Commercial uptake for early hemophilia gene therapies has fallen short of blockbuster expectations. Market leaders have faced reimbursement resistance and pricing pushback: Biomarin explored divesting Roctavian after weak uptake, Pfizer withdrew its hemophilia B candidate, and CSL Behring’s Hemgenix underperformed versus forecasts. Stakeholders cite high list prices, payer concerns over longevity of benefit, and patient plan churn as barriers to adoption. Patient advocates and clinicians note clinical value for individuals, but industry executives must address payer risk, outcome durability and novel payment models to restore confidence. Clarification: Hemophilia gene therapies are one‑time treatments intended to reduce or eliminate the need for routine clotting factor infusions.