FAQ: Policies for Pharmacists to Track Heading into 2026 Midterms

With the US midterms less than a month away, the policies that shape what pharmacies pay for drugs, what they're reimbursed, and what their patients can afford are already shifting. This election could decide how fast those changes come and which direction they take.

“Regardless of which party controls Congress after the midterms, pharmacists should prepare for continued pressure on drug pricing, PBM practices, and health care affordability,” Adino “A.J.” Barbarito, Esq, senior associate in Frier Levitt’s Life Sciences Litigation practice group, told Drug Topics®. “A Democratic-led Congress would likely prioritize restoring Affordable Care Act (ACA) subsidies, expanding Medicare drug price negotiation, and intensifying oversight of health care consolidation and vertical integration. However, given the reality of a Republican-controlled executive branch, there would be no guarantee that those bills would become law.”

In part 2 of our pre-election series, Barbarito walks through the issues pharmacists should watch out for heading into November. They include PBM reform, which has rare bipartisan support and an open Centers for Medicare & Medicaid Services (CMS) comment window that runs through November 23, as well as the White House's Most-Favored-Nation (MFN) pricing deals, Medicare drug price negotiation, and the expiration of enhanced ACA subsidies, which is already being felt at the pharmacy counter.

Read through Barbarito’s perspective as he details the key shifts potentially stemming from one of the most anticipated elections in recent US history.

READ MORE: FAQ: How the 2026 Midterms Could Reshape Pharmacy Policy

How is PBM reform momentum expected to shift, if at all, after the 2026 midterms conclude?

PBM reform momentum is likely to remain strong or accelerate after the midterms, regardless of which party controls Congress. The issue has unusual bipartisan support. H.R. 7895, the “PBM Kickback Prohibition Act,” was reported by the House Education and Workforce Committee in July 2026 and awaits a floor vote. A bipartisan coalition of state attorneys general filed a comment letter in April 2026 supporting the Department of Labor (DOL) PBM disclosure rule.

The Consolidated Appropriations Act of 2026 (CAA 2026) is a major reason: It includes reforms that will affect PBM operations in the commercial market and Medicare Part D beginning in 2028. Section 6223(a) requires the Centers for Medicare & Medicaid Services CMS to set standards for the “reasonable and relevant” contract terms that Part D plans and PBMs must offer pharmacies. On September 24, 2026, CMS published a request for information (RFI), CMS-4217-NC, seeking input on those standards. Comments are due November 23, 2026, and the standards will apply for plan years beginning January 1, 2029. Because CMS has not established additional requirements for what constitutes reasonable and relevant terms, pharmacies have an opportunity to help shape the final standards through the comment process.

Under a Democratic Congress, expanded Medicare drug price negotiation, an extension of out-of-pocket caps to private insurance, and heightened scrutiny of MFN agreements would likely remain priorities. PBM and 340B reform would remain priorities as well, reflecting the bipartisan nature of those issues.

Under continued Republican control, PBM and 340B reform would also remain active priorities, along with possible codification of MFN elements and a consumer-affordability framework. The next legislative vehicle may be 340B reform, and the FDA user-fee reauthorization expiring in September 2027 could provide an opportunity for additional pharmacy-relevant reforms.

With many of the MFN drug pricing policies beginning to work in tandem rather than in silos, can pharmacists expect any significant change in drug price trends as we approach 2027?

Pharmacists should expect meaningful but uneven changes in drug pricing as several federal approaches converge heading into 2027. MFN agreements are voluntary arrangements between the administration and drug manufacturers that tie the US price for certain medicines to the lowest prices paid in other developed countries. In theory, that approach can reduce prices for covered products, but its effect depends on the producers and purchasers included in each arrangement.

The White House reports that the agreements now cover 26 manufacturers and roughly 89% to 90% of the branded US market. The White House has characterized the result as the sharpest annual drug price decline in more than 60 years, based on Bureau of Labor Statistics data showing a 3.1% annual decline. CMS has also proposed a Medicare Part D model known as GUARD. Set to begin January 1, 2027, the proposed model would require manufacturer rebates when prices exceed those in comparable countries, and CMS expects it to lower Part D spending and beneficiary costs. However, caution is warranted.

The MFN deals are voluntary, several signers continued to raise list prices, and most commercially insured Americans see no direct benefit from MFN arrangements or Inflation Reduction Act (IRA) negotiations. Separately, the IRA created a statutory Medicare Drug Price Negotiation Program (MDPNP), which allows Medicare to negotiate prices for selected high-spend drugs. The first 10 negotiated prices, representing discounts of 38% to 79% off list prices, took effect in 2026, with 15 more drugs slated for 2027. For pharmacists, these changes may mean shifting acquisition costs, changing formularies, and increasingly complex reimbursement calculations.

How might changes to Affordable Care Act subsidies affect patients and their interactions with pharmacists at the counter?

The expiration of enhanced Affordable Care Act (ACA) premium subsidies at the start of 2026 is already affecting patients at the pharmacy counter. When subsidies decline, patients may face higher premiums and less money available for prescriptions. Kaiser Family Foundation (KFF) estimates that average premium payments for subsidized enrollees rose 114%, with some premiums doubling or tripling. KFF later found that average premium payments across all enrollees rose about 58% as many switched to higher-deductible plans.

Paid marketplace enrollment fell by roughly 2.6 million people between February 2025 and February 2026, and KFF projects that up to 4.8 million could leave the marketplace in 2026. Pharmacists should anticipate more patients facing higher out-of-pocket prescription costs, requesting generic alternatives or discount programs, or abandoning prescriptions. Restoring the subsidies is a top Democratic priority, while Republicans view the pandemic-era expansions as having gone too far. The midterm outcome will influence whether patients see relief through restored subsidies, alternative coverage structures, or continued reliance on manufacturer assistance programs.

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