Healthcare affordability is America’s No. 1 financial concern. According to new polling from the Kaiser Family Foundation, roughly two-thirds of U.S. adults worry about being able to afford the care their families need.
Yet in the search for solutions, the federal government appears to be heading in the wrong direction. Policymakers are considering drug pricing models that risk erecting new barriers to care and worsening health outcomes — without delivering value to patients.
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The models at issue are the Global Benchmark for Efficient Drug Pricing Model and the Guarding U.S. Medicare Against Rising Drug Costs Model. Both would link Medicare payments to prices set in countries that operate under healthcare systems vastly different from our own. Many rely on strict price controls and coverage limits that impede access to new, more effective therapies. Bringing those constraints into Medicare would affect all beneficiaries, as well as their families and communities.
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The concern begins with how the health systems in these reference countries assess value. Their pricing approaches often depend on cost-effectiveness frameworks, such as quality-adjusted life years, that fail to reflect the realities and health needs of the full patient community.
These models rely on clinical data that frequently underrepresent subsets of the American population — including older adults, people living with disabilities and chronic diseases, and those in rural communities. As a result, they can fail to factor in differences in co‑occurring conditions, illness progression, overall health status, and therapeutic response. It’s unsettling that therapies offering meaningful benefits for many patients, especially those managing complex conditions, are often undervalued in coverage and payment policy.
For millions of patients who rely upon Medicare, the consequences would be significant. Any new barriers to timely treatment increase the likelihood of complications, disease progression, and avoidable declines in health. Communities with a higher prevalence of conditions such as HIV and AIDS, diabetes, asthma, and several forms of cancer would be among the most vulnerable.
Patient risks for preventable illness and complications would be exacerbated by the way these models would alter incentives within Medicare. By tying payments to lower benchmarks, they could skew payer incentives toward payer-defined cost reduction. That shift would undermine clinical decision-making informed by quality metrics that reflect patients’ needs.
And, crucially, these models would fail to deliver to patients the financial relief they promise. Analysis indicates they won’t lower what most patients pay out of pocket for treatment — in fact, they could actually drive up patient premiums and cost-sharing.
If the aim is to improve healthcare affordability and accessibility, policymakers should focus on the actual barriers patients encounter every day — including coverage limitations and administrative procedures that prevent patients from accessing timely care.
Federal and state policymakers ought to advocate a forward-looking, patient-centered realignment of America’s health research, delivery, and financing systems. Doing so requires reassessing how the major components of the healthcare ecosystem — human biology, disease progression, public and private insurance, clinical practice guidelines, and quality metrics — intersect. It also requires recognizing the value of preventing disease by incorporating avoided illness and downstream cost savings into how healthcare value is measured.
Achieving this vision demands a renewed recognition of the value of helping all people live longer, healthier lives. And it demands constructive collaboration to build a research infrastructure that eliminates unnecessary administrative burdens, prioritizes early detection and treatment, and accelerates the development, evaluation, and dissemination of new knowledge so clinicians can match patients with the most effective available therapies.
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The benefits of this approach would be shared broadly. By investing in patients across the full continuum of care, we can improve health outcomes while reducing long-term healthcare costs.
That’s the right prescription.
Gary A. Puckrein is president and chief executive officer of the National Minority Quality Forum.
