Mid-Year Check-In: Is Patient Affordability Getting Worse?

Pharmaceutical Commerce continues its H1 Review/H2 Outlook series, revisiting the predictions and priorities industry voices shared earlier this year. This installment features Amy Niles, chief mission officer at the Patient Advocate Foundation, in the second of a three-part video interview.

Where Niles found incremental progress on prior authorization reform, she is less optimistic about two other access risks she flagged in her 2026 outlook: Medicaid work requirements and the expiration of enhanced ACA premium tax credits.

About 18.5 million Medicaid enrollees will need to prove compliance with new work requirements enacted under the One Big Beautiful Bill Act, according to Kaiser Family Foundation data.¹ States must implement the requirement starting Jan. 1, 2027. Niles says the rules have proven more restrictive than they were originally conveyed.

“People are going to need to provide documentation about their work requirements or their volunteer commitments, and they’re going to be needing a statement from their healthcare provider that their health condition prevents them from working,” Niles says. Each state will also set its own guidelines for the severity of medical conditions that qualify for exemption, she says.

As a result, Niles expects millions of Medicaid enrollees to lose coverage, either because they don’t meet the work requirement or because the administrative burden discourages them from complying. “People might just be inclined to say, forget it, I’m not going to do that,” she said. “And as a result, millions will go without coverage. It’s going to tax the healthcare system significantly, moving forward.”

Niles is also skeptical about about the ACA exchanges, where she expects double-digit premium increases to continue. Roughly 3 million people had already dropped out of the exchanges as of February 2026, according to KFF.² “I think all of this does not bode well in terms of patient affordability for care, including prescription medications,” she said.

Those pressures show up directly in the Patient Advocate Foundation’s own polling of Medicare beneficiaries. Of more than 4,200 people surveyed, 83% said they live on a fixed income, and six in 10 said that income is not rising even as premiums, provider costs and pharmacy costs increase, Niles says. Four in 10 said they cannot absorb further cost increases.

“It continues to reflect what we’ve seen over many years,” Niles says. One in three respondents reported not filling or delaying prescriptions because of cost, and beneficiaries are increasingly cutting non-medical spending to cover medical costs or “making unfortunate decisions.”

Looking ahead, Niles says she expects the strain on Medicaid enrollees to intensify. “We’re going to see enormous challenges over the next couple of years,” she says. “These individuals are either going to continue to face these challenges, or they’re going to decide, I’m going to go without coverage because I’m not going to be able to meet these requirements.”

Watch the first part of her interview with PC:

1. Mid-Year Check-In: Has Prior Auth Reform Delivered?

References

1. Kaiser Family Foundation, “A Closer Look at the Work Requirement Provisions in the 2025 Federal Budget Reconciliation Law,” accessed July 23, 2026. https://www.kff.org/medicaid/a-closer-look-at-the-work-requirement-provisions-in-the-2025-federal-budget-reconciliation-law
2. Kaiser Family Foundation, “ACA Marketplace Enrollment Is Down By 3 Million After Big Jump in Premium Payments,” KFF Quick Takes, accessed July 23, 2026. https://www.kff.org/quick-insights/aca-marketplace-enrollment-is-down-by-3-million-after-big-jump-in-premium-payments/