From MFN to IRA, Experts Warn of a System Under Pressure in Wide-Ranging Policy Webinar

As drug pricing initiatives move forward while coverage policies grow more uncertain, the complexity of the Trump administration’s health care agenda is coming into sharper focus. During a March 3, 2026, webinar hosted by The American Journal of Managed Care^® (AJMC^®) and Managed Healthcare Executive^® (MHE), a pair of health policy experts assessed where things stand on drug pricing, the Affordable Care Act (ACA) subsidies, and other key priorities shaping the administration’s approach to health care.¹ The hour-long conversation covered a wide range of issues and revealed few easy answers.

The panelists were Lindsay Bealor Greenleaf, JD, MBA, head of market access policy strategy at ADVI Health, and Nick Ferreyros, managing director of the Community Oncology Alliance (COA). Moderators were Maggie Shaw, lead editor of AJMC, and Peter Wehrwein, managing editor of MHE.

The Great Healthcare Plan: What's Real

The administration's Great Healthcare Plan, released mid-January, includes most-favored-nation (MFN) drug pricing, expanded over-the-counter (OTC) drug access, ACA premium reductions, and new health savings accounts (HSAs). Wehrwein described it as “a gumbo” of proposals. The central question for both panelists: what can actually get done, and on what timeline?

Greenleaf separated the proposals into 2 buckets: executive action and Congressional action. On the executive side, the Center for Medicare and Medicaid Innovation (CMMI), the CMS subagency with authority to waive Medicare statutes, has already initiated MFN pricing processes for Medicare Part B, Part D, and Medicaid. Hospital price transparency enforcement, insurer oversight, and pending Federal Trade Commission (FTC) actions against CVS and Optum are also within the administration's reach.² HSA expansion, cost-sharing changes, and large-scale pharmacy benefit manager (PBM) reform, however, require Congress. Ferreyros was skeptical much would move legislatively before November: “Anything happening through the normal order is just not going to happen until at least after the elections.”

MFN Pricing: Leverage More Than Policy

Sixteen major manufacturers have voluntarily agreed to MFN pricing across all of Medicaid and for future drug launches,³ representing roughly 70% of affected spending. Greenleaf argued the administration has already achieved much of what it set out to do through the threat of regulation rather than its codification,⁴ and that pushing further carries real risk. “You don't need to finalize these models,” she said. “They've already achieved so much.” This was a point she had raised in a previous webinar on the GLOBE and GUARD models and how voluntary deals are reshaping the MFN landscape.⁵

Ferreyros raised a practical concern with MFN's foundation: Foreign drug prices are typically set under confidential contracts using health technology assessment frameworks that incorporate quality-adjusted life-years, a metric the US has consistently rejected as a basis for coverage decisions.⁶ Pegging US prices to those benchmarks is more complicated than it sounds. He also noted a significant political shift in that drug price negotiation was once a core Democratic priority. Now, a Republican administration is leading the charge. “That horse is out the door,” he said. “It is not getting put back.”

ACA Subsidies: Expired, With No Replacement Ready

Enhanced ACA marketplace subsidies expired at the end of 2025 after a House-passed extension failed in the Senate.⁷ The subsidies had helped push enrollment to 24 million people in 2025. For many lower-income enrollees, the resulting premium increases have been steep. Even before factoring in subsidy expirations, 2026 is reported to see a 26% average premium increase.⁸ “We can't leave cancer patients without affordable coverage,” Ferreyros said. “That's essentially what this has done.”

Greenleaf acknowledged the human cost but pointed to the fiscal and accountability problems with extending the subsidies unchanged. The 10-year price tag is $350 billion, and a December US Government Accountability Office report found $94 million in 2023 subsidies went to deceased individuals. “Republicans just didn't want to continue with business as usual,” she said. “Too much else needs to be done.” Both panelists agreed that the absence of a ready replacement is a political liability heading into the midterms.⁹

The IRA’s Impact on Community Oncology

Ferreyros spent considerable time on a consequence of the Inflation Reduction Act (IRA) price negotiations that have gotten limited public attention. Under current Medicare Part B rules, physicians who administer drugs are reimbursed at average sales price plus 6%. That add-on covers overhead, drug storage, and practice operations—what Ferreyros called “what keeps the lights on.” When the IRA's Maximum Fair Price takes effect for Part B drugs in 2028, the add-on will be calculated on a lower negotiated base. COA's modeling projects a 49% reduction in physician add-on payments, roughly $12 billion per year in oncology alone. An Avalere Health analysis commissioned by COA put the cumulative loss through 2032 at $12 billion to $19 billion for oncology and hematology alone.¹⁰

“That is a practice-ending event,” Ferreyros said. He added that when community oncology practices close, patients don't simply shift to hospitals. Hospital-based cancer care has longer wait times and costs Medicare substantially more, which works against the IRA's own savings rationale. His proposed fix is to structure Part B reimbursement the way the GLOBE and GUARD models work: The government is reimbursed the price difference, rather than reducing what providers are paid. COA has been raising this alarm for years.^11,12

On innovation, Greenleaf explained that new drug approvals fell from 65 in 2023 to 48 in 2024, the lowest since 2019.¹ She stopped short of attributing the decline solely to the IRA, but said the trend warrants attention—particularly with MFN pressure and 340B program expansion adding to the burden on manufacturers simultaneously.

Looking Ahead

The webinar didn’t end with a clear resolution, which may be the most accurate reflection of where things actually stand. Multiple significant policy changes are happening at once, their interactions aren't fully understood, and the window for legislative fixes is closing as midterms approach. Ferreyros put the stakes plainly: “If our elected officials don't achieve their ends with these things, what comes next? We have to align all the stakeholders for a grand bargain—because if we're not careful, it could go sideways.”

Greenleaf was cautiously optimistic. Ferreyros was more urgent. Both agreed that 2026 will go a long way toward determining how, or whether, these questions get resolved.

References

1. Ferreyros N, Bealor Greenleaf L, Shaw ML, Wehrwein P. Healthcare at a tipping point: politics and policy in ‘26. An AJMC/MHE webinar. March 3, 2026. Accessed March 3, 2026. https://www.ajmc.com/view/healthcare-at-a-tipping-point-politics-and-policy-in-26
2. Shaw ML. Express Scripts avoids fines but agrees to major structural overhaul. AJMC. February 5, 2026. Accessed March 5, 2026. https://www.ajmc.com/view/express-scripts-avoids-fines-but-agrees-to-major-structural-overhaul
3. Grossi G. AbbVie joins Trump drug pricing effort, pledges $100B in US R&D investment. AJMC. January 13, 2026. Accessed March 5, 2026. https://www.ajmc.com/view/abbvie-joins-trump-drug-pricing-effort-pledges-100b-in-us-r-d-investment
4. Grossi G. Trump strikes 9 new pricing agreements as drugmakers navigate tariff, regulatory pressure. AJMC. December 19, 2025. Accessed March 5, 2026. https://www.ajmc.com/view/trump-strikes-9-new-pricing-agreements-as-drugmakers-navigate-tariff-regulatory-pressure
5. Grossi G, Shaw ML. Most Favored Nation drug pricing moves forward, but experts warn details are still missing. AJMC. November 5, 2025. Accessed March 5, 2026. https://www.ajmc.com/view/most-favored-nation-drug-pricing-moves-forward-but-experts-warn-details-are-still-missing
6. Steinzor P, Colborn A. MFN drug pricing: risks to access, affordability, and innovation in health care. AJMC. July 16, 2025. Accessed March 5, 2026. https://www.ajmc.com/view/mfn-drug-pricing-risks-to-access-affordability-and-innovation-in-health-care
7. Bonavitacola J. House votes to extend ACA subsidies, eyes turn to Senate. AJMC. January 8, 2026. Accessed March 5, 2026. https://www.ajmc.com/view/house-votes-to-extend-aca-subsidies-eyes-turn-to-senate
8. Mattina C. Newly unveiled ACA premiums show 26% average increase before subsidy expiration. AJMC. October 29, 2025. Accessed March 5, 2026. https://www.ajmc.com/view/newly-unveiled-aca-premiums-show-26-average-increase-before-subsidy-expiration
9. Steinzor P. 5 consequences if ACA premium subsidies end in 2026. AJMC. October 31, 2025. Accessed March 5, 2026. https://www.ajmc.com/view/5-consequences-if-aca-premium-subsidies-end-in-2026
10. Caffrey M. Part B losses to oncologists due to IRA could total $12B through 2032 across Medicare, commercial plans. AJMC. September 17, 2024. Accessed March 5, 2026. https://www.ajmc.com/view/part-b-losses-to-oncologists-due-to-ira-could-total-12b-through-2032-across-medicare-commercial-plans
11. Caffrey M. Without IRA fix, COA warns community oncology practices will shut down. AJMC. June 30, 2025. Accessed March 5, 2026. https://www.ajmc.com/view/without-ira-fix-coa-warns-community-oncology-practices-will-shut-down
12. Caffrey M. For community oncology, good news in PFS offset by potential wreckage of MFP proposal. AJMC. July 15, 2025. Accessed March 5, 2026. https://www.ajmc.com/view/for-community-oncology-good-news-in-pfs-offset-by-potential-wreckage-of-mfp-proposal