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Pharmacists and policymakers in Washington may love the idea of keeping big health insurers from owning big pharmacy benefit managers.
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Analysts at one of the companies in charge of determining whether the big health insurers can make their bond payments and pay insurance claims see the PBM divestiture proposals as a problem for the insurers.
Dean Ungar and Scott Robinson, health insurance analysts at Moody's Investors Service, talk about the PBM divestiture proposals in a review of how insurers performed in the second quarter and the threats and opportunities facing them now.
The big health insurers Moody's rates now face shrinking profit margins at the Medicaid plans they manage for state governments, and they face margins hovering around zero at their Medicare plan operations, Ungar and Robinson warned in their health insurance sector update.
Commercial coverage margins are still over 6%.
But health insurers now face the possibility that the federal government could really implement One Big Beautiful Bill Act provisions and Republican proposals that would slash federal Medicaid funding and individual health insurance premium funding, the analysts said.
"Federal and state efforts to curtail activities by pharmacy benefit managers remain a credit risk for Cigna, CVS Health and UnitedHealth, which own the three largest PBMs, comprising 80% of the market," the analysts wrote. "Cigna owns Express Scripts, CVS Health owns Caremark and UnitedHealth owns OptumRx.
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Congress considered a bipartisan health insurer PBM divestiture bill in 2024, and Arkansas has actually enacted a PBM divestiture law, the analysts said.
"PBMs, which play multiple roles in drug distribution, and other entities have filed suit seeking to halt that law from taking effect," the analysts said. "A nationwide divestiture requirement would be a significant adverse development for the three insurers."
The backdrop: Pharmacists and their supporters argue that big health insurers have used their huge size and the size of their PBMs to run PBMs in ways that do more to increase the PBMs' profits than to lower employers' and patients' prescription spending.
The PBMs themselves point to their high employer plan retention rate as a sign that most employers are happy with their PBMs' efforts to hold down spending.
Many different types of health care providers, including optometrists and dentists, have been watching pharmacists' battle with PBMs carefully and proposing similar kinds of efforts to oppose the care management strategies that affect their services.
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