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New federal law already targets PBM pricing and rebate practices. An opinion on why state pharmacy ownership bans go too far, and the freight-rail lesson.
Cris Cantón/Getty Images
State Healthcare Reforms Have Gone Off the Rails
Nov 09, 2026
Government generally has two ways to address problems in a marketplace. It can establish clear rules, target harmful conduct and let competition produce better outcomes. Or it can design the market itself by controlling business decisions and dictating how companies must operate. That is the decision facing lawmakers in healthcare today.
America's freight-rail experience shows what is at stake. For decades, the Interstate Commerce Commission controlled railroad rates, restricted routes and made it hard for carriers to shed unprofitable lines. Intended to stabilize an essential industry, the rules instead contributed to bankruptcies and lagging investment.
Congress changed direction with the Staggers Rail Act of 1980. The law preserved protections against unreasonable rates and anticompetitive conduct but gave railroads greater freedom to set prices, negotiate contracts and organize their networks. As a result, inflation-adjusted freight rates fell by nearly half over the ensuing decades while freight volume grew by more than 50 percent.
The lesson was not that government has no regulatory role. It was that regulation works best when it addresses identifiable misconduct without substituting political judgment for competition. The modern debate over pharmacy benefit managers, or PBMs, presents much the same choice.
PBMs administer prescription-drug benefits for insurers and government health plans. They negotiate discounts and rebates with drug manufacturers, determine which drugs are covered, contract with pharmacies and process claims. Many also run their own pharmacies to help lower drug prices. Health plans hire them to use their purchasing power and expertise to control costs.
Critics contend that some PBM practices produce conflicts of interest or higher costs. They point to rebate arrangements, spread pricing (charging a health plan more for a prescription than the PBM reimburses the pharmacy), and incentives that may favor drugs with higher list prices. PBMs have also been accused of steering patients toward affiliated pharmacies and underpaying independent ones.
These concerns deserve serious consideration. But the real question is not whether challenges exist, but which remedies address them without unnecessarily restricting competition or market choice.
Washington has chosen the targeted approach. Through Section 6224 of the Consolidated Appropriations Act of 2026, Congress restricted how PBMs serving Medicare plans may be compensated, required rebates and discounts to be passed through to plan sponsors, mandated detailed reporting and provided sponsors with extensive audit rights. Other provisions establish transparency and rebate protections for employer-sponsored health plans.
The Federal Trade Commission (FTC), meanwhile, has pursued enforcement actions targeting the same pricing, rebate, and transparency concerns. Its settlements require contract options that calculate patients' costs closer to net prices, pass rebates through at the pharmacy counter, let health plans move away from spread pricing and guaranteed-rebate arrangements, and offer community pharmacies cost-plus reimbursement.
Taken together, the federal law and settlements show how targeted intervention can address the practices that prompted calls for PBM reform without displacing market choice. They impose enforceable rules while leaving employers and health plans free to choose among competing arrangements.
The Trump administration has effectively chosen this approach: address the specific practices driving concerns about PBMs without dictating how companies must structure their businesses. With those reforms now in place, states pursuing far more sweeping measures should have to explain what problem remains that requires breaking apart lawful businesses.
Arkansas enacted the nation's first law barring PBMs from owning or operating pharmacies. Tennessee has since enacted its FAIR Rx Act. Both laws face legal challenges, and a federal court has temporarily blocked the Arkansas measure, but that has not stopped lawmakers elsewhere from considering similar proposals.
These mandates are not an indictment of any one business practice but of an industry as a whole. A PBM could comply fully with every federal requirement, abandon disputed pricing practices and offer transparent contracts, and still be forced to restructure or withdraw its pharmacy operations. This would disrupt pharmacy access for millions and could set a troubling precedent for other businesses weighing investments based on what were previously settled rules.
The contrast is clear. In a free and fair marketplace, government should establish clear rules, punish demonstrated misconduct, and step back to let competition determine how businesses organize. An industry's political unpopularity is not a reason to abandon those principles, and neither is the fact that some critics have a legitimate case.
There is also a more basic question: How does forcing a PBM to sell or close a pharmacy make a prescription less expensive? Ownership bans do not themselves lower a drug's list price, increase manufacturer discounts, or reduce a patient's copay. They dictate who may own a pharmacy without demonstrating how that restructuring lowers healthcare costs.
States pursuing ownership bans are choosing a far more sweeping approach. When government can address specific problems directly, forcing companies to divest lawful businesses is difficult to justify as consumer protection. It is government-directed market restructuring, and lawmakers should be wary of the precedent it sets.
Jack Yoest is an Associate Professor of Practice at The Catholic University of America's Busch School of Business. He served as Assistant Secretary for Health and Human Resources for the Commonwealth of Virginia and is the author of Learning to Win: The 45 Laws of the Public Policy Process.
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Ice Police Law Enforcement Investigation and Department of Justice Customs Immigration Enforcement
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I Believe in Immigration Enforcement. But, What Happened to TK Should Concern Us All.
Nov 05, 2026
TK was born in Guatemala in 1962. He arrived in the United States in 1965, at the age of three, as a lawful permanent resident with his immigrant mother and American stepfather. For the next 61 years, he lived what most people would recognize as an American life.
TK grew up in American schools, graduated from a Texas high school and attended college. As a child, his classmates struggled to pronounce his given name, Enrique. They began calling him “Keke,” a nickname that eventually became “TK”—the name he has been known by ever since. He married, raised three daughters, divorced, and eventually remarried, all in the US. Today, he is a grandfather and a successful businessman whose life has been rooted in this country since the age of three.
English is his first language. America is not simply where he resides. It is where his life happened.
Today, TK is in federal immigration detention, facing possible deportation to a country he left six decades ago and has only returned to a handful of times.
TK's history is not without complications. He was arrested in 2003, an event whose legal consequences deserve appropriate consideration. But so do the 23 years that followed.
He overcame personal obstacles, rebuilt his life, and built a successful business that requires frequent international travel. Over the past decade, TK has traveled between the United States and the Caribbean dozens of times without difficulty. I was fortunate to accompany him on one trip earlier this year. We returned without any issues.
About a month ago, his permanent resident card was renewed without incident.
Then, after returning from another routine business trip this month, he was referred for secondary inspection, found inadmissible, and taken into federal custody.
What followed has been as disturbing as the detention itself.
TK was permitted one telephone call. After his transfer to another facility, communication effectively disappeared.
TK initially appeared in ICE's online detainee locator, but only briefly. Following his transfer, however, I could no longer establish his whereabouts through the system. Nearly 24 hours passed before TK managed to borrow telephone access from another detainee, for a price.
He told me where he was and asked for help.
I called the detention facility twice. Both calls were answered dismissively. I was instructed to call during normal business hours or told that the person answering was not employed by ICE and could not address my questions since TK was brought in by ICE.
I was not asking difficult questions or requesting preferential treatment. I was trying to assist someone in federal custody and get basic information: how do I obtain his belongings, visitation, etc.
Next, I tried to deposit money into his commissary account so he could buy basic necessities like toothpaste and food beyond the peanut butter and jelly sandwiches he was being provided. I tried two online systems, two separate accounts, and two different credit cards. Every transaction failed. Eventually, the accounts were locked, “Too Many Attempts”.
The solution? Call Customer Service during normal business hours.
It was Saturday. Monday was a holiday.
Four days before I could even seek assistance with a failed payment system. Now Tuesday and seven calls later. Nobody available. Every call went to voicemail. Imagine a facility that is designated as “Undercapacity,” and everyone is busy?
Consider the situation: A person is detained by the federal government, transferred without reliably accessible location information, afforded extremely limited communication, and left dependent on administrative systems that cannot be corrected over a holiday weekend.
In the American criminal justice system, even individuals accused of serious offenses, murder, sex trafficking, generally have established procedures for prompt judicial oversight and consideration of pretrial release. Immigration detention operates differently, and access to bond or prompt judicial review is restricted.
These legal distinctions are important. But they do not eliminate the fundamental question of what procedural safeguards and basic standards of treatment should accompany government detention.
There is another question worth examining.
People who enter the United States unlawfully generally understand that apprehension may lead to detention and deportation. But does that understanding prepare their families for the experience of losing contact with someone in federal custody?
What happens when a spouse, parent, or child is detained, transferred between facilities, and becomes difficult to locate? When families cannot obtain reliable information, when calls go unanswered and when uncertainty extends for days, weeks or longer?
Could some of the anger and confrontation surrounding immigration enforcement stem not simply from opposition to deportation, but from fear about the whereabouts and treatment of loved ones?
That possibility deserves examination. Understanding the sources of public distrust does not require excusing threats or violence.
I experienced less than 24 hours of that uncertainty before TK contacted me. For families who endure it much longer, the consequences may be profound.
I have experienced firsthand individuals entering the US illegally across the southern border. They were generally arrested (because they surrendered), processed, and released with a court date several years away in a matter of days. TK, a lawful permanent resident for over 60 years... detained indefinitely.
I support immigration enforcement unequivocally. A sovereign nation has the right and responsibility to protect and control its borders and enforce its laws. What I question is whether our immigration detention system operates with the transparency, proportionality, and accountability we should expect from the federal government.
I also recognize that lawful permanent residence does not confer citizenship, and that immigration law may impose consequences for conduct that occurred decades ago. TK's legal status and eligibility for release must be determined under the applicable law. That is the law.
But the legality of detention and the administration of detention are separate matters.
Perhaps each failure has an explanation: a database that updates slowly, a contracted facility with limited authority, a payment vendor closed for the weekend. But this is 2026, not 1982. Imagine your phone or your tablet “updates slowly,” or a payment vendor is “closed for the weekend.” The frustration you feel from such a mundane service is something you've grown to feel entitled to. Individually, these explanations are barely reasonable. Collectively, they reveal a system in which responsibility is fragmented, and those seeking answers have few places to turn.
I believe that immigration laws should be enforced. I also believe that the authority to deprive someone of liberty carries an obligation to ensure meaningful communication, access to basic necessities, and accountable treatment, even for those who entered the US illegally.
TK's case will ultimately turn on the facts and the law. It should.
But his experience leaves a question that should concern Americans regardless of their views on immigration:
If the federal government has the power to take away a person’s freedom, shouldn’t it also be responsible for ensuring that person can be found, contacted, and treated with basic dignity? Even Amazon can track a package.
Spencer Ross is the Chief Operating Officer (COO) of TerraKross Building Contractors & Developers, LLC.
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A Flock camera monitors passing traffic in Miami, Florida.
(Photo by Joe Raedle/Getty Images)
Flock Cameras and ALPR technology: We shouldn't trade privacy for the false promise of public safety
Nov 05, 2026
As corporations, politicians, and tech bros usher in the era of artificial intelligence (AI), our community members continue to fight back against AI's incorporation into daily life. Particularly when it comes to opposing Automated License Plate Readers (ALPRs).
ALPRs are becoming so sophisticated, with more AI components, that they cannot only surveil us using our license plates and the make and model of our car, but also increasingly distinguish how we dress and look, using AI to profile us into a large-scale database for future reference.
In Texas, there is consistent and growing backlash against ALPRs. So much community disdain has spurred Governor Abbott to pause all funding he initiated by funneling $30 million into Flock cameras. Most recently, Governor Abbott has stopped issuing permits for Flock and other ALPR contractors to install cameras on Texas roads. A performative push to pacify his constituents before this November’s election.
Meanwhile, Florida banned ALPRs on all state-maintained roads and highways, a move that reaches across the political aisle. While some leaders consider how much surveillance their constituents will allow, more and more people are being stopped because of false positives caused by the erroneous nature of ALPR cameras.
One report from the Los Angeles Police Department (LAPD) showed that its internal Flock camera audits revealed a 32.3% false-positive rate. That means one in three drivers were falsely accused of driving a stolen vehicle. This, along with privacy and data concerns, led the LAPD to cancel its Flock contract. The false positives are becoming more common with ALPR devices. A college student who recently bought a new car has been stopped twice because the Flock system flagged the car’s temporary tags.
In other situations, it has led to false accusations and jail time. Lindsay Brooke Isaacs was charged with eight felonies for the alleged murder of three individuals during a car crash. Lindsay spent 13 days in jail before the officers realized they had arrested the wrong person. Another woman was falsely accused of stealing a package and spent weeks proving her innocence. The rate of false positives should leave you shivering in fear that one day you will be driving and falsely accused and arrested for a stolen vehicle, package, or worse, the death of another person.
A CNU study revealed that Flock cameras are often placed in low-income Black and Brown neighborhoods. The report noted that 8 out of 10 cameras were installed in Black neighborhoods. These areas had 4 times as many cameras as predominantly white, affluent neighborhoods. It is quite clear who the target of mass surveillance is.
Many proponents of ALPRs will parrot the common Flock marketing talking points about how effective mass surveillance is in reducing crime. However, in Atlanta (home to Flock’s corporate headquarters), they found that more mass surveillance devices do not mean less crime, nor do they lead to more crimes being solved.
Flock Safety isn’t the only ALPR manufacturer. Vigilant Solutions also openly shares over 1.5 billion data points with ICE and grants 9,200+ agents access to its database. Axon lurks in the shadows, covertly capitalizing on Flock’s flailing public image. Many municipalities have given in to malicious compliance, pretending to heed constituents' concerns.
Once municipalities end their contracts with Flock Safety, many immediately opt to contract with Axon, preferring their covert cameras that tend to “blend into surroundings." Police are even begging Axon to make some of its other cameras look different from Flock’s so citizens don’t destroy them.
One thing to note about Axon is that they are one of the biggest contractors with law enforcement. Many departments already use their tasers and body cameras. Once they add an ALPR contract to those lucrative deals, it will be difficult for the public to remove them.
According to ACPC, Flock cameras have increased eightfold. Yet, crime clearance rates across eight different categories, including homicide, car theft, and robbery, have all remained static. Most proponents of ALPRs can only share anecdotal stories of success because when we examine the statistics and raw data, it’s clear we are being sold a mass surveillance system disguised as an ineffective public safety tool.
ALPR devices do not solve crime. They will not reduce crime. They are more likely to be used against you, linking you to an alleged crime you never committed. This can lead to hardships, the loss of the presumption of innocence, and jail time. Corporate talking points have been market-tested to prey on our fears and make us believe that an expensive mass surveillance system is the only way we can be safe.
There is no shelter, no alternative, for mass surveillance. We must stop it before the digital panopticon is solidified and normalized. Citizens are asking, fighting, and defending our rights to be protected and honored, yet our elected officials and law enforcement officers would rather ignore and undermine them all. All to normalize a dystopian future of AI cameras on every block, because a flock is only safe when the shepherd has eyes on your every move.
Christopher Rivera is the senior advocacy manager for the criminal legal program at the Texas Civil Rights Project.
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Uber drivers participate in a rally outside of the Uber Headquarters on January 05, 2023 in New York City. Uber drivers in NYC participated in a 24-hour strike outside of the company's NYC headquarters
Michael M. Santiago/Getty Images
21st-Century Gig Workers Need Portable Benefits
Nov 04, 2026
In recent years, the US labor force has been undergoing a fundamental transformation. In today’s "Uber economy," gig workers, freelancers, contractors, temps, permatemps, remote workers after COVID, and so-called “independent workers” have been championed by Silicon Valley and Wall Street as the “new way to work”—the wave of the future, especially with AI changing the nature of work itself.
Many US consumers have driven in an Uber taxi, but don’t realize that most drivers earn below minimum wage after accounting for vehicle expenses, gas, maintenance, and unpaid time waiting for passengers. Those drivers are so-called “independent contractors,” so the billion-dollar Uber is not responsible for providing healthcare, Social Security contributions, workers' compensation, or unemployment compensation, not to mention sick leave or vacation pay.
Another type of “gig-preneur” can be found on platforms like Fiverr, an online job brokerage that connects buyers to sellers of numerous tasks and services called micro-gigs. Each gig pays as little as $5 per job (hence its Fiverr name). One worker, after fulfilling 27 orders, made $176 in total. “I’ve seen panhandlers get more money outside of the 7-11,” she complained.
Other workers swept up in this job market degradation don’t work gigs; they have regular jobs. Meet Chris Young, an assembly-line worker at a Nissan manufacturing plant in Tennessee. Young works alongside dozens of other employees doing the exact same job, but he doesn’t work directly for Nissan. Instead, he works as a “perma-temp” for Yates Services, a private contractor that provides a majority of Nissan’s workers. He builds the same Infiniti SUV as Nissan workers, but he and other Yates employees get half the salary, less job security, and far fewer safety-net benefits. Some “temps” have worked at the same company for as long as 11 years—hence the new term "perma-temp.”
How many new economy workers?
America is a wealthy nation, but these drastic changes to the job market have left millions of Americans without access to that wealth. How many of these new economy workers are there? It’s hard to say because they are difficult to count.
The Bureau of Labor Statistics counts about 12 million “independent contractors” (7.4% of 162 million workers in the US) and another 2.8 million (1.7%) on-call workers, over 9 percent of the total workforce. But the BLS uses a narrow definition of “worker,” and broader definitions push total estimates much higher, from 16.5 million to over 30 million workers, depending on whether researchers count occasional side gigs or secondary jobs. Industry trackers like MBO Partners estimate that roughly 75 million Americans (46%) engage in some form of independent work yearly, with 22% treating it as their primary full-time career, more than double the 10% who did so in 2019.
New app- and web-based technologies are making it easier than ever to hire such workers. Employers also have strong incentives to do so, especially in certain industries and occupations, by taking advantage of what is known as the “independent contractor loophole.” An employer can lower labor costs dramatically by around 30%, just by evading contributions for a worker’s health benefits, Social Security, Medicare, unemployment, workers' compensation, lunch breaks, paid sick days, and vacation leave. A McKinsey report also found that independent contractors get paid 20-30% less than employees. So these savings provide a powerful incentive for an employer to hire as many contractors as possible.
To be sure, some businesses benefit from labor flexibility, since they need to ramp up and down in response to fluctuations in demand for their product or service. But hiring a large contractor workforce lets a company greatly lower labor costs by wiping out workers’ safety net, undermining a key component that has made the U.S. economy so successful.
A portable safety net provides the best of both worlds
Fortunately, an innovative solution exists. It’s called a “portable safety net,” or “portable benefits.” It would allow any worker hired by multiple employers during the year to benefit from a robust safety net. Here’s how it works.
Each business that hires an independent worker would contribute a set amount above the worker's wage, prorated by the hours the worker worked for that employer. Those payroll deductions would go into an Individual Security Account for each worker, helping that worker pay for her/his safety net. The ISA accounts would be structured to direct the payroll deductions into existing federal and state safety net programs -- Social Security, Medicare, unemployment insurance, and workers’ compensation -- as well as other safety net components, especially health care, and possibly paid sick days and vacation (the worker also would have some wages deducted, much like regularly employed full-time workers do).
For example, suppose Donna is a regular employee working 20 hours a week for a hairdresser, then contracts for 10 hours a week with TaskRabbit, and drives 10 shifts for Uber. She would earn 50 percent of her benefits from the hairdresser, 25 percent from TaskRabbit, and the remaining percentage based on her Uber driving wages. Each company would deposit the funds into her ISA.
This is similar to how Social Security and Obamacare work now, where a personal ID number tracks a retirement or health care account for people who work for multiple employers.
A portable safety net for all workers who need it would have several benefits. It would allow some scheduling flexibility for workers and businesses, as well as the health and financial security that workers and their families need. It would also improve affordability for many individuals and families, especially after the Trump administration’s deep cuts to Medicaid, Medicare, SNAP, and other programs.
A portable safety net would also move us beyond labor abuses and lawsuits over who’s a contractor or regular employee and entitled to safety-net coverage, because all workers would be covered. It would also remove the perverse incentive for businesses to use cheaper contractors to undercut competitors, which unleashes a race to the bottom.
Note that requiring all businesses in an industry to pay into their workers’ ISAs would not hurt the competitiveness of any of those businesses, because all employers would be subject to the same rules. Businesses could pass the costs of this kind of “safety net insurance plan” on to customers, since customers are the largest pool capable of absorbing them. Many customers would also be the same workers receiving benefits, so it would be a virtuous circle, “a rising tide lifting all boats.”
Several 21st-century countries already do something like this, and in the US, 40 business, government, labor, and NGO leaders from the right and left have endorsed a portable safety net and agree it is a necessary foundation for the 21st-century economy. President Barack Obama endorsed portable benefits in his 2016 State of the Union address, and Uber and Lyft have supported legislation proposed in state legislatures in New York, Washington, and New Jersey. But the legislation died in all three states when Uber and Lyft made a measly offer: instead of something close to 20% of a worker’s wage to provide an adequate safety net, they offered only 2.5%.
A portable safety net for all workers is long overdue. This has the makings of a win-win solution. We need to ensure the labor force and the broader economy are built on a fair, healthy foundation for the future. All Americans deserve to be enriched by technology and innovation, not made obsolete or impoverished by it.
Steven Hill is a fellow at Rutgers University’s Institute for the Study of Employment Ownership, and was previously a leader at FairVote, New America and Center for Humane Technology. See more of his writing at DemocracySOS.
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