PBM Reform in Wisconsin: How Lobbyists, Leadership, and “Local” Allies Keep the Status Quo
Introduction – The Bill That Should Have Passed
In 2021, Wisconsin lawmakers introduced a bipartisan PBM reform bill that looked like a sure thing. It had 104 co-sponsors—nearly every legislator in Madison. It had strong testimony from pharmacists, employers, and patient advocates. It was designed to protect small businesses, lower drug costs, and bring transparency to the pharmacy benefit manager (PBM) industry.
Then, in just 18 hours spread over two days, the bill was gutted. Key provisions banning spread pricing were stripped out. Transparency measures were watered down. By the time it reached the floor, it was a shadow of its original self.
When the vote was called, the bill passed unanimously in the Assembly and with only one “no” vote in the Senate—but by then, most of the meaningful reform had been erased.
The reason? Wisconsin’s political power structure and the deep-pocketed lobbying forces aligned with PBMs.
Wisconsin’s PBM Landscape: Not Just the Big 3
Nationally, three PBMs—CVS Caremark, Express Scripts, and OptumRx—control nearly 80% of the market. In Wisconsin, there’s a fourth major player: Navitus Health Solutions.
Navitus runs the state employee health plan and has long branded itself as a “transparent PBM.” On paper, it’s incrementally better than the Big 3, but it has its own specialty pharmacy business that generates substantial profits.
In a telling move, Navitus recently left the “transparent PBM” trade group and joined PCMA—the national lobbying powerhouse representing the Big 3 PBMs. This alignment with the very companies they once claimed to be different from signaled to reform advocates that Navitus had gone to the dark side.
The Lobbying Web in Madison
The PBM lobby isn’t the only player working to block reform. Wisconsin’s political landscape on healthcare is heavily shaped by:
- PCMA – The national PBM trade group, now representing Navitus and the Big 3.
- AHIP – America’s Health Insurance Plans, the national health plan lobby.
- The Wisconsin Insurance Alliance – State-level insurance lobby with deep political connections.
- WMC – Wisconsin Manufacturers & Commerce – The state’s most powerful business lobby, publicly opposing PBM reform.
Why would WMC, supposedly an advocate for business competitiveness, oppose lowering drug costs for employers? The answer: WMC is a paid insurance broker for UnitedHealthcare, earning significant commissions by acting as a sales arm. UnitedHealthcare owns OptumRx, one of the Big 3 PBMs. Any reform cutting into OptumRx’s profits threatens WMC’s brokerage revenue.
Leadership Power and the Speaker’s Role
In Wisconsin, legislative leadership has the power to decide which bills get hearings, which amendments are adopted, and how the calendar is set. The Speaker of the Assembly personally oversaw the gutting of the PBM reform bill—removing or weakening provisions opposed by the PBM, insurance, and WMC lobbying coalition.
In a system where leadership holds that much control, it only takes opposition from a handful of power players to neutralize a bill, no matter how much rank-and-file support it has.
How the Bill Was Dismantled
The original bill included:
- A ban on spread pricing in state-funded programs.
- Mandatory 100% pass-through of manufacturer rebates to plans and patients.
- Strict transparency and reporting requirements.
- Guardrails to prevent PBM-owned pharmacy steering.
By the end of the 18-hour amendment process, spread pricing stayed legal. Rebate pass-through became optional. Transparency rules were softened. Steering protections were gone.
The Cost of This Political Game
- Patients Pay More – Without spread pricing bans and rebate pass-through, inflated drug costs remain baked into the system.
- Independent Pharmacies Close – PBMs can keep reimbursing below cost, forcing more local pharmacies to sell or shut down.
- Taxpayers Lose – The state employee plan, run by Navitus, remains shielded from meaningful oversight.
- Employers Get Gouged – WMC’s opposition ensures many businesses continue overpaying for prescriptions, while WMC profits from UnitedHealthcare commissions.
What Reform Advocates Can Learn
- It’s Not Enough to Have Votes – Even with near-unanimous co-sponsorship, leadership can still block meaningful change.
- Follow the Money – Opposition from WMC and others isn’t philosophical—it’s financial self-interest.
- Name the Power – Vague criticism doesn’t move the needle. Voters need to know exactly who is blocking reform and why.
- Leverage Other States’ Success – Arkansas, West Virginia, and North Dakota have implemented strong PBM reforms despite fierce opposition.
The Path Forward
PBM reform in Wisconsin will require a coordinated, persistent campaign that unites pharmacists, employers, patients, and taxpayers. It will require spotlighting lobby influence and leadership decisions – not just debating policy in committee rooms.
The PBM-insurance-WMC alliance may have the money, but voters have the numbers. If enough Wisconsinites connect rising drug costs and pharmacy closures to PBM practices—and to the politicians protecting those practices – the political calculus in Madison can change.
Conclusion – This Fight Isn’t Over
The 2021 reform effort was sabotaged in under two days, but it proved something important: the public and most legislators want action. The only barrier is political leadership aligned with powerful lobbies.
The next bill must come with something the lobbyists can’t counter—an army of informed voters ready to hold their representatives accountable. In Wisconsin, PBM reform isn’t about partisanship. It’s about breaking the grip of special interests.
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