Every Dollar Counts Act of 2026
- Sponsor
- Rep. Murphy, Gregory F. [R-NC-3]
- Committees
- Ways and Means Committee (primary)
- Last action
- Apr 14, 2026
Bottom line
The Every Dollar Counts Act of 2026 requires health plans to count all out-of-pocket drug costs towards deductibles and maximums, potentially lowering consumer financial burdens and impacting drug pricing calculations for government programs.
What it actually does
This bill mandates that all out-of-pocket spending on prescription drugs must count towards an individual's health plan deductible and out-of-pocket maximum, even if the individual chooses to purchase the drug without immediately applying their insurance benefits. It amends the Public Health Service Act, ERISA, and the Internal Revenue Code to implement this requirement. Additionally, it includes conforming amendments to the Social Security Act to exclude these specific types of price reductions from Medicaid's "best price" and "average manufacturer price" calculations.
Proponents argue
Supporters argue this bill enhances consumer protection by ensuring that every dollar spent by an individual on prescription drugs, regardless of how it's paid, contributes to their annual cost-sharing limits. This prevents situations where patients pay significant amounts for drugs, often through manufacturer coupons or direct purchases, only to find those payments don't help them meet their deductible or out-of-pocket maximum, thereby delaying when their insurance fully kicks in. It aims to make healthcare costs more transparent and predictable for patients.
Opponents contend
Opponents might argue that this bill could inadvertently increase healthcare premiums or shift costs to other beneficiaries if health plans are forced to absorb more costs earlier in the year. There could also be concerns that the conforming amendments related to Medicaid drug pricing might have unforeseen impacts on drug manufacturers' incentives or the overall drug market, potentially affecting drug availability or pricing strategies for government programs. Some might also argue that this could complicate existing benefit structures or coupon programs.
The bill is very short and straightforward, making it highly accessible for a reader to understand its core provisions quickly.
Sections 2(a), 2(b)(1), 2(c)(1)
Mandating Out-of-Pocket Drug Costs Count Towards Deductibles and Out-of-Pocket Maximums
This core provision requires all group health plans and health insurance issuers to count any money an individual spends out-of-pocket on a prescription drug towards their annual deductible and out-of-pocket maximum. This applies even if the individual chooses to buy the drug without immediately using their insurance benefits, for example, by using a discount card or manufacturer coupon. The goal is to ensure that all personal spending on covered drugs helps the patient reach their annual cost-sharing limits faster.
Supporters argue
Supporters argue this provision directly benefits consumers by ensuring that all their drug spending contributes to their financial protection under their health plan. It prevents "phantom" spending that doesn't advance them towards their deductible, making healthcare costs more transparent and equitable. It particularly helps patients relying on manufacturer assistance programs.
Critics contend
Critics might argue that this provision could lead to higher premiums for all enrollees as health plans may face increased costs by reaching out-of-pocket maximums sooner. They may also contend that it could disrupt existing pharmacy benefit manager (PBM) contracts and drug pricing strategies, potentially leading to unintended consequences for the broader drug market.
Tradeoffs
The tension lies between providing immediate financial relief and predictability for patients and the potential for increased costs for health plans, which could be passed on to consumers through higher premiums or other cost-sharing adjustments.
Sections 2(d)(1) and 2(d)(2)
Exclusion of Certain Drug Price Reductions from Medicaid Best Price and Average Manufacturer Price Calculations
These amendments modify the Social Security Act, specifically sections related to Medicaid's "best price" and "average manufacturer price" calculations. They clarify that any price reduction an individual receives when purchasing a drug without applying their health plan benefits (e.g., through a discount program) should not be included when determining the drug's "best price" or "average manufacturer price" for Medicaid purposes. This prevents these specific consumer discounts from artificially lowering the baseline prices used for government drug purchasing programs.
Excludes price reductions from individual drug purchases (without applying benefits) from "best price" and "average manufacturer price" calculations under the Social Security Act (Medicaid drug pricing).
Section 2(d)(1) and 2(d)(2)
Why it matters:This is standard legislative practice for technical conforming amendments that adjust existing legal frameworks to accommodate new policy. It's not necessarily evasive but requires specific expertise to fully grasp its implications.
Case for: This provision prevents unintended consequences where consumer-level discounts could artificially lower the "best price" for Medicaid, which could disincentivize manufacturer coupon programs or create complex compliance issues. It ensures the primary policy goal of counting patient out-of-pocket costs is achieved without disrupting existing drug pricing mechanisms for government programs.
Case against: This could be seen as protecting pharmaceutical manufacturers from having to offer deeper discounts to Medicaid, potentially leading to higher costs for government programs and taxpayers. Some might argue that any price reduction should contribute to the "best price" to maximize government savings.
Estimated impact: Likely impacts billions in Medicaid drug spending and manufacturer rebates, depending on the volume and value of individual drug purchases made without applying benefits.