The Medicine Cabinet in Five Years

In installment 3G, we met George: seventy-eight years old, fourteen pills, three prescribers, none of whom had seen the complete list. The problem was not any single medication. The problem was the pile. Now the question: five years from now, will the pile look different? Will the drugs be better? Will they cost less? Will anyone be watching the whole?

New drugs are indeed entering the pipeline for pain, heart failure, kidney disease, osteoporosis, and cognitive decline (installment 3I surveys each of them honestly). But a better drug means nothing if the person who needs it cannot afford it, and a breakthrough treatment changes nothing if no one reviews whether the old prescriptions it was meant to replace are still being filled. This installment focuses on the two forces that will shape the medicine cabinet more than any molecule: what drugs cost and how the system that manages them is finally, tentatively, beginning to change.

What’s Changing in the Price

The Inflation Reduction Act of 2022 set in motion the most significant changes to prescription drug pricing in Medicare’s history, and 2026 is the year those changes begin reaching the pharmacy counter.

The first ten drugs negotiated under the IRA took effect January 1, 2026, with price reductions ranging from 38 to 79 percent. Januvia (for diabetes) dropped from $527 to $113 per month. Eliquis (for blood clots) fell from $521 to $231. Entresto (for heart failure) came down substantially. These are medications that millions of Medicare beneficiaries take daily for exactly the conditions this series covers.

A second round of fifteen drugs, including Ozempic and Wegovy, will see negotiated prices take effect in 2027. CMS announced those prices in late 2025: Ozempic, Rybelsus, and Wegovy will cost $274 per month under Medicare, down from list prices exceeding $1,000. A third round will add up to fifteen more drugs for 2028, and twenty for 2029 and each year after. The numbers accumulate.

The $2,100 annual out-of-pocket cap on Part D spending (up from $2,000 in 2025, when the cap was first introduced) means no Medicare beneficiary will pay more than that amount for covered prescriptions in a year, regardless of how many drugs they take. Before 2025, the catastrophic threshold was $8,000, and even after reaching it, beneficiaries still owed a percentage. The cap’s elimination of that ongoing cost exposure is projected to save approximately 11 million enrollees an average of $600 per year. For those not receiving low-income subsidies, the average savings are closer to $1,100.

At the same time, biosimilar competition is finally arriving for some of the most expensive drugs older adults take. More than ten biosimilar versions of adalimumab (Humira) are now on the market, with list-price discounts of 50 to 85 percent. Nearly all Part D plans now include at least one adalimumab biosimilar on their formularies, up from 65 percent in 2024. Another twenty-five biosimilars are expected to receive FDA approval between 2026 and 2027.

But these numbers come with friction. Biosimilar adoption has been slow: adalimumab biosimilars captured less than 2 percent of prescriptions in their first year, even as net spending on adalimumab dropped 45 percent (mostly through rebates to maintain Humira’s formulary position, not through patients actually switching). Nearly 40 percent of patients who did switch to a biosimilar reverted to the brand-name drug within thirty days, often driven by the nocebo effect, a real psychological phenomenon where anxiety about a new medication produces perceived side effects. For older adults, who are disproportionately affected by this switchback trend, the promise of biosimilar savings remains partly theoretical.

And none of these reforms changes the underlying dynamic: pharmaceutical companies set initial prices based on what the market will bear, not what production costs. The IRA negotiates prices for a growing but still limited list of drugs. The vast majority of medications in a typical senior’s cabinet remain outside the negotiation window. Generics, which account for 90 percent of prescriptions but only about 18 percent of drug spending, remain the backbone of affordable treatment. The real savings story for most people still comes down to whether their specific drugs have generic alternatives and whether their plan covers them favorably.

The Digital Layer

The most structurally interesting development may be the one furthest from the medicine cabinet itself. In December 2025, CMS and the FDA simultaneously announced two linked programs: the ACCESS model and the TEMPO pilot. Together, they represent something new in how Medicare pays for chronic disease management.

ACCESS is a ten-year voluntary model, beginning July 2026, that pays providers and organizations for managing chronic conditions (diabetes, hypertension, chronic kidney disease, cardiovascular disease, chronic musculoskeletal pain, depression) using technology-supported care. The payment is tied to outcomes: if a patient’s blood pressure improves, the provider gets paid. If it does not, payment is reduced. CMS will waive patient copays for services delivered under ACCESS, and referring physicians can receive modest payments for co-managing enrolled patients.

TEMPO, the FDA’s companion pilot, creates a pathway for digital health devices (including AI-enabled tools and wearables) to be used in ACCESS before receiving full FDA authorization, provided manufacturers collect real-world performance data. The FDA will select up to ten manufacturers per clinical area.

Why does this matter for the medicine cabinet? Because the conditions ACCESS covers are the conditions that generate most of the prescriptions in this series. If technology-supported care can improve blood pressure control, the second blood pressure medication in George’s organizer might become unnecessary. If continuous glucose monitoring and behavioral support improve diabetes management, metformin’s dose might come down. The best way to reduce the pill count may not be better pills. It may be better systems for managing the conditions the pills are prescribed to treat.

ACCESS and TEMPO are experiments, not guarantees. The model has not started. No digital health devices have been selected. The payment rates have not been published. Whether the program survives a decade of political transitions is anyone’s guess. But the structural idea, paying for health outcomes rather than for prescriptions written, is the kind of shift that could eventually change what the medicine cabinet holds.

What Has Not Changed

For all the movement in pricing and policy, several realities persist. The fifteen-minute office visit remains the standard, and no reform changes the fact that reviewing fourteen medications takes longer than fifteen minutes. The specialist fragmentation 3G described is untouched: a cardiologist, an endocrinologist, and a neurologist still operate in parallel, and the interaction effects between their prescriptions still go unreviewed unless someone insists.

Medicare still does not pay for comprehensive medication reviews as a standalone service. A pharmacist can bill for Medication Therapy Management under certain Part D plans, but eligibility thresholds are high, access is uneven, and most beneficiaries have never heard of the program. The AI deprescribing tools 3G described are years from clinical deployment. In the meantime, the brown bag review remains the best available intervention, and it depends entirely on whether a patient or caregiver knows to ask for one.

The negotiation program, for all its ambition, covers a small fraction of the drugs Medicare pays for. Ten in 2026. Twenty-five by 2027. Sixty by 2029. Medicare covers thousands. Generics, which account for 90 percent of prescriptions but only about 18 percent of drug spending, remain the backbone of affordable treatment. For most people, the real savings story still comes down to whether their specific drugs have generic alternatives and whether their plan covers them favorably.

At the Kitchen Table

Here is what to watch over the next five years. The IRA will continue adding negotiated drugs each year. Ask your pharmacist each January whether any of your medications now carry lower prices. If your plan changes its formulary in response, review your options during open enrollment.

If you take a biologic (for rheumatoid arthritis, psoriasis, inflammatory bowel disease), ask whether a biosimilar is available and whether your plan covers it preferably. If you are offered a switch, know that the clinical evidence for biosimilar safety and efficacy is strong; the anxiety is understandable but the science is clear.

Watch for ACCESS model availability in your area after July 2026. If you are managing diabetes, hypertension, chronic pain, or depression, technology-supported care with outcome-based payment could change both what you pay and how your conditions are managed.

The next installment surveys the specific drugs and treatments entering the pipeline for the conditions this series covers: pain, heart failure, kidney disease, osteoporosis, arthritis, cognitive decline, and the conditions for which the pipeline remains stubbornly empty. Better drugs may be coming. But whether they reach your medicine cabinet depends on the pricing reforms, system changes, and coverage decisions this installment has described. The molecules are only half the story. The infrastructure is the other half.