TL/DR –
The U.S. reimbursement policy experienced significant upheaval in 2025 due to new mandates, stalled subsidy negotiations, and pricing pressures. Changes include the introduction of Medicaid work requirements, movement on the Most Favored Nation (MFN) drug pricing policy, the end of the government shutdown with Affordable Care Act subsidies remaining unresolved, and a potential impact on innovation due to the MFN order and broader U.S. drug pricing reform. Additionally, the White House announced pricing agreements with Eli Lilly and Novo Nordisk, which are set to sharply reduce the cost of GLP-1 therapies.
Top 5 Transformative Events in 2025 US Healthcare Reimbursement
As the second half of 2025 experienced drastic upheavals in US reimbursement policy, uncertainty shrouded the future of payers, providers, and patients. Amidst changes in Medicaid eligibility to agreements on glucagon-like peptide 1 (GLP-1) therapies, here are the five most pivotal reimbursement issues of 2025.
5. New Medicaid Work Requirements Risk Leaving Millions Uninsured
Passed in July 2025, House Rule 1 or the “One Big Beautiful Bill Act,” stipulates that Medicaid beneficiaries must attest to at least 80 work hours monthly every six months. The Congressional Budget Office forecasts that this could potentially lead to 5.2 million adults losing their Medicaid coverage by 2034. As a domino effect, decreased access to care, poorer health outcomes, and significant financial stress could be inflicted upon rural and safety-net hospitals that depend on Medicaid funding. Read the article.
4. Unresolved Details in Most Favored Nation Drug Pricing Raise Concerns
The Trump administration’s Most Favored Nation (MFN) drug pricing policy is progressing despite unresolved operational and legal details until November 2025. This instability is causing concern among manufacturers, payers, and patients. Experts discussed the potential impact of two proposed demonstration models, the GLOBE and GUARD, during an MJH Life Sciences® webinar. Read the article.
3. Uncertain Future of ACA Subsidies After Government Shutdown
The fate of enhanced Affordable Care Act (ACA) subsidies is still in limbo after the 2025 federal government shutdown. This leaves millions of marketplace enrollees uncertain about future insurance costs. If subsidies expire at the end of 2025, low-income patients could see their premiums more than double. Experts warned that failing to extend the subsidies could increase uninsurance rates, particularly among older adults and people with chronic conditions. Read the article.
2. The MFN Order and US Drug Pricing Reform: A Threat to Innovation?
Experts raised concerns that the MFN order might significantly impact US drug pricing by pushing prices closer to international benchmarks. They warned that aligning US prices with those set by foreign governments could dampen investment incentives, especially when combined with the Inflation Reduction Act. While proponents argue MFN could lower costs for some patients, speakers emphasized that opaque global pricing, legal uncertainty, and potential tariff-driven market disruption may ultimately restrict access, destabilize the biopharma ecosystem, and reduce the pipeline of breakthrough therapies. Read the article.
1. Trump Administration Announces Drug Pricing Deals With Lilly, Novo
In a breakthrough move, the White House announced pricing agreements with Eli Lilly and Novo Nordisk in November that will significantly reduce the cost of GLP-1 therapies such as semaglutide and tirzepatide for Medicare, Medicaid, and patients purchasing through the new TrumpRx direct-purchase platform. Both companies also committed to MFN-aligned pricing on future products and additional discounts on insulin and other chronic disease drugs. Read the article.
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