A year ago, President Trump pledged to lower Medicaid drug prices.
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Trump → pledge → prices
Has that happened?
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that → happen → ?
When President Trump talks about accomplishments of his second term, he often mentions the deals he's struck with pharmaceutical companies to lower drug prices.
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he → talk → prices
"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.
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Trump → go → Sept
"And that alone should get us a big victory in our midterms that are coming up."
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that → get → midterms
Last year on Sept. 30, the president 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.
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he → gather → companies
Eventually, the White House said 26 companies signed agreements, but they have not been made public.
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they → say → agreements
Trump refers to these agreements as "most favored nation" deals, meant to bring U.S. drug prices in line with what other wealthy countries pay for drugs.
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countries → refer → drugs
The most buzzed-about part of the first announcement was the creation of TrumpRx, a website for consumers to find discounts on some drugs if they choose not to use their health insurance.
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they → buzz → insurance
But, as NPR has reported, the drugs available are limited, and most consumers will get a better price if they just use their insurance and pay the copay.
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they → report → copay
But Trump's announcement also included another promise, for the low-income and disabled Americans who are covered by Medicaid:
"Today Pfizer is committing to offer all of their prescription medications to Medicaid," he said on Sept. 30, 2025.
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he → include → Sept.
It's gonna have a huge impact on bringing Medicaid costs down like nothing else.
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It → go → nothing
And Trump said he expected other drug companies would do the same.
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companies → say → same
Medicaid covers 66 million Americans, and its net spending on prescription drugs grew by 46% between 2019 and 2024, costing taxpayers $46 billion dollars that year, according to the nonpartisan health policy research group KFF.
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spending → cover → group
But turning Trump's promises into an operational program has been difficult.
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turning → turn → program
A year later, that effort has been plagued by uncertainties, delays and a general lack of transparency.
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effort → plague → transparency
The pilot program relies on voluntary participation, by both drug companies and individual states, which means the number of drugs that will be discounted, and the number of patients who will have access to those prices, could be lower than what Trump originally promised.
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Trump → rely → what
Companies might not offer all of their drugs
Because the administration has refused to release the actual pharmaceutical agreements, it's not clear if participating companies have to offer Medicaid most-favored nation discounts for all their drugs.
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companies → offer → drugs
NPR reached out to Pfizer and 16 other major drug companies that struck pricing deals with the Trump Administration over the past year.
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that → reach → year
None would confirm to NPR that all of their drugs would be discounted in Medicaid, or say exactly which ones would be discounted.
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ones → confirm → Medicaid
Gilead told NPR it is working with states to make "selected covered products available," including drugs that treat hepatitis C, hepatitis B and HIV.
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that → tell → C
Sanofi said it would make the discounted pricing available for "certain wholly owned medicines that treat diabetes, cardiovascular and neurological conditions, and cancer."
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that → say → diabetes
Eli Lilly said it didn't have a final list but expected "many" of its medicines to be part of the pilot program at a discount.
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many → say → discount
It said "any" of its "eligible covered outpatient drugs " could be selected — except for its GLP-1 medicines that are part of another pilot program in Medicare.
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that → say → Medicare
Genentech would only say that "certain medicines" would be a part of the Medicaid program.
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medicines → say → program
Two companies told NPR the terms of the Medicaid agreements were confidential.
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terms → tell → agreements
The federal regulatory agency, the Centers for Medicare and Medicaid, wouldn't tell NPR how many of each company's drugs would get Medicaid discounts either.
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many → tell → discounts
This fact that companies aren't discounting all of their drugs as part of this pilot program is worrisome, said Dr. Thomas Hwang of Brigham and Women's Hospital in Boston.
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Hwang → discount → Boston
It makes it easier for companies to game the system, he said
"
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he → make → system
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.
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Hwang → have → which
In other words, the companies might publicly get credit for discounts that are actually negligible.
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that → get → discounts
"So there would be an incentive for companies to try to limit their liability and pay less to Medicaid," Hwang explained.
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Hwang → try → Medicaid
"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.
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drugs → worry → offered
The discounts won't reach all states
Even if pharmaceutical companies do end up offering lower prices on a wide range of products, those new prices won't simply take effect nationwide.
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prices → reach → effect
Instead, the discount program is being set up as a voluntary pilot.
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program → set → pilot
That means every state has to decide whether to opt-in, and then agree to certain conditions.
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state → mean → conditions
The pilot is called the Generous model.
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pilot → call → ?
Deadlines for drug companies and states to sign up were originally set for the spring and summer, but they've been pushed back.
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they → sign → spring
"It's always a bad sign when you keep pushing back your deadline," said Ameet Sarpatwari, a professor of population medicine at Harvard, and a drug policy researcher.
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Sarpatwari → keep → Harvard
Why states might hesitate to commit
Even though the aim of the Generous pilot program is lower drug prices, a state that signs up could be exposing itself to some financial risks.
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that → hesitate → risks
…and 14 more, not listed.
The Aporia
