President Trump has repeatedly blasted health insurers and drug manufacturers in public for their alleged profiteering off the backs of patients. But thus far his administration’s policies have had little material impact on either industry or patients’ out-of-pocket costs.

The President has asserted that the only healthcare plan he would sign off on was one that removed the insurers who had “ripped off” America for “long enough.” It’s a frequently voiced refrain. Just this month, Trump said at a rally, “we will pass a truly great healthcare plan that will stop all payments to big insurance companies.”

But at a recent summit convened by Secretary of Health and Human Services Robert F. Kennedy Jr.’s Make America Healthy Again movement, insurers along with their lobby group had a seat at the table. The meeting in Washington DC included a panel featuring top executives from two of the largest for-profit insurers in the country, who helped sponsor the event.

In addition, Trump’s promises to crack down on health insurers haven’t aligned with the administration’s actions that have enriched them with larger payment increases than expected. This especially applies to Medicare Advantage, the private alternative to traditional Medicare, the government health insurance program for those over 65 and certain disabled individuals.

And in the commercial health insurance sector, consumers continue to face escalating premiums and deductibles well in excess of the already elevated consumer price index inflation rate. This exacerbates the problem of affordability for the typical American whose wages haven’t grown commensurately.

Also, the President’s rhetoric toward pharmacy benefit managers — calling them, among other things, “rich as hell” — hasn’t been backed up by particularly robust measures to protect patients or rein in the middlemen. He has mostly let them off the hook . PBMs are intermediaries that play an important role negotiating prescription drug prices on behalf of employers, health plans and others. The three biggest PBMs — CVS Health’s Caremark, Cigna’s Express Scripts and UnitedHealth’s Optum Rx — together control 80% of prescriptions in the United States. They’re now part of vertically integrated healthcare conglomerates that offer health insurance and own and control specialty pharmacies that supply high-cost and often complex medicines, certain healthcare provider clinics and even manufacturers of pharmaceutical products.

The Trump administration framed provisions in the 2026 Consolidated Appropriations Act and Federal Trade Commission settlements as “historic victories,” curbing problematic behavior in the PBM industry. But critics say the actions brought about by the FTC and Congress appear weaker than what was originally vowed by the administration.

Legislation signed by the President includes imposition of transparency rules related to PBM disclosures on their compensation and delinking drug list prices and pharmaceutical manufacturer rebates. In this context, by 2028 PBMs will have to replace rebates that are based on list prices with flat administrative fees which are fully visible to those with whom PBMs contract. Traditionally, drug makers have offered PBMs rebates that reduce net prices in exchange for preferential positioning on formulary, which in turn can move market share towards preferred products. Though PBMs pass through a considerable portion of these payments to entities with whom they contract, patients generally don’t see these rebates at the point of sale or pharmacy counter.

The opaque process of rebating has long been criticized by lawmakers and regulators alike. The FTC under the Biden administration sued PBMs, alleging they engaged in anticompetitive practices. Ultimately, the agency led by a new chairperson appointed by Trump finalized settlements with Express Scripts and CVS Caremark this year to resolve a landmark insulin pricing lawsuit. It’s likely a third settlement with Optum Rx is forthcoming. As the FTC disclosed in its interim and final reports over several years of investigations, drug manufacturers competed for favorable formulary placement not by lowering list prices, but by increasing them. And higher list prices implied larger rebates for PBMs. As a result, PBMs steered patients toward the higher-priced insulins that generated the most rebate revenue. They did this while excluding or disadvantaging lower-list-price alternatives. This practice isn’t confined to insulin products. It happens in the biologic and small molecule spaces across multiple therapeutic categories.

Yet neither the CAA law or the FTC settlement bans rebates or spread pricing. PBMs are still able to spread price in Medicaid — pay less to pharmacies than they receive from Medicaid — in states where it’s permitted. And while the settlements require PBMs to offer plan sponsors a “standard offering” that passes 100% of manufacturer rebates directly to patients at the pharmacy counter, the agreements allow employer plan sponsors to opt out.

Moreover, the FTC has faced criticism for not including monetary penalties or admissions of misconduct and liability. There’s no restitution fund, for instance, for patients who paid inflated insulin co-payments. There’s merely a consent order which essentially entails promises to behave better along with limited government oversight and monitoring.

Trump boasted in August of this year that his administration brought about the first drop by more than 3% in prescription drug prices in more than 60 years. But the facts suggest a far more nuanced narrative is at hand, with a combination of market forces, the Inflation Reduction Act’s drug pricing provisions passed under President Biden and the Trump administration’s regulatory actions playing roles.

The most-favored nation policies being pushed by the Trump administration strive to better align prescription drug prices between the U.S. and peer nations in the Medicaid program, which provides health insurance for low-resourced individuals. In exchange for a three-year reprieve from threatened tariffs on their products, the President has signed deals with 26 pharmaceutical companies. The agreements are set to expire less than three years from now.

The deals between the administration and drug manufacturers serve as pillars of the so-called GENEROUS model in which the federal government seeks to peg the net prices paid by Medicaid to an undisclosed MFN index. This voluntary demonstration project commenced in January of this year.

Trump also announced last autumn the establishment of a new direct-to-consumer website called TrumpRx, operated by the federal government. The portal has been operational since January and offers dozens prescription drugs at discounted prices.

Besides the fact that the federal government has now gotten involved, there’s nothing new about DTC portals for prescription drugs. They’ve existed for quite some time for a variety of pharmaceuticals. And they’ve recently become essential vehicles for companies like Eli Lilly and Novo Nordisk to sell their popular weight loss medicines at considerable discounts compared to list prices.

In numerous public remarks and social media posts, Trump has claimed that TrumpRx provides a means for Americans to now pay the “lowest” prices for their drugs. However, research reveals the falsity of the administration’s claims that TrumpRx offers Americans the world’s lowest prices on prescription drugs.

As for the GENEROUS model, without being privy to the details of the agreements it’s unknown whether the prices are in fact lower than what Medicaid already achieves using its existing system of supplemental rebates. Additionally, enrollees will not see changes to what they pay out-of-pocket as their cost-sharing was minimal to begin with.

Participation in the Medicaid model GENEROUS exempts companies from having to join the mandatory GLOBE and GUARD models in Medicare, due to launch in January 2027. These demonstration projects aim to tie U.S. prices to international reference pricing benchmarks. Because of the exemptions, the GLOBE and GUARD models have largely been neutered in terms of the cost savings the government will be able to generate.

Under another MFN-based program in Medicare called Bridge drug makers have agreed to supply specific weight-loss medications such as Wegovy, Zepbound and Foundayo at lower net prices ($245), allowing the Centers for Medicare and Medicaid Services to offer them to eligible seniors at a flat $50 per month co-payment. While the initiative partially closes a gap in coverage of obesity medicines in Medicare, it only does so through December of next year. Furthermore, it’s subject to automatic prior authorization which can impede patient access.

A top official at CMS, Chris Klomp, has said that the MFN-inspired models aren’t intended to necessarily lower U.S. prices. In March, Klomp spoke at a STAT News conference and maintained that manufacturers could “price wherever they want.” The purpose isn’t a price cap. Rather it’s to raise prices in international markets. However, it remains to be seen how feasible this goal is, as severe budget constraints throughout Europe continue to keep a lid on prices or even decrease them further in countries such as Germany.

After securing access to heavily redacted versions of the MFN agreements signed with Pfizer and Eli Lilly, the consumer advocacy group Public Citizen suggests the cost savings claimed by the administration for its MFN models are a “ mirage .” Furthermore, corporate statements indicate that the financial impact of these deals on their bottom lines is “immaterial.” Likewise, they don’t appear to be helping patients much in terms of their struggle to afford medicines.