Analyzing the “Big, Beautiful Bill”: How OBBBA is Set to Reshape the Health Care Marketplace

The One Big Beautiful Bill Act (OBBBA), signed by President Donald J. Trump in July 2025, contains nearly 900 pages of legislation with far-reaching implications for the US health care system and the pharmaceutical marketplace. The bill’s provisions are expected to have a mixed and potentially disruptive effect on patients, pharmacies, manufacturers, and insurance plans.

Impact on Patient Health Coverage

The OBBBA is anticipated to significantly alter the landscape of health insurance coverage, particularly for vulnerable populations.

Medicaid: Due to new policies emphasizing redeterminations and work requirements, it is estimated that 11.8 million people could lose their Medicaid coverage over time. Medicaid is noted for providing generous prescription benefits with low or no co-payments to the most fiscally vulnerable patients.
ACA Exchange Plans: The bill is also projected to cause 5.1 million people to leave the Affordable Care Act (ACA) exchanges. This is a result of decreased subsidies, which will lead to increased premiums. The article suggests that these rising premiums will have a broader effect, putting upward pressure on all other insurance categories.

Effects on the Pharmaceutical and Pharmacy Industries

The OBBBA is expected to create a mixed environment for pharmaceutical manufacturers and a new set of challenges and opportunities for pharmacies.

For Manufacturers: The net effect is a mix of challenges and benefits. On one hand, fewer insured customers mean a smaller market for prescription fills. On the other hand, fewer Medicaid enrollees mean fewer prescriptions will be subject to the Medicaid Rebate Program, providing some financial relief. The bill is expected to accelerate the growth of “cash pay” and “direct purchase” programs, where manufacturers sell drugs directly to patients without involving a PBM. As an example, the article mentions that Eliquis (apixaban) will now be sold directly to patients at a 40% discount.
For Community Pharmacies: Pharmacies are advised to prepare for an increase in uninsured patients and a rise in cash-pay transactions. The focus will likely be on generic fills, with branded medications continuing to offer low margins. This shift may also lead to more direct conversations between pharmacies and brand manufacturers about inclusion in direct purchase programs.
For PBMs and Wholesalers: The growth of cash-pay and direct purchase programs is seen as a threat to the market control of Pharmacy Benefit Managers (PBMs). These “end-arounds” also challenge the traditional role of wholesalers, as pharmacies may seek to procure branded medications directly from manufacturers to avoid high markups.
For 340B Entities: Health systems that predominantly serve Medicaid patients will face significant financial strain due to a rise in uncompensated care. These providers, who often have the most 340B-eligible prescribers, are expected to “triple down” on prescription capture to retain revenue.

A New Avenue for Direct Primary Care

A less-publicized provision of the OBBBA allows for the cost of direct primary care (DPC) to be reimbursed through health savings accounts. This policy change is expected to “supercharge” the growth of DPC, which typically offers unlimited access to primary care for a fixed monthly subscription. This could also create new opportunities for pharmacies to participate in a more integrated way with the direct care movement.