Originally published by our sister publication Specialty Pharmacy Continuum
By Gina Shaw
About 1 in 4 patients admit that an out-of-pocket cost of just $50 to $100 may be enough to stop them from starting a newly prescribed therapy, according to the latest Peer Engagement Survey from Nuvera Life Science Consulting presented at InformaConnect Patient Assistance and Access Programs meeting, in Philadelphia, in March 2026.
The survey also found that 41% of patients who don’t fill a new prescription cite out-of-pocket cost as the primary reason, and that nearly 35% are already struggling to afford their medications, before the next round of policy changes hits. “We know where this leads,” said Corey Ford, a principal at Nuvera (part of Inizio Engage). “High out-of-pocket cost is a primary factor for why patients may not take that first fill.”
With a cascade of policy rollbacks, expiring subsidies, and payor-driven benefit changes converging over the next 18 months, Mr. Ford warned that patient access programs (PAPSs) are about to face a perfect storm of disruption that makes that the Medicare Part D benefit redesign seem like a spring shower.
The One Big Beautiful Bill Act, signed into law on July 4, 2025, is already reshaping the insurance landscape. The law did not extend the enhanced Affordable Care Act (ACA) premium tax credits that expired at the end of 2025. “Because of this, we have seen a reduction in enrollment in the marketplace by 1.4 million, with likely most of these individuals who are now uninsured,” Mr. Ford said. “Plans had no choice but to make some tough decisions. And so now we’re seeing narrow benefit designs as well within the exchanges.”
For silver plan enrollees without cost-sharing subsidies, he added, “their deductible went up by over $400 this year.”
The Medicaid provisions in the One Big Beautiful Bill are adding to the erosion. An executive order cutting Navigator funding by up to 90% is a prime example, Mr. Ford noted. (Those funds refer to federal and state financial grants awarded to organizations that provide free, unbiased assistance to individuals navigating the ACA, also known as Obamacare.)
“This is the support that helps individuals fight and find the right plan for them,” he said. Special enrollment periods for low-income patients were ended. And a rule by the Centers for Medicare & Medicaid Services (CMS) now in process would raise the catastrophic plan out-of-pocket maximum to more than $15,000 while eliminating standardized plan designs.
“According to the Congressional Budget Office, we could see 10 million Medicaid beneficiaries becoming uninsured by 2034, close to 4 million losing insurance because of the lapsed enhanced subsidies, and somewhere between 400,000 and 900,000 losing insurance because of the ACA regulatory changes,” Mr. Ford said. He also flagged the risk of safety-net hospital closures in rural areas. “States might have to make some tough decisions around eligibility and coverage, including states that have expanded Medicaid.”
He also noted that, according to the Kaiser Family Foundation, the employee share of employer-sponsored premiums has risen 26% over five years, while specialty drug cost-sharing averages 27% on the employer side and nearly 50% on the exchanges, based on Nuvera’s analysis of data from HealthCare.gov.
Disenrolled Medicaid beneficiaries migrating to the exchanges “are essentially going from paying nothing in their out-of-pocket costs to now having to pay the highest out-of-pocket cost in the commercial benefit,” Mr. Ford said. That simultaneously drives up demand for both PAPs and copay assistance.
Medicare Part D prior authorization requirements are already up 3 percentage points in 2026, he reported, noting that “nearly 75% of [plans] are looking to narrow formularies this year,” he said, with step therapy rising in rheumatology and weight management. The Nuvera analysis found that site-of-care mandates are also shifting infused therapies onto the pharmacy benefit, where patient cost-sharing is typically higher.
“With all the challenges that patients are also facing, there’s going to be a ton of confusion among stakeholders,” Mr. Ford said. “So, there will be a strong need for robust education, very much like what we’ve done recently with the Part D benefit redesign. We don’t want our patients to be caught off guard.”
On accumulators, maximizers, and alternative funding programs—which continue to evolve and expand—he noted that the Help Ensure Lower Copays Act has been introduced for the third consecutive Congress. “But even though it enjoys a modicum of bipartisan support, it’s hard to see this getting passed in this Congress.”
Mr. Ford reported no relevant financial disclosures.