Feeling Owl Right? No? As I look at my calendar, I’m feeling a little antsy about the week ahead. Everything is positive, even great, but it feels like a gauntlet.
The other significant factor is the upcoming September 29th Most Favored Nation (MFN) deadline. This date marks 60 days since the seventeen letters went out to pharma CEOs telling them to get in line. We are watching and waiting to see what happens next. Rumor mill is spinning the greatest hits.
Caught my Eye
Let Me Sell You a Shovel. Late Thursday, President Trump announced 100% tariffs on brand name pharmaceuticals starting October 1 under national security law (Section 232). The exception? If a pharmaceutical manufacturing is breaking ground or has a factory under construction. It is unclear how these tariffs work with those negotiated with Europe this summer (15%).
Tide-l Wave. JAMA has a paper on Medicare Part D coverage of GLP-1s and it is about what you’d expect – prior authorization is universal to stop off-label use and there has been a broad shift to coinsurance, especially in standalone prescription drug plans. Part D plans (STILL) cannot cover GLP-1s for obesity but coverage for cardiovascular was starting to be seen in 2025 for Medicare Advantage plans.
Foreign Concept. About three years ago when I joined the wholesaler side of Cencora, I was learning more about supply chain dynamics and had the type of realization that keeps you up at night (or at least me) – if China wanted to really hurt the U.S., it could limit pharmaceutical supplies. Not everyone has access to David Senior as a tutor of all things wholesale (IFYKYK), but they have access to the work of Brooking’s Marta Wosińska.
Then and Now. JAMA Health featured a follow up survey of physicians originally done in 2011 that found that today more physicians agree that they receive useful education about new treatments. Overall there was a slight softening toward pharmaceutical representatives but mostly things were remarkably similar.
Rare Disease Revamp. Haystack Project has a paper on how to revamp the FDA for rare disease therapies.
Taking it to the Court. AstraZeneca brings their Inflation Reduction Act lawsuit to the U.S. Supreme Court.
Refresher. 340B background and update by AEI.
Reviewing the Fundamentals – Medicaid Work Requirements
Recently the GAO put out a report that looked at Georgia’s rollout of Medicaid work requirements. With the rest of the country having to do work requirements in 2027, a lesson from the one state doing it might be a relevant example for the steps ahead. Because spending twice as much on administrative expenses than healthcare costs is probably not something we want to repeat.
The waiver for Georgia’s Pathways to Coverage was approved by the Trump administration in October 2020. It aims to provide Medicaid coverage to adults ages 19-64 with incomes up to 100% of the Federal Poverty Level (FPL) (approximately $15,650 for an individual in 2025). However, unlike full Affordable Care Act Medicaid expansion, Georgia’s program conditions coverage on work or “community engagement.”
The program’s launch was delayed by two years due to legal challenges from the Biden administration. Since beginning in July 2023, Georgia’s program has been the only active Medicaid work requirement in the nation. The core of the policy mandates that enrollees must demonstrate at least 80 hours per month of a “qualifying activity,” such as working, volunteering, or pursuing education, to maintain coverage.
The program has not had a smooth rollout. It has faced low enrollment and has failed to meet initial projections. A major criticism has been the program’s high administrative costs (e.g., IT systems, outreach, and consulting). Plus, it has been difficult for beneficiaries to navigate the monthly reporting because of technology glitches and program design.
The Centers for Medicare & Medicaid Services (CMS) recently extended Pathways to Coverage through December 2026 but with modifications. To reduce administrative burden, the state is dropping the monthly reporting requirement and switching to just the initial application and annual renewal. Also, the list of qualifying activities was expanded to include parents and legal guardians of children under six who are enrolled in Medicaid.
Some see Georgia’s program as proof that it looks to limit coverage through administrative barriers rather than boosting employment. No matter what, lessons lurk if CMS looks for them.
For the Files
Keep this around until the end of November when the 2027 negotiated prices are released. Useful context as you’re thinking about those prices.
Can’t remember anything about the 2027 Medicare negotiations? KFF cheat sheet.
