“Who decides what you pay for your medicines? Not who you might think,” a concerned woman’s voice says in a radio spot airing in the District last month. “More than one-third of the list price of a medicine is rebated back to middlemen, like insurers and pharmacy benefit managers.”

With national and state advertising campaigns, white papers and cartoon infographics, the powerful and well-funded drug-industry lobby spent 2017 working to redirect public anger about drug prices to pharmacy benefits managers (or PBMs): links in the supply chain that sits invisibly between the patient and the drugmaker — in the process bringing a long-simmering feud between two big health-industry players into the open.

Nearly a year ago, President Trump put drug companies on notice, accusing them of “getting away with murder.” Lawmakers, too, seemed ready to take on pharmaceutical prices, after a year bookended by outrage over EpiPen’s rising cost and the smirks of “pharma bro” Martin Shkreli, a former hedge fund manager who became notorious for ordering a 5,000 percent price increase on an old drug used by cancer and AIDS patients.

But the drug companies’ fight with PBMs and insurers has helped thwart any real action — splintering the problem into a multi-industry echo chamber of accusations that’s hard to comprehend, much less solve.

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