When the U.S. Patient Protection and Affordable Care Act (ACA) was passed in 2010, the view from Washington was that a broken and overly expensive healthcare system was going to finally have relief and be more accessible. While the focus of the bill was on enhanced access, predictions were made about how the U.S. healthcare system would transform to a value-based, cost-effective system versus the fee-for-service based model that had driven the U.S. to a cost of care per capita which (at $7,929) was 48% higher than any other country with >1,000,000 population in the world. For the pharma industry, the implications of concrete changes such as industry fees and price cuts on Medicaid and Medicare were clear; however, the impact of the transition to a value-based model was less clear and led to a lot of guesswork throughout the industry about how best to compete in this new paradigm. Some of the issues at the time included: exchanges and the structure of drug plans, cost effectiveness and its impact in formulary/reimbursement decisions, and outcomes-based contracting. Six years later, it is important to answer some key questions such as: what really happened, how did all of this work out for pharma, what is likely going to happen in the next five years, and what will it mean for pharma given the market dynamics and policy environment in the U.S.?