WASHINGTON, DC - NOVEMBER 6: A chart addressing various Trump administration initiatives aimed at lowering drug prices for Americans. President Trump announced that his administration has reached agreements with, among others, the drugmakers Eli Lilly and Novo Nordisk that reduce the cash-pay price of some GLP-1 weight loss medications sold directly to consumers on the TrumpRx online platform. (Photo by Andrew Harnik/Getty Images)

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Direct-to-consumer options for certain prescription drugs offer cash-pay customers lower prices but preserve inequities in the healthcare system.

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

Besides the fact that the federal government has 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.

While these portals offer increased convenience and lower prices for some, particularly the growing number of un- and underinsured, they mostly benefit those who can afford to pay out-of-pocket. As such, they serve to reinforce an already heavily tiered system that favors patients with disposable income while bypassing the need for robust insurance protections for others.

Thus far, 17 pharmaceutical manufacturers have agreed to sell some of their medications at discounts, on TrumpRx and in Medicaid, the main public program providing health insurance coverage for low-resource individuals and families.

The strictly confidential and temporary (duration of three years) agreements between the Trump administration and drug manufacturers are presumably based on so-called most-favored nation prices or the (second) lowest offered in a basket of nine other similarly wealthy nations. The administration is striving to better align prescription drug prices between the United States and peer nations. However, research reveals the falsity of the administration’s claims when it touts TrumpRx as offering Americans the world’s lowest prices on prescription drugs. For Medicaid, without knowing 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. Moreover, enrollees will not see changes to what they pay out-of-pocket as their cost-sharing was minimal to begin with.

Thus far, TrumpRx has had little impact on the prices consumers pay. Critics have noted that most of the pharmaceuticals currently available on TrumpRx are in the latter stages of the product life cycle, which means that they already face lower-priced generic or biosimilar competitors. And often savings offered on websites such as Mark Cuban’s Cost Plus Drug Company are considerably more for generic products than what TrumpRx delivers. Similarly, companies such as BlinkRx and GoodRx offer channels for patients to access more affordable prescription medications.

A platform like TrumpRx that primarily focuses on branded products is mostly irrelevant for patients who are insured for the medications. Co-payments tend to much lower than the discounts offered by TrumpRx.

While portals can help under- or uninsured patients, those who cannot afford these upfront costs face continued access barriers. The prices are still out of reach. In turn, this may exacerbate disparities.

Cash-pay purchases generally do not count toward insurance deductibles (amount patients must spend before insurance kicks in) or out-of-pocket maximums. This implies that should patients need other prescription medicines in a given year, which many people do, they’ll be on the hook in the deductible phase of their pharmacy benefit. This may cause patients to lose the safety net of their insurance, leaving them financially exposed.

Representative Greg Murphy (R-NC) introduced a bill that would require insurers to count purchases made through DTC platforms like TrumpRx towards a patient’s deductible and out-of-pocket maximum. This could make such portals more usable for insured patients.

The proposal reflects a recognition that cash-pay models have limited impact when they exist outside the insurance system. The change could benefit patients in cases where cash prices undercut insurance costs, particularly for those enrolled in high-deductible plans, which Republicans like Murphy and the Trump administration favor.

But there are tradeoffs, as mandating that plans integrate the amount spent on TrumpRx drugs could lead to higher premiums as payers try to offset costs. Additionally, even if premium growth could be tempered by way of high-deductible plans, with so many insurers these days requiring that hundreds if not thousands of dollars be spent out-of-pocket before insurance starts paying, integration of TrumpRx purchases may not matter.

DTC platforms are a solution to a problem that wouldn’t exist if insurance coverage were better. The most acute issue for American patients is lack of universally comprehensive insurance coverage and the ever-rising cost of health insurance premiums coupled with higher deductibles.

Ultimately, more robust insurance protections in the form of lower deductibles and co-payments, premium growth caps and stricter medical loss ratio provisions may be more structurally sound than platforms that reinforce a tiered system.