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.
"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. "And that alone should get us a big victory in our midterms that are coming up."
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. Eventually, the White House said 26 companies signed agreements, but they have not been made public.
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.
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. 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.
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. "And it will be at the most favored nation prices. It's gonna have a huge impact on bringing Medicaid costs down like nothing else."
And Trump said he expected other drug companies would do the 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.
But turning Trump's promises into an operational program has been difficult. A year later, that effort has been plagued by uncertainties, delays and a general lack of 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.
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.
NPR reached out to Pfizer and 16 other major drug companies that struck pricing deals with the Trump Administration over the past year. None would confirm to NPR that all of their drugs would be discounted in Medicaid, or say exactly which ones would be discounted.
Gilead told NPR it is working with states to make "selected covered products available," including drugs that treat hepatitis C, hepatitis B and HIV.
Sanofi said it would make the discounted pricing available for "certain wholly owned medicines that treat diabetes, cardiovascular and neurological conditions, and cancer."
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. 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.
Genentech would only say that "certain medicines" would be a part of the Medicaid program.
Two companies told NPR the terms of the Medicaid agreements were confidential.
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.
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. It makes it easier for companies to game the system, he said
"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. In other words, the companies might publicly get credit for discounts that are actually negligible.
"So there would be an incentive for companies to try to limit their liability and pay less to Medicaid," Hwang explained. "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."
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. Instead, the discount program is being set up as a voluntary pilot. That means every state has to decide whether to opt-in, and then agree to certain conditions.
The pilot is called the Generous model. And the ramp-up has been slow. Deadlines for drug companies and states to sign up were originally set for the spring and summer, but they've been pushed back.
"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.
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.
The federal government splits the cost of Medicaid with the states. In most states, Medicaid is the biggest part of the state budget, after education.
But unlike the federal government, states have to balance their budgets every year, according to Jack Rollins, who directs federal policy at the National Association of Medicaid Directors.
Even if a prescription drug is expected to save money on projected health care costs over many years, a state Medicaid program might not have enough budgeted to pay for every patient who needs the drug in a given year.
"Everything in Medicaid is going to be a trade-off," he said. "There's no silver bullet to the drug costs that we're navigating."
State budget managers already try to control Medicaid costs using various coverage rules for drugs with high price tags.
For example, some drugs might require a doctor to submit a "prior authorization" request to the state Medicaid program. Another rule is to require patients to try cheaper drugs first, to manage their condition, before trying a more expensive brand.
But in the Generous pilot program, states would have to toss out their own coverage criteria and accept a standardized system, if they want the negotiated price.
That would mean states that previously had some coverage limitations on certain drugs might be forced to offer unfettered access, says Sarpatwari.
"Then all of a sudden your state Medicaid plans might be spending a whole lot more because a whole lot more people might be getting the drugs," he says.
The deadline for states to apply was Sept. 10, and a few states like Massachusetts said publicly that they would opt-in. California officials said they would apply, but as a means to see more details before committing. States have until September 30 to finalize and sign binding agreements.
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