The Trump administration’s Most Favored Nation drug pricing policies are redrawing the boundaries of global pharmaceutical market access. While some industry leaders maintain that the full impacts of MFN policies will not be seen until 2027, the early evidence suggests that changes in government, health system, and manufacturer policies and practices are already underway.
Historically, pharmaceutical manufacturers have been able to approach global market access as a collection of national or regional challenges that did not necessarily intersect. This allowed for the development of pricing and reimbursement strategies specific to individual markets. Companies could pursue the U.S. market separately from those in countries with different evidence requirements or payment models. While the individual approaches may have informed each other, they did not need to be managed as a single integrated strategy.
MFN drug pricing is altering this dynamic. Now, what a manufacturer accepts in one market can directly impact what it can charge in another. The commercial logic that once allowed for independent U.S. and international strategies is under growing pressure.
New models, new frameworks
As we have previously reported, CMS has introduced three MFN pricing models that tie U.S. drug pricing to net prices available in selected foreign markets: GENEROUS for Medicaid, GLOBE for Medicare Part B, and GUARD for Medicare Part D. Taken together, these models reference nineteen countries, including the United Kingdom, Germany, France, Japan, Canada, Switzerland, and Australia. Under their frameworks, pricing and reimbursement decisions in those markets carry direct implications for U.S. reimbursement.
The result, as a leading market access economist recently observed, is that “whatever’s happening in Europe is going to impact your U.S. price.” For companies that have previously treated their U.S. and international operations as largely separate commercial functions, this represents a new challenge.
That challenge is already playing out in concrete ways. The United Kingdom offers one example of how MFN pricing pressure originating in the United States can impact another country’s domestic pharmaceutical policy.
Changes in the UK
In December 2025, the UK and the United States announced a landmark pharmaceutical pricing agreement as part of the broader UK-US Economic Prosperity Deal. The agreement secured zero percent tariff treatment on UK pharmaceutical exports to the United States through January 2029, a significant commercial advantage for UK-based manufacturers. In exchange, the UK committed to substantially increasing National Health Service (NHS) spending on medicines over the next decade, with the goal of doubling its current investment in new medicines by 2036. To support that commitment, the National Institute for Health and Care Excellence (NICE) will evaluate new medicines against a revised cost-effectiveness threshold from April 2026, representing a 25 percent increase in the net price the NHS will pay for prospective new medicines.
Supporters of the agreement, including the Association of the British Pharmaceutical Industry, welcomed the threshold increase from £20,000-£30,000 to £25,000-£35,000 per quality-adjusted life year (QALY) as an overdue correction, noting that NICE’s baseline had not been raised in more than twenty years and that the change brings UK thresholds closer to the international average for comparable countries. Others have criticized the change, with health economists questioning whether it reflects empirical evidence or geopolitical pressure, a distinction with significant implications for the long-term integrity of evidence-based health technology assessment (HTA) decision-making.
The strategic implications for manufacturers extend well beyond the UK market itself. The GENEROUS carve-out addresses part of the concern about reference basket exposure, though questions remain about how GLOBE and GUARD will treat UK net prices as those models are finalized. Despite the threshold increase, UK net prices frequently remain among the lowest in comparable developed markets.
As Sreeram Ramagopalan, a market access economist and recent guest on the Market Access Podcast with host Stefan Walzer, observed: even with the new threshold, “the price achievable in the UK may not be sufficient to match the price achievable in the US, and now with the various MFN models, the UK is a reference market for all of them.” Manufacturers may find that launching in the UK at a higher price still results in an overall decline in global revenue if the corresponding U.S. price adjustment exceeds the UK revenue gains.
Rippling impacts
European leaders have acknowledged the international implications of U.S. drug pricing policy. In some cases, their responses have been pointed. During the World Economic Forum in Davos in January, President Trump asserted that he had successfully pressured French President Macron to increase drug prices in France. The official Élysée response was swift and unambiguous, noting that “[Macron] does not set their prices. They are regulated by the social security system and have, in fact, remained stable. Anyone who has set foot in a French pharmacy knows this.”
In a February 2026 address delivered in Paris, Belgian Deputy Prime Minister and Minister of Public Health Frank Vandenbroucke argued that, “The Trump administration wants European prices without the European model. It wants lower numbers on the invoice, but not the solidarity that produces them.” Whether or not one accepts Vandenbroucke’s characterization, the commercial consequences of MFN policies are undeniable.
Germany and Canada
Because Germany is both a major pharmaceutical market and a frequent reference country in international pricing systems, developments in German pharmaceutical policy carry weight well beyond its borders. STAT News reported in May 2026 that the Trump administration had begun pressing Germany directly on prescription drug prices.
There has also been significant domestic pressure on Germany’s statutory health insurance system, which faces a projected shortfall of €15.3 billion by 2027 and could see a deficit as great as €40 billion by 2030. In April, German Chancellor Friedrich Merz announced that his cabinet had agreed on a healthcare reform package with tighter controls on pharmaceutical costs projected to save over €16 billion. As German policymakers move to constrain pharmaceutical spending, manufacturers face a more restrictive domestic reimbursement environment in a market that is also a factor in their U.S. pricing exposure.
Canada is the only country included in all three reference baskets that has also been approved by the FDA as a source for state-level drug importation programs. As a result, it faces a unique dual exposure.
In March 2026, Canada’s Health Minister Marjorie Michel and Trade Minister Dominic LeBlanc met personally with pharmaceutical sector representatives to discuss MFN implications alongside the upcoming Canada-United States-Mexico Agreement review, and the government announced the creation of a Pharmaceutical and Life Sciences Sector Task Force. Calling for “urgent, collective action,” Dr. Bettina Hamelin, President and CEO of Innovative Medicines Canada warned that MFN pricing policies had “triggered a global chain reaction that threatens to disrupt access to existing medicines, delay or altogether halt the launch of new medicines, and undermine confidence in Canada’s pharmaceutical market.”
The country-by-country picture that emerges from the United Kingdom, Germany, France, and Canada is not a collection of isolated national responses. It is the early outline of a systemic shift, and the data already reflect that.
In releasing its annual Patients W.A.I.T. Indicator Survey last month, the European Federation of Pharmaceutical Industries and Associations, stated that it had found “widening inequality” in access to and availably of 168 new medicines across 36 countries. The organization noted that, “The situation looks likely to be compounded by the introduction of the US Most Favoured Nation Policy.”
Some 2,000 patients were impacted in February when Amgen withdrew Repatha, its cholesterol-lowering treatment, from the Danish market. Because Denmark routinely achieves low net prices for prescription medicines, it is especially exposed to the MFN dynamic. Amgen’s Danish country director acknowledged that “a changed global regulatory environment and global market dynamics” had made continued supply under existing conditions untenable. It was the first widely documented instance of a manufacturer exiting a market in direct response to MFN pricing pressure.
In an interview with Sundhedspolitisk Tidsskrift, a Danish publication covering health policy, Martin Bødtker Mortensen, a cardiologist at Denmark’s Aarhus University Hospital who also serves as an adjunct professor at Johns Hopkins University, offered a pointed observation. “Normally medicine prices fall over time,” he said. “Here the tendency seems to be the opposite.”
A new strategic reality
During Novartis’s April 2026 earnings call, the company’s CEO Vas Narasimhan said, “It’s really a 2027 story where you start to see the impact of MFN on launches in Europe.” The comment is notable for both the timeline and the source. Novartis concluded a voluntary pricing agreement with the Trump administration in late 2025. Narasimhan’s statement suggests that the terms of the agreement may not have resolved underlying strategic uncertainty.
The implications of MFN pricing had become a recurring topic of discussion among market access professionals. During a panel discussion in Philadelphia last month, Applied Policy Vice President for Health Policy Brittany La Couture joined experts from the United States and Europe in considering whether the traditional separation between domestic and international market access strategies remains viable in an environment where pricing decisions in one market can directly affect reimbursement in another.
Across markets, pricing and reimbursement decisions that were once made within largely national frameworks must now be made with one eye on their implications for other countries. As a result, we can expect to see not a series of national policy adjustments, but a fundamental change in the architecture of global pharmaceutical market access.
For manufacturers that have historically separated their U.S. and international commercial functions, the strategic implications are significant and immediate. As Sreeram Ramagopalan said on the Market Access Podcast, manufacturers need to be “thinking holistically on a global level,” setting a price floor that optimizes revenue and determining where and at what price it makes sense to launch. This challenge could fall most heavily on small to mid-sized manufacturers, who have historically been most likely to manage U.S. and international strategies as separate functions and who are therefore least prepared for an environment in which those functions are inextricably linked.
Decisions regarding the order of product launches must now account not only for individual market revenues but for the cumulative effect of net prices across reference basket countries on U.S. reimbursement exposure. Evidence-generation strategies must be designed from the earliest stages of clinical development, keeping in mind the requirements of multiple HTA bodies. And pricing decisions in any reference basket country must be modeled for their downstream implications across the full basket, not evaluated in isolation.
Ramagopalan also observed that manufacturers who open clinical trial sites in countries they subsequently decline to launch in may face reputational consequences that can complicate future research partnerships and investigator relationships, a risk that is easy to underestimate when launch decisions are driven by factors that patient communities and investigators may not fully understand.
Those risks extend to pharmaceutical innovation itself. Writing in ISPOR’s Values and Outcomes Spotlight, Sean Sullivan, Jens Grueger, and Krisit Marti observe that revenue losses for manufacturers in the United States are unlikely to be compensated by higher revenues abroad. This could have consequences for research and development investment that will ultimately affect patients in all markets.
The geopolitical debate over what MFN represents is ongoing. What is not in debate is that its effects are already being felt by manufacturers, health systems, and patients across multiple countries simultaneously.
The old model, in which a company could optimize its U.S. strategy largely independently of its international approach, reflected a world in which pricing decisions in one market had limited consequences in others. That world is changing rapidly. Manufacturers that recognize this early and build the integrated global market access capabilities to respond to it will be better positioned to navigate what is shaping up to be a prolonged period of policy change across the markets that matter most.