Trump Medicaid drug-price pilot sees limited company, state uptake

States weigh annual budgets against multi-year savings claim

Trump regularly cites drug-price deals among his second-term accomplishments. “We went from the highest prescription drug prices, by far, anywhere in the world, to the lowest prescription drug prices anywhere in the world,” Trump said during his remarks at the midterm Republican National Convention in Dallas on Sept. 10. “And that alone should get us a big victory in our midterms that are coming up.”

That claim traces to an announcement one year ago this week. On Sept. 30, 2025, Trump and his health officials gathered in the Oval Office to announce a major agreement with Pfizer — the first of what he said would be a series of deals with pharmaceutical companies. The White House eventually said 26 companies signed agreements, but the agreements have not been made public. Trump refers to the deals as “most favored nation” agreements, meant to bring U.S. drug prices in line with what other wealthy countries pay.

“Today Pfizer is committing to offer all of their prescription medications to Medicaid,” Trump said on Sept. 30, 2025. “And it will be at the most favored nation prices. It’s gonna have a huge impact on bringing Medicaid costs down like nothing else.” Trump said he expected other drug companies to do the same.

The same announcement also produced TrumpRx, a website for consumers to find discounts on some drugs if they choose not to use their insurance. As NPR has previously reported, the drugs available through TrumpRx are limited, and most consumers get a better price by using insurance and paying the copay.

The Medicaid component of the announcement was a separate promise aimed at the 66 million low-income and disabled Americans covered by the program. Medicaid’s net spending on prescription drugs grew 46 percent from 2019 to 2024, reaching $46 billion in 2024, according to KFF.

But turning Trump’s promises into an operational program has been difficult. A year later, the effort has been marked by uncertainties, delays and a general lack of transparency. The pilot relies on voluntary participation from both drug companies and individual states, which means the number of drugs discounted and the number of patients with access to those prices could fall short of what Trump originally promised.

NPR contacted Pfizer and 16 other major drug companies that struck pricing deals with the Trump administration over the past year. None would confirm to NPR that all of their drugs would be discounted in Medicaid, or specify which ones would be. Gilead said it is working with states to make “selected covered products available,” including drugs that treat hepatitis C, hepatitis B and HIV. Sanofi said it would make discounted pricing available for “certain wholly owned medicines that treat diabetes, cardiovascular and neurological conditions, and cancer.” Eli Lilly said it did not have a final list but expected “many” of its medicines to be part of the pilot; the company said “any” of its “eligible covered outpatient drugs” could be selected, except for its GLP-1 medicines, which are part of a separate Medicare pilot. Genentech said only “certain medicines” would be a part of the program. Two companies told NPR the terms of their Medicaid agreements were confidential.

The Centers for Medicare and Medicaid Services, the federal agency overseeing the pilot, also declined to tell NPR how many of each company’s drugs would receive Medicaid discounts.

The pattern worries Dr. Thomas Hwang of Brigham and Women’s Hospital in Boston. “Companies have every incentive to cherry-pick [for this program] the products for which they already give Medicaid the best discounts and for which the international price may not be that much lower,” Hwang said. In other words, the companies might publicly get credit for discounts that are actually negligible, NPR reported. “So there would be an incentive for companies to try to limit their liability and pay less to Medicaid,” Hwang explained. “That gaming is what worries me about this backsliding over the past months — from the initial messaging that all drugs will be offered from participating manufacturers, and now to maybe only certain drugs will be offered.”

The Medicaid pilot, called the Generous model, was originally scheduled to ramp up in the spring and summer. Both drug-company and state sign-up deadlines have been pushed back. “It’s always a bad sign when you keep pushing back your deadline,” said Ameet Sarpatwari, a professor of population medicine at Harvard Medical School and a drug policy researcher.

Even if drug companies do offer lower prices on a wide range of products, the new prices will not simply take effect nationwide. Each state must decide whether to opt in and accept the program’s conditions, and that decision carries specific financial risk. The federal government splits the cost of Medicaid with the states, and in most states Medicaid is the largest part of the state budget after education. Unlike the federal government, states have to balance their budgets every year, according to Jack Rollins, who directs federal policy at the National Association of Medicaid Directors. And even if a prescription drug is expected to save money on projected health care costs over many years, a state Medicaid program might not have enough budgeted to pay for every patient who needs the drug in a given year — creating a direct mismatch between the program’s multi-year savings projections and the state’s annual-budget constraint.

“Everything in Medicaid is going to be a trade-off,” Rollins said. “There’s no silver bullet to the drug costs that we’re navigating.”

State Medicaid programs already manage high-cost drugs through tools such as prior authorization, which requires a doctor to submit a request, and step therapy, which requires patients to try cheaper medicines first. Under the Generous pilot, participating states would have to discard those coverage criteria and accept a standardized access system in exchange for the negotiated price.

“Then all of a sudden your state Medicaid plans might be spending a whole lot more because a whole lot more people might be getting the drugs,” Sarpatwari said.

The deadline for states to apply was Sept. 10. Massachusetts said publicly that it would opt in. California officials said they would apply, but as a way to see more details before committing. States have until Sept. 30 to finalize and sign binding agreements.