On 12 May 2025, the Donald Trump administration signed an executive order establishing a “most-favoured-nation” (MFN) pricing system for medicines in the United States. Under this system, the United States would align the prices of its medicines with the lowest price paid by any of the advanced economies used as reference countries.

This international reference pricing mechanism applies to three models within the US health system:

The MFN mechanism puts pressure on the pharmaceutical markets included in that reference basket. The United States is the industry’s most profitable market because of its high prices. Faced with the possibility that a lower price in another country could also reduce the US price, companies have threatened to delay launches, withdraw products or simply refrain from marketing them in the reference countries. In 2025, Amgen withdrew Repatha from Denmark, citing “changes in global market dynamics”. The low price secured by the country through its tendering procedures—recognised as good practice—ultimately became a reason for the medicine’s withdrawal.

National responses

In the absence of a collective response, the affected countries have chosen to act separately and have pursued markedly different strategies.

United Kingdom

London and Washington announced an agreement in December 2025 under which zero tariffs would apply to British pharmaceutical exports to the United States. In return, the NHS committed to doubling its investment in new medicines by 2036, while NICE raised its cost-effectiveness threshold by 25% from April 2026.

Italy

Italy has resisted accepting higher prices, although it has also increased pharmaceutical budgets to accommodate somewhat higher prices, in line with pressure from the industry.

Germany

Germany reformed its pricing legislation in January 2025. Since then, pharmaceutical companies have been allowed to keep their discounted reimbursement prices confidential, provided that they apply an additional 9% rebate and demonstrate local research and development activity. The reform also removed international reference pricing as a negotiation criterion. In parallel, the Government announced a health reform package in April that includes tighter controls on projected pharmaceutical expenditure of more than EUR 16 billion. In May 2026, the United States opened a formal trade investigation under Section 301 into Germany’s pharmaceutical pricing system. The proceedings could lead to trade sanctions against the European country.

Spain

Spain is enshrining the confidentiality of its net prices in law through a compromise amendment incorporated into legislation on newborn screening. The amendment, agreed by the PSOE, Sumar and PP, modifies Articles 97 and 106 of Royal Legislative Decree 1/2015. It establishes that financing agreements with pharmaceutical companies will be confidential and that neither the public authorities nor the companies may disclose them. The official justification has been explicit. Secretary of State Javier Padilla stated that “the publication of the net price could constitute a barrier to access to innovative medicines in Spain”. The reform seeks to anticipate the entry into force of the mechanism that uses Spain as a reference country. It will also affect the appeals on points of law pending before the Supreme Court, brought by Salud por Derecho, Civio and the Council for Transparency and Good Governance, concerning whether the Transparency Act requires disclosure of the net prices paid by the public health system.

Canada

The new Patented Medicine Prices Review Board (PMPRB) Guidelines, in force since January 2026, compare Canadian prices with the highest prices in eleven reference countries and expressly exclude the United States. At the same time, another Trump administration initiative—the rule allowing medicines to be imported from Canada—seeks to leverage those very low Canadian prices for the benefit of the US market.

Japan

The Japanese Government has responded by reducing aggregate pharmaceutical expenditure for this year by JPY 105 billion. In June 2026, Health Minister Kenichiro Ueno warned that the MFN mechanism could drastically worsen the situation and called for the issue to be addressed urgently. Japan is considering reforms to its foreign reference price adjustment system in order to raise prices under the national health insurance (NHI) system and move out of the lowest end of the MFN basket. For now, however, there is no clear solution to the fiscal constraint driving the annual cuts.

Implications for global health and transparency

The dynamic created by the MFN policy is a race among countries seeking to avoid exclusion from the launch market, either by paying more directly or by becoming less transparent and risking paying more without knowing it. Each national decision, taken in isolation, follows a coherent domestic logic. Collectively, however, the result is a global pharmaceutical system that is less transparent, less equitable and more favourable to industry than any alternative based on coordination and transparency.

World Health Assembly resolution WHA72.8, adopted in 2019 with the support of Spain, Italy, Germany and other European countries, urged Member States to make public the net prices paid by their health systems. The reasoning was sound: if no one other than the pharmaceutical industry knows how much others are paying, health systems negotiate in the dark. Although all parties believe they have secured the best negotiated deal, the (anecdotal) evidence shows that prices are not adjusted according to variables such as each country’s GDP.

The consequences of this process for global health could be serious. If low prices become a reason to delay or avoid launches, patients in countries with greater bargaining power will ultimately be penalised. Negotiating a good price would thus become a risk to access to medicines.

Moreover, the chain of reference pricing does not end with the 19 countries included in the MFN mechanism. Many low- and middle-income countries use European, Japanese or Canadian prices in their own negotiations. If those prices rise or cease to serve as reference points because the market is no longer attractive, poorer countries will lose a crucial negotiating tool without having had any say in these decisions.

Pharmaceutical price transparency is not merely a principle. It is a governance tool that enables health systems to make evidence-informed decisions, control expenditure and be accountable to the public. Its erosion weakens the ability of all States to manage access to medicines in a sustainable and informed manner.

Salud por Derecho’s proposal

Trump’s MFN clause is triggering an uncoordinated race towards opacity. Countries would rather conceal their prices than risk being excluded from the launch market, but each individual response has negative effects on access overall.

Against this backdrop, Salud por Derecho is not starting from scratch. In March 2025, before the MFN mechanism took its current form and more than a year before the Spanish confidentiality amendment, we had already proposed a series of measures to the Ministry of Health to strengthen transparency in the pharmaceutical market, in line with resolution WHA72.8. That framework is more relevant today than ever. We also called for the amendment currently being considered in Spain to be calibrated so as to reduce its long-term effects and its impact across the entire portfolio of medicines covered by the National Health System.

The logic of the MFN policy does not block the entire pharmaceutical transparency agenda. Progress can be made in areas that do not expose any country to the risk of medicines being withdrawn from its market, because they do not entail publishing the net price used as the anchor for the US benchmark. There are three priorities.

• Transparency of R&D costs. Pharmaceutical companies should be required to disclose all public, private and philanthropic funding received, broken down by stage of development. This would not affect the calculation of the MFN benchmark. It would, however, directly undermine the underlying argument supporting the policy: the narrative of European “free-riding” on US innovation can neither be substantiated nor refuted without data on how much each party actually invests. In the current context, this is probably the priority with the greatest strategic impact: pursuing transparency where the ground is not mined. Although the new Royal Decree on Health Technology Assessment represents progress in this regard, it excludes a major source of funding.
• Transparency regarding the duration of monopolies. Publishing a single expiry date covering all forms of protection for a medicine—patent protection, regulatory exclusivity and market protection—would likewise not interfere with the logic of the MFN policy. This is a proposal with low political risk and high accountability value that Spain can promote without coming into conflict with US pressure. This is what we proposed here.
• A peer-to-peer net price-sharing mechanism, instead of unilateral publication. The 2025 proposal to explore a pilot programme for sharing net prices between countries, building on the OECD’s work, is now more urgent. Sharing these prices confidentially among the 19 countries in the reference basket—without making them public, but allowing other purchasers to know them—would help restore some of the collective bargaining power that national opacity destroys. At the same time, it would prevent any single country from being exposed as the lowest anchor for the US benchmark. As a lesser evil, this would amount to defensible opacity vis-à-vis external actors, but genuine transparency among purchasers. It is the exact opposite of what Spain’s current reform proposes: closing off access equally to everyone, including Spain’s own European partners.

Amend the Spanish amendment rather than repeal it outright

The amendment adopted in June 2026 identified a genuine risk—that Spanish net prices would be exposed to the MFN mechanism—but attempted to address it using the wrong instrument: permanent, blanket confidentiality, introduced moreover without procedural transparency and through legislation on newborn screening.

Salud por Derecho’s 2025 position had already established the principle that should govern this issue: “Only economic or financial information submitted during the negotiation should be considered confidential, never the final price or the reimbursement mechanisms established by the public authorities and set out in a public contract.” That distinction—protecting the process without concealing the outcome—is precisely what the 2026 amendment abandoned and what we are calling for it to restore.

If that distinction is not restored, the amendment should be modified so that, at a minimum, any confidentiality that remains is time-limited rather than protected indefinitely. A defined period—ideally aligned with the stage at which the risk of exclusion from the launch market is greatest under the GLOBE and GUARD models—would make it possible to protect early access without foregoing accountability in the medium term. Moreover, if the Ministry’s aim is to move towards a strategic balance between protecting the net price and ensuring transparency, it must pursue measures to guarantee the latter with the same urgency.

Both approaches are based on the same principle: the response to the MFN policy must not turn secrecy into a permanent solution. It must pursue smart transparency—protected where necessary, coordinated wherever possible and subject to an expiry date whenever it is accepted as an exception. That was our position before the MFN mechanism existed, and Washington’s trade policy should not force us to abandon it. Without a response of this kind—coordinated and conscious of its limitations—the MFN policy will have succeeded, without explicitly seeking to do so, in dismantling one of the strongest pillars of progressive global pharmaceutical policy: the public’s right to know how much its health system pays for the medicines it funds.