Mid-Year Check-In: Where Is Patient Access Headed?

Pharmaceutical Commerce continues its H1 Review/H2 Outlook series with Amy Niles, chief mission officer at the Patient Advocate Foundation, in the third and final installment of a three-part video interview revisiting her 2026 predictions.

Niles notes the Medicare Part D out-of-pocket cap continues to ease costs for beneficiaries, even as the ceiling itself keeps rising. The cap was $2,000 in 2025, rose to $2,100 in 2026, and is set to reach $2,400 in 2027 under a final rule CMS issued in April.¹ “It’s certainly better than what Medicare beneficiaries were forced to pay years ago, but it’s trending in the wrong direction, and it is still unaffordable for many individuals,” she says, noting that the pharmacy cap covers only a piece of a beneficiary’s total cost of care.

Niles says she is watching Medicaid “very, very closely” heading into the back half of the year and is encouraging patients, patient groups and provider groups to get more involved in policy advocacy. “Sharing stories and making sure we continue to advocate for patient-centric policy solutions is really important,” she notes.

She is also concerned about rising ACA exchange premiums and the reduced coverage opportunities she expects beneficiaries to face there. Those pressures, combined with Medicaid changes, will strain the broader healthcare system, she says, pointing to more emergency room visits and more hospital closures, particularly in rural communities where access has already been a challenge for years. More than 200 rural hospitals have completely or partially closed since 2005, and over 400, more than 20% of all rural hospitals, are currently at risk of closure, according to the Commonwealth Fund.²

“All of this is going to continue to tax the healthcare system,” Niles says.

Watch the first and second installments of her interview with PC:

1. Mid-Year Check-In: Has Prior Auth Reform Delivered?
2. Mid-Year Check-In: Is Patient Affordability Getting Worse?

References

1. American Hospital Association, "CMS Proposes Medicare Advantage, Part D Payment Changes for CY 2027," AHA News, Jan. 27, 2026, https://www.aha.org/news/headline/2026-01-27-cms-proposes-medicare-advantage-part-d-payment-changes-cy-2027.
2. Kevin Bennett et al., “Why Rural Hospitals Are Facing a Funding Crisis — and How It Could Get Worse,” Commonwealth Fund, Feb. 9, 2026. https://www.commonwealthfund.org/publications/explainer/2026/feb/why-rural-hospitals-face-funding-crisis-how-it-could-get-worse