

4. PBM issues intersect with powerful interest groups and industry narratives

Partisanship doesn’t operate in a vacuum — it interacts with interest-group pressures.

PBMs, large insurers, and vertically integrated pharmacy systems are politically active. They warn legislators that sweeping reform could:

• raise plan costs for state employees,

• eliminate mail-order convenience,

• increase the cost of specialty drugs,

• or trigger federal preemption fights (ERISA, Commerce Clause).

For lawmakers, this creates political messaging complications:
Do they want to be painted as the politician who “raised healthcare costs”?
Even if the claim is misleading, few are willing to take that risk in competitive districts.

In partisan or swing states, those narratives carry more weight.

5. Short legislative calendars make complex bills difficult

Many states have:

• 30-day sessions,

• 60-day sessions, or

• biennial sessions with limited working days.

PBM reform bills often require:

• economic modeling,

• legal review,

• fiscal notes,

• stakeholder negotiations,

• public testimony from pharmacists and insurers,

• and cross-chamber revisions.

That timeline is incompatible with short or politically charged sessions.

Small transparency bills, however, can be passed quickly with minimal debate.

6. Partisan national politics spill into state debates

In some states, healthcare debates are shaped by national-level polarization.
PBM reforms — especially those involving prescription drug prices — risk being treated as symbolic “healthcare fights” tied to national narratives:

• “Government overreach into healthcare markets”

• “Corporate abuse of patients through consolidation”

• “States vs. big federal players”

These national frames complicate local compromise.

The more partisan an issue becomes, the smaller the window for bipartisan, structural solutions.

Bottom Line:

PBM reform sits at the intersection of complex policy, powerful industry influence, and partisan political dynamics.
Because of this:

• Big structural reforms require bipartisan alignment, political capital, and legislative time — all scarce resources.
• States with divided legislatures or tight calendars tend to avoid high-risk reforms.
• Incremental transparency measures usually win because they are easier to pass, cost less politically, and carry fewer legal risks.

The result is a patchwork of partial reforms, where only a minority of states implement the bold, structural changes that most directly impact patient choice, independent pharmacy stability, and community healthcare access.