田纳西州伊丽莎白顿的艾米和查理·约瑟夫，在政治上立场相反，但都对药房福利经理（即PBM）抱有共同的蔑视。
Amye and Charlie Joseph of Elizabethton, Tenn., are on opposite sides politically, but have a shared disdain for pharmacy benefit managers, known as PBMs.
Earl Neikirk/KFF健康新闻Amye Joseph表示，美国的政治两极分化使她的田纳西州家庭成为“有趣的时刻”。
Earl Neikirk/KFF Health News Amye Joseph says America's political polarization has made it an "interesting time" in her Tennessee household.
她和丈夫查理已经结婚35年了。她是共和党人。他是民主党人。但他们对利润驱动的医疗保健的共同幻灭提供了一个统一的目标：药房福利经理，称为PBM。
She and her husband, Charlie, have been married for 35 years. She's a Republican. He's a Democrat. But their shared disenchantment with profit-driven healthcare has provided a unifying target: pharmacy benefit managers, known as PBMs.
约瑟夫夫妇的挫败感集中在CVS Health上。该集团去年报告收入4000亿美元，包括一家大型健康保险公司（Aetna）、该国主要的PBM之一（CVS Caremark）和美国最大的零售药店连锁店（CVS Pharmacy）。“我们讨厌CVS。我要说实话，”艾米·约瑟夫说。
The Josephs' frustration is focused on CVS Health. The conglomerate, which reported $400 billion in revenue last year, includes a major health insurer (Aetna), one of the country's dominant PBMs (CVS Caremark), and America's largest retail pharmacy chain (CVS Pharmacy).
她对缺乏与药剂师面对面的互动、价格似乎在没有任何解释的情况下上涨以及这对夫妇的CVS Caremark药物计划的压力感到遗憾，要求他们使用CVS商店而不是当地的药房。
"We hate CVS. I'm going to be straight-up," Amye Joseph said.
“他们甚至不是中间人，”她说。“他们是CVS的抢钱者。“PBM被认为是一种管理处方和降低成本的方法。但这些中间人已经成为两党的出气筒，被指控以牺牲雇主、政府和病人的利益为代价攫取利润。
She laments the lack of face-to-face interaction with pharmacists, prices that seem to rise without explanation, and pressure from the couple's CVS Caremark drug plan to use CVS stores instead of their local pharmacy.
尽管华盛顿特区的医疗保健辩论仍然存在民主党和共和党的分歧，在一个对医疗保健成本上涨普遍感到沮丧的时代，采取PBM已成为一项统一的事业。
"They're not even a middleman," she said. "They're a money grab for CVS." PBMs were conceived as a way to manage prescriptions and hold down costs. But these middlemen have become bipartisan punching bags, accused of sucking up profits at the expense of employers, governments, and patients.
近年来，每个州都对PBM施加了限制。约瑟夫夫妇的家乡田纳西州共和党锁定了该州政府，越来越多的公司希望禁止拥有PBM的公司同时拥有实体药店，就像CVS一样拥有实体药店。
And while healthcare debates still divide Democrats and Republicans in Washington, D.C., taking on PBMs has become a unifying cause in an era of widespread frustration over rising healthcare costs.
这将保守、亲商的共和党人与传统上对政府监管更加开放的民主党人结盟。
In recent years, every state has imposed restrictions on PBMs. The Josephs' home state of Tennessee, where the GOP has a lock on state government, is among a growing number looking to outlaw companies that own PBMs from also owning brick-and-mortar pharmacies, as CVS does.
46brooklyn Research的首席执行官安东尼奥·奇亚恰（Antonio Ciaccia）表示，这项立法推动反映了即便是共和党内部也普遍感到，处方药市场正被操纵。46brooklyn Research是一家追踪药品定价的非营利智库。
That's aligned conservative, business-friendly Republicans with Democrats, who are traditionally more open to government regulation.
奇亚恰是PBM行业的批评者，他表示：“共和党人正在关注这个问题，他们说道：‘我们知道竞争本应发挥什么作用，但现实并非如此。’‘这根本不是一个自由市场。’”如今担任清洁工、曾是一名消防队队长的查理·约瑟夫（Charlie Joseph）在意识到，如果他在当地药店用现金支付，而不是使用自己的CVS Caremark药品计划，就能节省血压药的费用时，感到非常不满。
This legislative push reflects a feeling even in the GOP that the market for prescription drugs is being gamed, said Antonio Ciaccia, CEO of 46brooklyn Research a nonprofit think tank that tracks drug pricing.
现在，他以原本通过CVS计划购买30天药量的价格，就能买到90天的药量。
"Republicans are looking at this issue, saying, We know what competition is supposed to do, and it isn't happening, " said Ciaccia, a critic of the PBM industry. "This is not a free market." Charlie Joseph, a retired fire captain who now works as a custodian, was miffed when he realized he could save money on his blood pressure medication if he paid cash at his local pharmacy rather than using his CVS Caremark drug plan.
他说：“目前来说，这与其说是什么大问题，不如说是一种不便，但整个过程缺乏一致性。‘整个医疗体系，即使在好日子里，也令人感到沮丧。’”来自田纳西州伊丽莎白顿的查理和艾米·约瑟夫（Amye Joseph）并不喜欢与药品福利管理公司打交道。PBM公司原本被设计为药企与保险公司之间的中介，负责协商药品价格，但如今却因医疗成本问题而成为两党共同愤怒的目标。
He now buys a 90-day supply for the same price he would have paid for a 30-day supply through the CVS plan.
CVS发言人菲尔·布兰多（Phil Blando）表示，单种药品的价格可能会有所不同。
"Right now, it's more of an inconvenience than anything else as far as it goes, but there's no consistency," he said. "The whole healthcare thing is just frustrating, on a good day." Charlie and Amye Joseph of Elizabethton, Tenn., don't like dealing with pharmacy benefit managers. PBMs, designed as intermediaries between drugmakers and insurance companies to negotiate drug prices, have become targets of bipartisan anger over health costs.
他在一份声明中称：“仅看单一处方药的价格，并不能反映全面药品福利的价值。我们的重点仍然是为会员和计划赞助商提供尽可能低的总成本以及最大的整体价值。”
CVS spokesperson Phil Blando said the price of individual drugs can vary.
PBM官员则称，他们的行业遭到了不公平的指责。代表全美PBM公司的药品护理管理协会（Pharmaceutical Care Management Association）发言人格雷格·洛佩斯（Greg Lopes）表示：“PBM是处方药供应链中唯一致力于降低药品成本的环节，这使其成为了大型制药公司和药剂师等强势团体的攻击目标。”
"Looking at the price of a single prescription does not reflect the value of a comprehensive pharmacy benefit," he said in a statement. "Our focus remains delivering the lowest possible total cost and the greatest overall value for members and plan sponsors." Unified opposition PBM officials say their industry has been unfairly maligned. "PBMs are the only part of the prescription drug supply chain working to lower drug costs, which makes PBMs the target of powerful groups, Big Pharma and pharmacists," said Greg Lopes, a spokesperson for the Pharmaceutical Care Management Association, which represents PBMs across the nation.
“制药公司试图将高药价的责任推给PBM，以维持自身的利润空间，并削弱PBM降低药价的能力，”他说。
"Drug manufacturers attempt to shift blame for high drug costs to PBMs in order to retain their profit margins and weaken PBMs' ability to lower costs," he said.
乔治华盛顿大学研究医疗竞争问题的律师兼经济学家巴拉克·里奇曼表示，制药公司多年来一直试图将PBM描绘成不必要的中间商。他将大型制药公司与PBM之间的对抗称为一场企业界的“笼中对决”。
Drugmakers have worked for years to cast PBMs as unnecessary go-betweens, said Barak Richman, a lawyer and economist who studies healthcare competition at George Washington University. He called the fight between Big Pharma and PBMs a corporate "cage match."
“在医疗领域的许多问题上，我们存在着极为激烈且充满偏见的党派分歧，”他说，“但也有很多医疗政策，我认为并不明显带有党派色彩。”
"We have wildly passionate partisan divides on a lot of healthcare," he said. "But there's a lot of healthcare policy that I don't think is obviously partisan."
PBM并未赢得许多民主党人或共和党人的支持。去年，近40个州和美国领土的总检察长致信国会领导人，指出“水平整合与垂直整合已将PBM从有价值的行政服务提供者，转变成垄断市场的巨大企业”。在田纳西州等州的立法机构中，PBM与药房的共同所有权尤其受到抨击。独立药房几乎没有选择，只能与大型PBM签订合约，同时还要与大型集团拥有的药房竞争。许多立法者表示，他们希望保护小型企业。
PBMs haven't won over many Democrats or Republicans. Attorneys general from nearly 40 states and U.S. territories last year wrote a letter to congressional leaders arguing that "horizontal consolidation and vertical integration have transformed PBMs from useful administrative service providers into market-dominating behemoths." In state legislatures like Tennessee's, shared ownership of PBMs and pharmacies has drawn particular fire. Independent pharmacies have little choice but to contract with major PBMs while also competing with the conglomerate-owned pharmacies. Many lawmakers have said they want to protect small businesses.
田纳西州参议员鲍比·哈什巴格在二月份的一次立法听证会上表示：“如果一家企业主张，其药房除非由设定偿付率的同一实体拥有，否则无法生存，那么我们谈的就不再是自由市场，而是控制。”
"If a corporation argues that its pharmacy cannot survive unless it is owned by the same entity that sets the reimbursement rate, then we're not talking about a free market. We're talking about control," Tennessee state Sen. Bobby Harshbarger said in a February legislative hearing.
哈什巴格是一名共和党人，他领导了此次立法推动工作，同时也是田纳西州东北一个小城市的药剂师。
Harshbarger, a Republican who led the legislative push, is a pharmacist in a small city in northeastern Tennessee.
他的母亲、美国众议员戴安娜·哈什巴格（田纳西州共和党人）也是一名药剂师，并曾在联邦层面提出类似的PBM所有权禁令。参议院的版本法案则促成了一些意想不到的盟友合作，例如马萨诸塞州民主党参议员伊丽莎白·沃伦和密苏里州共和党参议员乔什·霍利。
His mother, U.S. Rep. Diana Harshbarger, R-Tenn., is also a pharmacist and has sponsored a similar PBM ownership ban at the federal level The Senate version has brought together some unlikely bedfellows, such as Sens. Elizabeth Warren, D-Mass. and Josh Hawley, R-Mo.
州议员与CVS的交锋：CVS官员辩称，田纳西州的这项立法方向错误。“任何拟议的改革都应以是否改善医疗可及性、简化患者就医流程以及提升负担能力为标准进行评估，”布兰多在一份声明中表示。
State lawmakers vs. CVS CVS officials argued that the Tennessee legislation was misguided. "Any proposed reform should be evaluated based on whether it improves access to care, simplifies the patient experience, and enhances affordability," Blando said in a statement.
目前尚不清楚禁止PBM（药品福利管理公司）所有权的法案是否真能在田纳西州实现这些目标。
It's unclear whether the PBM ownership ban will do that in Tennessee.
州议会研究人员的分析得出结论，该法案可能在短期内推高医疗成本。
alysis by the state legislature's researchers concluded that the bill could drive up healthcare costs in the short term.
为反对该法案，CVS发起了一场耗资700万美元的电视广告活动，声称如果法案通过，它将不得不关闭在该州所有的134家药店。这与该公司在邻州阿肯色州的做法类似——2025年当地议员通过类似措施时，CVS也曾发出过类似威胁。
To fight the bill, CVS launched a $7 million TV advertising campaign claiming it would have to close all its 134 pharmacies in the state, similar to its threat in neighboring Arkansas when state lawmakers there passed a similar measure in 2025.
CVS还向田纳西州的顾客发送了短信，呼吁他们联系议员，以维持药店继续营业。
CVS also sent text messages to Tennessee customers, asking them to contact their lawmakers to keep pharmacies open.
去年，CVS发出的这些“警告性”短信曾帮助推翻了路易斯安那州的另一项PBM所有权禁令。
Ominous texts from CVS helped kill another PBM ownership ban in Louisiana last year.
该法案的提案者表示，关闭药店并非唯一选择：CVS也可以选择出售其药店或PBM业务。
Sponsors of the legislation said closure wasn't the only option: CVS could also divest either its stores or its PBM.
但田纳西州的议员们仍决定推进该法案。来自田纳西州东北部（约瑟夫一家居住地）的共和党州参议员拉斯蒂·克罗在投票前对同事们表示，如此强烈的反对恰恰说明他们触碰到了关键问题。
Tennessee lawmakers moved forward. State Sen. Rusty Crowe, a Republican from northeastern Tennessee, where the Josephs live, told his colleagues before the vote that they should consider the fierce resistance a sign that they were onto something.
“我在越南战争期间就学到过，当你开始遭到火力攻击时，就说明你已经飞到了那个该死的目标上空，”他说。
"I learned when I was in the Vietnam War, when you start taking on flak, you know you're over the damn target," he said.
和田纳西州议会的大多数投票一样，共和党人并不需要民主党人的支持。但这一次，他们还是得到了支持。
As with most votes in Tennessee's legislature, Republicans didn't need support from Democrats. But they got it anyway.
田纳西州众议员、来自孟菲斯的民主党人安东尼奥·帕金森表示，他感觉自己是在投票支持降低药品价格，并支持“夫妻店”式药店。“如果这对我的选民有好处，我就会支持。”在已通过所有权禁令的州中，CVS并未出售或关闭其药店——这些法律尚未生效。在CVS质疑该法律合宪性后，阿肯色州的禁令正在法院面临诉讼。CVS也在田纳西州提起了诉讼，尽管该州的所有权禁令要到2028年才会生效。
State Rep. Antonio Parkinson, a Democrat from Memphis, said he felt like he was voting in favor of lower drug prices and supporting "ma and pa" pharmacies. "If there's a benefit to my people, I'm supporting it." CVS has not divested or closed its pharmacies in states that have passed ownership bans — the laws have yet to take effect. The Arkansas ban is being held up in court after CVS challenged the constitutionality of the law. CVS also sued in Tennessee, though the ownership ban doesn't take effect until 2028.
本报道来自NPR与纳什维尔公共广播电台KFF健康新闻的健康报道合作项目。
This story comes from NPR's health reporting partnership with Nashville Public Radio KFF Health News