The Machinery Behind Your Bill

CMS proposed cutting 340B outpatient reimbursement from ASP plus 6 percent to ASP minus 33 percent in its 2027 OPPS rule, and competing bills landed alongside it. The bipartisan House SECURE 340B Act and Senator Cassidy's Senate draft mark the first serious attempt to modernize the program since 1992, so market access teams without a 340B strategy are flying blind on a channel that touches one in six drug dollars.

The Patients First Act would tie Medicare physician reimbursement to inflation for the first time, and two Medicare Advantage bills cleared House Ways and Means 42 to 0 on electronic prior authorization and revenue disclosure. Critics now peg Medicare Advantage overpayments near 140 billion dollars a year, and Representative Doggett is pushing a bipartisan bill to curb the practice. When a vote goes 42 to 0, something real is happening, and commercial teams should build their payer strategy around it.

A federal judge blocked Colorado's Prescription Drug Affordability Board from enforcing its upper payment limit on Amgen's Enbrel, freezing the boldest state price-cap experiment in the country. Every state building an affordability board now watches this case, and the tool patients hoped would cap their costs sits in legal limbo.

HRSA reported that 340B purchases hit 100 billion dollars in 2025, up from 16.2 billion in 2016 and now more than 16 percent of US drug spending, with ten drugs driving over a quarter of the total. Congress built the program to help safety-net providers stretch limited dollars, and the gap between that purpose and a 100 billion dollar channel is where the political pressure now sits.

An Iowa Medicaid audit found a major PBM generated more than 100 million dollars in profit through accounting built to circumvent the state's ban on spread pricing. Auditors called it a shell game, and every dollar a PBM hides inside a Medicaid program is a dollar that never reached patient care.

A JAMA study of more than 2 million first-time brand-drug fills found insurers rejected 32 percent of initial attempts through formulary exclusions, prior authorization, and step therapy, while ACA insurers proposed a median 14 percent premium hike for 2027. The barrier is no longer the price of the drug, it is the coverage decision made before the patient reaches the pharmacy.

North Carolina built a healthcare affordability commission and seated hospitals, insurers, employers, and agencies, but no patients. Patients hold expertise no claims database captures, from denied prior authorizations to the real cost of an appeal, so advocacy that means anything puts a patient in the seat, not a summary of one.

Since 2000, 743 acute-care hospitals closed while hundreds opened, but the closures cluster in low-income counties while 73 percent of the new hospitals opened in the richest 40 percent of the country. Wendell Potter matched the closure data to county income and found a clear pattern, so access now depends on the zip code a patient lives in. Advocacy that ignores where care physically exists misses the barrier that stops treatment before cost ever enters the conversation.

Bristol Myers Squibb published a white paper on early patient engagement, built with advocacy partners, documenting how it moved patient voice into clinical development. Companies that seat patients before the launch move in concert with the community, and companies that skip that step learn what patients think from a press release.

Oncologists called Revolution Medicines' daraxonrasib the biggest pancreatic cancer advance in decades, comparable to the first checkpoint inhibitors, and convened a panel to work through what comes next. Pancreatic cancer has carried some of the lowest survival rates in oncology for twenty years, and the trial result is the beginning of the access work, not the end of it.

Former LifeMD employees told STAT that providers were expected to review roughly 25 cases per hour across a base of 365,000 subscribers, and the FDA named Dexcom the first participant in a pilot that lets digital health devices skip premarket authorization in exchange for real-world evidence. Digital-first care is scaling faster than the guardrails around it, so advocacy has to hold telehealth prescribers and AI-enabled devices to a real safety standard.

Anthropic announced it will develop its own drugs and released Claude Science aimed at biopharma R&D, with a stated focus on rare disease where the biology is clear but the economics are not. AI is moving from the lab bench toward the pipeline, and advocacy organizations that understand how these tools shape research priorities will shape who benefits from them.