President Trump announced Friday that all 50 states, the District of Columbia, and Puerto Rico will join the administration's Medicaid most-favored-nation drug pricing model, the clearest statement yet of the program's scope. Under the model, the net price of selected Medicaid drugs is brought down to the prices paid in certain other countries, on the theory that the United States, which pays nearly three times what other developed nations pay for prescriptions, should not. The announcement answered the coverage question. It did not answer the price question, because the deals that would set those prices have never been made public.
The program's mechanics explain both its promise and its limits. The administration has said it signed agreements with 26 drugmakers, including 17 of the largest global companies, with Pfizer, Eli Lilly, and Novo Nordisk among the names reported. The agreements are voluntary on both sides: companies choose which medicines to include, and states choose whether to join, with binding state agreements due September 30. The model's design is that Medicaid pays the lower international price for the drugs in the agreements. The savings claims attached to that design are large: the administration cites more than $64 billion for state Medicaid programs and a longer-range estimate of $529 billion over ten years.
The verification problem at the center of the program
The claims cannot be checked from the outside, and that is a structural feature, not an oversight. None of the deal contents are public, and 17 major companies contacted by NPR declined to confirm full participation, with some describing only selected or certain medicines. Researchers cannot verify the savings figures because the inputs are sealed. Kathy Hempstead of the Robert Wood Johnson Foundation put the consequence plainly: the lack of information creates a barrier to legislative action, because it is unclear what Congress would even codify. A pricing program whose terms cannot be inspected is a claim, not yet a fact.
The cherry-picking risk follows from the same opacity. If companies choose which drugs to include, they have every incentive to offer medicines where the gap between U.S. and international prices is already small, and to keep high-price, high-revenue products out. The model's savings then depend on the composition of the deals, which is exactly the information that is not public. Experts have warned of this structure from the start. The nationwide announcement does not change it.
What states give up when they sign
The state side of the bargain is the part the announcement compressed. States that join accept a standardized system and discard their own coverage criteria, such as prior authorization and step therapy, which are the tools states use to control their own spending. Expanding access without those controls can raise state spending even if unit prices fall, because more prescriptions get filled. States balance their budgets annually, and Medicaid drug spending is not where they look for surprises: net spending on prescription drugs in Medicaid grew 46 percent between 2019 and 2024, reaching $46 billion. A model that trades price controls for utilization controls is a different deal than the announcement describes.
The enrollment pattern reflects that caution. Massachusetts said it would opt in. California said it would apply to see more details before committing. The September 30 deadline for binding agreements is days away, which means the states signing this month are signing on the strength of the administration's representations rather than the deals' text. That is a remarkable way to enter a national drug pricing program, and it is the direct result of the opacity at the program's center.
The political calendar the announcement serves
The timing is not incidental. The announcement came as cost-of-living issues dominate the campaign ahead of the November midterms, and the drug pricing deals are the administration's central economic accomplishment claim. Medicaid covers 66 million Americans, which makes the program's scope announcement a genuine policy event and a political one at once. The first MFN commitment, with Pfizer, was announced in September 2025 alongside the creation of TrumpRx, so the national rollout completes a year-long arc on exactly the schedule a campaign would choose.
What the model will actually do to drug prices, state budgets, and patient access is still behind the September 30 deadline and the unpublished agreements. The program is national now. The evidence for what it achieves is not. Those two facts will have to be reconciled in the months after the agreements bind, when the first actual prices and the first actual savings become visible, and the claims meet the data.