What.a.week. The whirlwind of the Access conference, tons of pharmaceutical health policy news – and apparently a whole lot of new subscribers. Hi, welcome. Quick intro: I’m Jennifer Snow, I run Apteka Policy, 25 years in pharmaceutical health policy. I take the dense policy stuff – IRA negotiations, 340B fights, PBM reform – and tell you what it means for coverage, access, and your strategy. You have enough information, what you’re missing is the interpretation. That’s what I do. Glad you’re here.

Hyperbole vs. Reality. The New York Times published a cross-country drug price comparison this week that, I mean, should put the “lowest prices in the world” claim to rest for anyone who was still taking it literally. They looked at eight countries, compared what patients pay for a set of drugs against TrumpRx’s U.S. list prices, and also checked a subset against what Germany’s public system pays. The pattern isn’t ambiguous.

Germany comes in lower than TrumpRx in more than half the cases they could match – and that’s before accounting for confidential rebates that would push German net prices further down. For patent-protected drugs, the gaps are meaningful. Ngenla is roughly $2,700 more per month here. Ozempic and Xeljanz are both cheaper abroad by non-trivial amounts.

There is a version of this story where TrumpRx still “wins.” It’s just a narrower version than rhetoric suggests. For certain GLP-1s, TrumpRx looks competitive relative to some European markets. But Japan undercuts both, with Wegovy and Zepbound priced at roughly half of what TrumpRx lists. (So, not the lowest in the world, then.)

The administration’s response has been that comparisons need to adjust for differences in national income and purchasing power. That may be a valid methodological point in theory. But perception is reality and patients aren’t feeling the savings.

What TrumpRx is: a meaningful discount off U.S. list prices for a subset of drugs. For cash-pay patients in categories like GLP-1s and fertility treatments, that matters. But it’s not delivering the lowest prices in the world. And that gap between the claim and the reality is likely to define the next phase of this conversation, because it reframes TrumpRx from a solution to a partial step in a system that still prices above its peers.

But we’re early days. TrumpsRx has potential to be ground-breaking for consumers, but the environment around it has to shift first. Real insurance integration is the unlock.

Process Matters (and a win for Science).  A federal district court in Massachusetts issued a preliminary injunction this week blocking both the January 2026 revision to the CDC childhood immunization schedule and the appointments of new ACIP members.

The ruling turns on process rather than substance. And I mean that literally – that distinction is the whole point.

The court found that the revised immunization schedule was issued without consultation with ACIP, despite multiple federal programs – including those under the Affordable Care Act, Medicaid, and the Vaccines for Children program – being directly tied to ACIP recommendations. You can’t sidestep the advisory process and then have the outputs of that process apply to programs that depend on it.

The court also raised concerns about the reconstituted ACIP’s composition. Following the removal of the prior committee, new members were appointed on an expedited basis. The judge found that several appointees appeared to lack relevant expertise, raising questions under the Federal Advisory Committee Act, which requires that advisory bodies be fairly balanced in terms of knowledge and experience.

The immediate effect: the revised schedule is stayed and the reconstituted ACIP can’t operate – including any votes it may already have taken.

More broadly, this reinforces something that keeps coming up in health policy right now. Even where there’s authority to make substantive changes, the processes by which those changes are developed and implemented are often embedded in statute. Deviating from those processes creates legal vulnerability, regardless of the policy objective. This doesn’t resolve the underlying debate about vaccine recommendations. It resets the conditions under which that debate will proceed.

Here’s the rub. It takes resources to fight to find the way back to process. Smashing norms might yield quick policy headlines but it takes time and money to fight the

Money Talks. A JAMA study published something that gets assumed but rarely quantified: it measures the role of provider economics in biosimilar adoption.

The study examined oncology biosimilars across more than 1,500 hospitals between 2020 and 2024 and compared acquisition prices – what hospitals paid manufacturers – to reimbursement rates from insurers. Over that period, acquisition costs for biosimilars dropped sharply, in some cases by more than 60%. Reimbursement rates also declined, but at a slower pace. That created a widening gap between what hospitals paid and what they got paid back.

That gap matters because it creates a direct financial incentive to adopt biosimilars. And that is exactly what happened. Biosimilar market share increased rapidly, reaching more than 80% in several categories by 2024.

What I found interesting is that adoption wasn’t primarily driven by payer mandates or utilization management. It was driven by margin.

This raises a question about where the benefits of biosimilar competition go. The expectation is that lower prices will translate into savings for payers and patients. In practice, at least in this phase, a portion of those savings is being retained at the provider level. That doesn’t undermine the value of biosimilars. (But it does mean competition alone doesn’t determine where savings accrue – that’s shaped by reimbursement policy, contracting dynamics, and how quickly different parts of the system adjust.

The key variable going forward is how quickly payers recalibrate reimbursement as biosimilar prices fall. If that adjustment accelerates, the margin incentive that drove early adoption narrows. And with it, potentially, the pace of uptake.

Consider the Questions Asked.  KFF’s March tracking poll are interesting – the more you sit with it – the more it feels like something has actually shifted.

Fifty-nine percent of adults say they’re worried about affording prescription drugs for themselves or their families. That was 45% in 2020. That’s a meaningful change in a relatively short period, moving in the wrong direction.

Over the past year, 27% of adults report not filling a prescription because of cost. Nineteen percent cut pills or skipped doses. Thirty-one percent substituted an over-the-counter drug instead. Forty-three percent did at least one of those things. Two years ago, that number was 31%.

That’s a broad base of the population making real tradeoffs. Not a niche group. And it is important to think about and consider. Consider, not panic. You would need to dive further into what the actual impact to patient access is. Polling is only as good as the questions and the instrument being used.   

The trust numbers are where this turns data into politics. And this is where I said the words “meh” out loud.  Roughly seven in ten adults continue to say there isn’t enough government regulation on drug prices – a number that’s held steady across administrations and policy changes.

Back to the perception is reality from above BUT, it’s a poll of people who don’t necessarily follow what the government is doing about drug pricing. It’s like if you wanted to ask me about foreign policy, I would answer your questions, but my opinion really shouldn’t matter much. It’s not my lane.

What I take away from this work is that people are feeling the affordability gap. That is connected to drug pricing but more closely connected with benefit design and a host of other issues. I also get this (potential) march toward bigger healthcare reform. Not anytime soon – we aren’t broken enough yet – but a few years out? Maybe.

Hell No (But Make It Voluntary). More than two months after major insurers pledged to reduce prior authorization requirements, the early feedback from physicians is not complicated.

One interventional radiologist’s summary: “hell no.”

The Washington Post reporting this week captures a pattern that’ll feel familiar to anyone who’s watched these kinds of commitments before. The insurers point to changes that have been made, and in some cases those changes are real. But they tend to be concentrated in areas that don’t meaningfully reduce day-to-day burden.

Lower-volume services get easier to approve. But for high-volume, clinically routine treatments – particularly in oncology – physicians report that the underlying process looks largely the same.

That disconnect reflects something structural. Prior authorization is managing utilization and, by extension, financial risk. If that remains, adjustments to the process tend to shift how prior authorization is experienced, not whether it exists.

There’s a forward-looking argument about electronic prior auth – more automated systems providing near real-time responses. That may change the operational experience. It doesn’t change the incentive to review.

Which is why voluntary is not going to work. Without changing the financial incentives that drive utilization management, improvements tend to be incremental and uneven. Until legislation moves that imposes concrete guardrails, the gap between commitment and experience is likely to persist. And right now, legislation isn’t exactly moving quickly.

Reimbursement Fundamentals: Predictable Consequences

Last January I got yelled at on a ski lift by one of my best friends. I was trying to explain why she couldn’t access Flovent. Apparently, I was not the only one she yelled at. There is a pharmacist in Boulder, CO who probably still remembers her rant.

I thought about her this week when Senator Hassan released her investigation report, because the numbers in it are not easy to look at. A 20% decline in inhaled corticosteroid use among asthmatic children. A 17.5% increase in asthma-related hospitalizations.

Flovent didn’t go away because demand disappeared or because something clinically better suddenly replaced it. It went away because the way it was priced stopped working inside the system we’ve built over the last couple of decades. And that system, whether anyone likes it or not, has been built on a very specific set of financial flows.

For a long time, products like Flovent operated inside a rebate-driven model. High list price paired with significant rebates, with the difference between the two doing a lot of work across the system. Plans relied on that rebate revenue to offset premiums. Pharmacy benefit managers (PBMs) used it as the backbone of formulary negotiations. Pharmacies had reimbursement and margin tied – directly or indirectly – to those higher benchmark prices. 340B entities relied on the spread between acquisition cost and reimbursement to fund programs. And manufacturers used that same structure to manage best price exposure and maintain flexibility across payers.

It’s not a clean system, and no one really defends it on aesthetics. (hahahahaha.) People understand how to operate inside it. The incentives, while messy, are at least legible.

What changed for Flovent wasn’t a vague shift in the policy environment. There was a specific trigger. The American Rescue Plan, passed in 2021, eliminated the cap on Medicaid drug rebates. Previously, no matter how much a manufacturer had raised its price over the years, rebates were capped at 100% of average manufacturer price. Once that cap was gone, drugs that had accumulated years of above-inflation price increases were suddenly facing rebate obligations that could exceed what the drug itself cost.

Let me repeat that a different way – every time the drug would be used, the company would lose money. They would owe money for utilization. GSK was looking at an estimated $367.6 million per year in Medicaid rebate penalties.

The decision to pull Flovent on January 1, 2024 – exactly the day those new obligations kicked in – was about resetting the rebate baseline entirely. GSK discontinued the branded product and launched an authorized generic through Prasco. Under Medicaid rules, an authorized generic is treated as a new product with no pricing history. Rebate slate: cleared.

Here’s where it gets a little maddening. The authorized generic did have a lower list price than Flovent’s peak – and that’s the number that made headlines. But list price and net price are not the same thing. (I know. I know. Bear with me.) List price is what’s printed on the label. Net price is what’s actually paid after rebates and discounts move through the system. Johns Hopkins estimated the net price of the authorized generic ended up around four times what Flovent’s net price had actually been.

Hassan’s report has put real numbers to the disruption: the hospitalization increase, the drop in ICS use, the families who lost access to a drug their kids had been stable on for years. That is a serious finding and it deserves to be treated seriously. Especially with an angry mom on a ski lift.

But here’s where I want to push back on how this is being framed.  When you remove the rebate cap on a product that’s been priced above inflation for a decade, you’ve created a situation where the manufacturer loses money every time the drug is dispensed. That’s not a minor inconvenience – that’s an existential math problem. The authorized generic structure was the exit the rules left open, and GSK used it. I think the timing and the execution deserves scrutiny, and Hassan’s report makes a credible case that patients paid the price. But if we spend all our energy on GSK’s decision and none of it why, we are doomed to repeat history. Policy changes have consequences and this one was pretty damn predictable. Companies may be willing to make less but they don’t want to lose money on every script fill.

I also want to note that PCMA published a piece this week titled “How a Big Drugmaker’s Games Inflated Costs and Hurt Access to Life-Saving Medication for Kids; and How PBMs Stepped in to Fill the Void.” I mean. The PBM industry trade group positioning PBMs as the heroes of the Flovent story is a choice. The same PBMs who used Flovent’s rebate structure as the backbone of their formulary negotiations for years. We can talk about GSK’s role here without pretending the rest of the system was a passive bystander.

There is some genuinely good news in all of this. On March 4, the FDA approved the first true generic fluticasone propionate inhaler, with Glenmark planning distribution starting this month. That is how the system is supposed to work. Competition enters, prices come down, access improves. Hassan’s report and the pressure that followed appear to have contributed to moving that process along.

This isn’t really a story about a single inhaler. It’s about what happens when you remove one lever without thinking about the broader environment, the if/thens.