State Sen. Bobby Harshbarger (R-Kingsport) recently backed a proposal to bar pharmacy benefit managers (PBMs)—the intermediaries that negotiate drug prices on behalf of health plans—from owning or operating pharmacies. It sounds like a straightforward solution to “conflicts of interest.” In practice, it would shrink competition, push up premiums, and narrow access to medicine—especially for the Tennesseans with the least room to maneuver.

PBMs exist because scale matters. By pooling the purchasing power of millions of patients across public and employer plans, they extract lower prices and larger rebates from pharmacies and manufacturers. Those savings don’t disappear into the ether; they are typically passed through to plans and their members, showing up as lower premiums or reduced costs at the counter.

Critics seize on a familiar claim: PBMs sometimes steer patients to their own or affiliated pharmacies with discounts and convenience perks. That’s true—and it helps generate higher volumes that lower the per-drug acquisition cost, which can translate into lower prices for everyone, including customers who aren’t covered by the affiliated PBM. Volume, not villainy, is doing much of the work here.

Independent pharmacists—Harshbarger among them—argue that these arrangements undercut mom-and-pop shops, starving them of fair reimbursement and driving closures. Force PBMs to divest their pharmacies, they say, and you neutralize the bias. The problem is that Tennessee already prohibits PBMs from paying non-affiliated pharmacies less for dispensing the same drugs. Nationally, independent pharmacies often receive higher reimbursement rates than chain pharmacies, and their footprint has grown significantly over the past decade. One reason is that many independents band together through Pharmacy Services Administrative Organizations (PSAOs), which, similar to PBM, consolidate negotiating leverage to improve terms.

So why are pharmacies closing? Look to the map, not the middleman. Rural depopulation has thinned the customer base for brick-and-mortar stores of all kinds, pharmacies included. At the same time, consumers have embraced mail delivery—an obvious lifeline for people living far from a storefront or juggling chronic conditions. Many of those mail-order operations are affiliated with PBM. Ban PBMs from owning pharmacies, and you don’t eliminate a monopoly; you eliminate a lifeline. Seniors, patients managing complex regimens, and those dependent on regular refills would feel it first.

Even advocates of tighter PBM oversight concede the risk: laws like Harshbarger’s can deepen “pharmacy deserts,” those stretches of the map where getting a prescription filled requires a long drive or a reliable delivery service. In many rural counties, the only operating pharmacy is PBM-affiliated. It’s far from evident that a new independent owner could keep the lights on if divestiture were forced by law.

Arkansas offers a cautionary tale. After adopting a PBM-ownership ban, the state is watching more than twenty largely rural PBM-affiliated pharmacies shut their doors. Closures like these disrupt care for patients who don’t have easy substitutes, and Tennessee would be no different. The harm would be most acute for individuals relying on rare, specialty, or orphan drugs—medicines that already traverse limited distribution channels and are often available only through PBM-linked pharmacies.

None of this absolves PBMs of scrutiny. Some have paid hefty settlements for alleged price-fixing or for failing to pass through negotiated rebates. Tennessee regulators have accused Express Scripts of violating state law. Oversight should be real, specific, and enforceable.

However, Harshbarger’s approach—modeled after Arkansas, echoed in Louisiana, and mirrored in federal proposals—targets the ownership structure rather than the conduct. It would shield competitors from competition while doing little to punish bad behavior. The predictable result: fewer pharmacies in hard-to-serve areas, higher insurance premiums as plans lose bargaining leverage, and reduced access to needed medications.

If the aim is to help patients, the remedy is stronger competition and clearer rules—not a ban that narrows choice. Existing federal and state laws should be vigorously enforced against anticompetitive contracting and business practices, with meaningful sanctions against proven offenders. What Tennessee policymakers shouldn’t do is choke off the delivery channels and rural outlets that keep people on their medications. Regulate PBMs—yes—but regulate behavior, not ownership, so access and affordability move in the right direction.