Don't Panic about MFN (yet)

A Fresh Take on the Impact of Most-Favoured-Nation Drug Pricing Reform in the US

In Canada, there are two shopworn tropes about the perils of sharing the longest undefended (for now, anyway) border with the United States (US). One is the old adage about the US sneezing and Canada catching a cold, which was originally coined in the 19^th century about then hegemonic France’s effect on wider Europe. The other originates from a speech by Pierre Trudeau at the Washington Press Club in 1969 and likens our bilateral relationship to a mouse sleeping with an elephant.

Recent efforts by the Trump administration to resurrect a botched first-term “Most Favored (sic) Nation” (MFN) policy as a way to bring sky high US drug prices back to planet earth—like one of Elon’s Space X rockets (when it doesn’t explode first)—inspires a blending of the two metaphors, with a subtle twist. Managing the fallout for Canada of Trump’s second stab at MFN pricing is more like sharing a bed with a flatulent elephant. It’s unpleasant for the mouse but probably not contagious, at least not for now.

If you’re paying even the least bit of attention to professional networking platforms and to the webinar circuit in the pharma space in Canada lately, you’re probably getting an earful about MFN and the predicted catastrophic consequences of it on drug pricing and access in Canada. Industry is already recycling its default ask for the eradication of the Patented Medicine Prices Review Board (PMPRB) as a preemptive mitigation strategy. Patient groups are spooked but don’t feel they have a good handle on the issue.

For those readers who know what I’m talking about and find themselves worrying about MFN’s purported devastating impact on Canada, allow me to echo the very sage advice given to the fictional interstellar travelers in Douglas Adam’s classic book “The Hitchhiker’s Guide to the Galaxy”: “DON’T PANIC.”

Panic is no more effective a strategy than nostalgia, and based on what we know about MFN policies in the US as of this moment, panic is at the very least premature and probably a complete waste of energy over the longer term, as will be explained. If you need to panic about geopolitics, President Trump has you covered on many other more plausible fronts. Personally, I’m focusing my panic on escalating trade wars, the collapse of the liberal world order and whether I can survive another loss to the US in Olympic hockey in four years (in breaking news, I have added war engulfing the Middle East to my list).

Most favored what now?

What is MFN exactly? In a nutshell, it is a concept that originates from trade policy and simply means that a country can’t discriminate in its trading terms as between different countries who are also parties to the MFN. In the context of US drug policy under President Trump, the concept has been repurposed to mean that a drug manufacturer must sell its drug in the US at the lowest price it sells it anywhere in the world. This is not the first time President Trump has sought to introduce his unique take on MFN into US drug pricing. His previous administration tried to do so but the measure was soon challenged in court by the pharmaceutical industry and quickly struck down. What is different this time is whereas the previous MFN policy referenced list prices in other countries as setting the benchmark for the US price, this new round of MFN initiatives references international net prices, which are much, much lower than list prices, and subject to confidentiality provisions in each country they’re agreed to. Also, this new incarnation of MFN is not as clumsily crafted as the previous one and is being rolled out much more strategically. It’s the combination of these two features that has people freaking out about what this means for prices in the rest of the world. If the US goes from paying the highest prices in the world, to the lowest, presumably every other country will be making up the difference. Either that, or the industry rolls over and accepts a huge hit to its bottom line. So yeah, higher prices it is.

But you said not to panic

Here’s the thing. The prices of drugs in the US and the obscene disparity between US prices and those in the rest of the world are the perennial bogeyman of US presidential politics. Every President in recent memory has made getting prices down a campaign priority. At a time when his own approval rating is in the dumps, and affordability is top of mind for the electorate, President Trump is punching down on the one industry he knows is held in even lower regard by most Americans. This must be what Melania meant in her Amazon documentary when she hilariously encouraged him to describe himself as a “unifier” at his second inauguration.

The problem is that the US drug pricing system is so vast and so complicated with so much money and competing powerful interests at stake, real meaningful reform burns a hellfire of political capital and happens about once a decade, often in the form of legislation that is so publicly contentious it becomes part of the cultural lexicon, like “Obamacare” for example. In contrast, this new round of MFN initiatives that the Trump Administration has cobbled together is a cleverly assembled bricolage of executive orders, regulatory rulemaking, and expansive interpretations of delegated authorities. It does not repose on legislative amendment of any kind.

The good news for the rest of the world is that President Trump doesn’t really care about—or understand— drug pricing enough to put his boldly proclaimed MFN policy objectives to Congress and negotiate true meaningful reforms that would directly address the problem. The bad news is that there are some very capable people who work deep within the machinery of Health and Human Services (HHS), in an agency known as the CMS Innovation Center, who have been tasked with giving operational form to the President’s rhetoric and they do very much care about and understand drug pricing in the US and elsewhere.

At the end of the day though, whether they are well or poorly conceived, executive shortcuts on major questions of US governance often collapse under judicial scrutiny, and the striking down of President Trump’s ill-founded tariff program by the US Supreme Court a few weeks ago is a timely and very portentous reality check on the fate of his MFN aspirations.

What exactly MFN is— and isn’t

In keeping with its broader modus operandi, the Trump administration has flooded the zone with… announcements about various MFN-related initiatives. It’s natural to fear what we don’t understand, so let’s unpack them and gain some comfort from our knowledge of their scale, scope and sustainability.

Before doing so, it is helpful to have a basic understanding how the US drug pricing and reimbursement system works and where Medicare and Medicaid fit within it. While the US system is vastly more complicated than Canada’s, one area of commonality is that both countries have a mix of public and private drug coverage, and roughly the same 40%/40%/20% split in total pharmaceutical expenditures accounted for by government, private health insurance and out of pocket payers respectively.

The federal government’s Medicare program, which covers the everyday prescription drug needs of people 65-years of age or older (“Part D” drugs) and physician-administered specialty drugs (“Part B” drugs), accounts for about 34% of spending. The federal and state governments work together to offer coverage to eligible low-income claimants through Medicaid, which accounts for another 11% of spending. The rest of the market is either employer-sponsored or individual private health insurance coverage, at about 40% and out of pocket at about 15%. There are some important subtleties within these figures but it’s not necessary to go deeper to have sufficient context for what follows.

One final bit of necessary information before turning to our discussion of MFN is the role of the Center for Medicare & Medicaid Innovation (CMMI)—referred to above and hereafter as the CMS Innovation Center —in the US system. The CMS Innovation Center was created in 2010 under the Affordable Care Act—more commonly known as the aforementioned ObamaCare— to test drive alternative payment and service delivery models aimed at reducing federal health spending while maintaining or improving quality of care. It is a division of the Centers for Medicare and Medicaid Services (CMS) which is responsible for administering these two massive government programs. The CMS Innovation Center has authority to temporarily waive certain Medicare and Medicaid requirements in order to conduct time-limited demonstrations, typically referred to as “models”. If a model is shown to reduce spending without harming quality, or improve quality without increasing spending, it can be expanded and made permanent by the Secretary of HHS. However, that authority is circumscribed by certain fundamental parameters which will most certainly be engaged if an attempt is made to make any of the provisional MFN initiatives permanent, as will be explained.

There are basically three MFN tracks that the Trump administration has announced. One applies to Medicaid (GENEROUS), and the other two to Medicare (GLOBE and GUARD). There is also TrumpRx, the direct-to-consumer website that purports to offer MFN pricing to out-of-pocket payers, and some ancillary stuff, but the three programs described below are the backbone of the policy and the principal source of concern for payers and patients in other countries.

Track 1: GENEROUS

GENEROUS is a model framed as a targeted effort to align certain Medicaid drug prices more closely with net prices paid in comparable high-income countries. Under the model, participating manufacturers would provide supplemental rebates that align Medicaid prices with an international benchmark derived from net prices in eight OECD countries, including Canada. CMS intends to use manufacturer-reported net prices (after discounts, rebates, and other concessions), adjusted for gross domestic product per capita using a purchasing power parity (PPP) method, to calculate an international reference price. The benchmark is structured around the second-lowest net international price in that basket following GDP/PPP adjustment, and that figure informs the level of additional supplemental rebate.

As designed, this iteration of MFN would layer an additional rebate on top of the existing Medicaid Drug Rebate Program framework rather than replace it. Participation is voluntary for both states and manufacturers, with manufacturers incentivized to opt in through more predictable coverage conditions within participating Medicaid programs. The model applies to selected high-cost drugs and is time-limited. It purports to test whether a structured international benchmarking mechanism can generate incremental savings for state and federal Medicaid budgets without destabilizing access.

Importantly, the GENEROUS model does not aspire to reconfigure the statutory Medicaid rebate formula or impose a universal international reference price across all drugs covered under Medicaid. While GENEROUS is the only MFN initiative currently in active implementation phase, it remains in application and contracting stages. Operational participation will depend on states electing to join and manufacturers agreeing to provide the requisite supplemental rebates. The test period is expected to run for approximately five years.

Track 2: GLOBE

GLOBE is structured as a Medicare Part B payment model aimed at incorporating international price referencing into the reimbursement of physician-administered drugs. Part B drugs are currently reimbursed based on a statutory formula tied to Average Sales Price (ASP) plus an add-on percentage. GLOBE would test whether introducing an international reference benchmark into that framework can reduce Medicare spending on high-cost biologics and specialty injectables.

Under the model as proposed, CMS would calculate an international benchmark using net prices in a defined basket of 19 OECD countries, including Canada. That benchmark would then be used either to adjust inflation rebate calculations or to place downward pressure on the effective Medicare reimbursement amount for selected drugs. Unlike GENEROUS, which layers supplemental rebates onto Medicaid’s existing rebate structure, GLOBE directly touches Medicare’s reimbursement mechanics.

GLOBE purports to test whether international benchmarking can be integrated into Medicare’s statutory payment structure in a way that generates savings without impairing beneficiary access or destabilizing provider economics.

Track 3: GUARD

GUARD focuses on Medicare Part D — the outpatient drug benefit for seniors delivered through private insurance plans. Unlike Medicaid or Medicare Part B, Part D does not operate through a government-set reimbursement formula. Instead, private plans submit annual bids to the federal government based on the prices they expect to negotiate and the risk profile of their members.

GUARD would test whether international price benchmarks can be introduced into that competitive framework to put downward pressure on what Medicare ultimately pays for selected high-spend drugs. Rather than directly setting a government purchase price, the model would seek to influence plan payments or rebate structures so that negotiated net prices move closer to those observed in the same 19 OECD countries as GLOBE.

Because Part D is a huge market ($140B USD annually) and central to overall Medicare drug spending, the fiscal implications of any international benchmarking mechanism could be significant. At the same time, GUARD must operate within a program Congress intentionally structured around private negotiation and plan competition. It does not replace the bid-based model but attempts to layer international price referencing onto it.

GUARD purports to test whether international benchmarking can reduce Medicare spending within a competitive insurance framework without disrupting plan participation or beneficiary access.

GLOBE, GUARD and the higher-of rule

In one other important respect, GLOBE and GUARD are structurally different from GENEROUS: they do not anchor their benchmark to a single, clearly defined international price floor such as the second-lowest net price in a comparator basket. Instead, both Medicare models are designed around a dual-calculation approach that would use the higher of the average net prices across comparator countries and the second lowest list price in that same group of countries as the benchmark by which to set US prices.

That “higher-of” construction makes GLOBE and GUARD more conservative in their downward pressure on US prices. Whereas GENEROUS is explicitly structured to align Medicaid prices with a relatively low international reference point, the Medicare models build in a buffer by selecting the more permissive of two benchmarks. Given that even the second lowest international list price is still likely to be much higher than average net prices, GLOBE and GUARD can’t rightfully be described as pure “net price” importation schemes.

So, will it work?

Now that we’ve unpacked the mechanics of the three MFN tracks, the more important question is not what they look like on paper, but how likely they are to be effective and enduring.

GENEROUS is structurally modest. It is voluntary. It operates within Medicaid, a joint federal–state program already built around statutory rebates. It layers an additional supplemental rebate on top of an existing framework rather than displacing that framework, and tests whether it can generate incremental savings. It is limited to selected high-cost drugs, is explicitly time-bounded and doesn’t try to reset or override the statutory Medicaid rebate formula as a whole. In other words, it bears all the hallmarks of genuine experimentation.

GLOBE and GUARD are different in many material respects. Both operate within Medicare, which is a much larger market than Medicaid, accounting for nearly one-third of total US spending on prescription drugs, but far more tightly wired into congressionally prescribed payment mechanics. Medicare Part B reimbursement is defined in statute. Medicare Part D was deliberately constructed as a competitive, bid-based private insurance system with explicit limits on federal interference in price negotiations. Both are legislatively anchored in referencing domestic US prices, not foreign, in determining how much to pay for a drug.

If the HHS Secretary should seek to expand either model administratively there is a significant risk courts would strike them down as a de facto rewrite of Medicare’s pricing and rebate formulas and an attempt to impose federal price controls through administrative means.

In addition, both “models” are mandatory, not voluntary. That makes a huge difference in terms of due process rules they are subject to under US administrative law. Failure to abide by that law is what ultimately felled Trump’s previous attempted foray into MFN policy in 2020. In fairness though, this time around the administration does seem to be respecting that aspect of the law. As mentioned, there are some very capable people behind the scenes who are doing their best to perform alchemy on the President’s primitive policy ideas.

A ”major question” about MFN

One can hardly fault a presidential administration for trying an end run around Congress in seeking to realize its policy objectives. Executive Orders are issued amok under President Trump but stretching the bounds of executive power in this way has been a growing trend under successive administrations of both political stripes for decades. Punching legislation through Congress is a slugfest fraught with peril, particularly in matters of drug pricing and reimbursement. The Obama administration was made all too painfully aware of this fact, which is why it created the CMS Innovation Center under the Affordable Care Act. It was conceived as a vehicle for tinkering with Medicare and Medicaid without having to go back to Congress at each turn of the screw.

The problem is the more you try to do indirectly what only the legislative branch is authorized to do directly, things get messy, complicated and precarious. Under what has come to be known as the “major questions” doctrine, courts are reluctant to accept that Congress has delegated to executive agencies the authority to decide questions of vast economic and political significance unless it has spoken clearly. The doctrine does not prohibit ambitious policy, but it does require clarity of delegation.

Recent Supreme jurisprudence offers a very powerful and timely reminder of that point. The Supreme Court’s decision striking down President Trump’s tariff program earlier this year was not a judgment on the wisdom of tariffs. It was a judgment on the limits of delegated authority. When the executive branch stretches broadly worded statutes to support sweeping economic interventions, the Court has shown a willingness to pull the plug. In a separate concurring opinion, Justice Gorsuch explained the rationale for the doctrine in elegant and compelling language:

“Most major decisions affecting the rights and responsibilities of the American people (including the duty to pay taxes and tariffs) are funneled through the legislative process for a reason. Yes, legislating can be hard and take time. And, yes, it can be tempting to bypass Congress when some pressing problem arises. But the deliberative nature of the legislative process was the whole point of its design. Through that process, the Nation can tap the combined wisdom of the people’s elected representatives, not just that of one faction or man.

There, deliberation tempers impulse, and compromise hammers disagreements into workable solutions. And because laws must earn such broad support to survive the legislative process, they tend to endure, allowing ordinary people to plan their lives in ways they cannot when the rules shift from day to day.

One could well imagine this same reasoning being applied by the courts to strike down President Trump’s administrative gerrymandering of MFN into Medicare. Whether the courts ultimately come to this view is an open question, but an avalanche of litigation on this question is a certainty if GLOBE or GUARD proceed in their current form.

Why does industry appear to be cooperating?

One of the more curious features of this latest MFN round is the degree of apparent industry cooperation. Flashy public announcements of pricing “agreements” and the willingness of some manufacturers to engage with the GENEROUS model might seem counterintuitive, particularly given the industry’s successful litigation against the 2020 MFN rule, but the incentives are different this time.

First, the current initiatives are structured in ways that give manufacturers room to manage exposure. GENEROUS is voluntary and rebate-based. Participation can be calibrated. The drugs that have been targeted by the Trump administration thus far for MFN deals are mainly legacy products that are coming to the end of their exclusivity lifecycle. Participation gives manufacturers some strategic agency in negotiating the fine details of the model, in particular how net prices will be determined. Finally, cooperation may be less costly than confrontation, particularly if the alternative is more aggressive legislation.

Second, there is a reputational and political dimension. Drug pricing remains one of the few issues that reliably unites American voters across party lines. Open resistance to a high-profile affordability initiative carries risk. By engaging constructively, drug manufacturers can signal responsiveness while helping shape implementation details behind the scenes. Participation also creates space to influence guardrails, data methodologies, and operational timelines in ways that litigation cannot. It’s a strategy known to most Canadians as ragging the puck.

Third, and perhaps most importantly, the industry is betting that cooperating with the administration on operationalizing GENEROUS, will ease the pressure to proceed with the proposed changes to Medicare, a market which dwarfs Medicaid. The reality is the Medicaid Drug Rebate Program is already very effective at securing competitive prices for many drugs and GENEROUS is not expected to significantly impact the industry’s bottom line. If MFN experimentation can be contained within Medicaid, cooperating in a limited test is a rational hedge against a far more dire escalation of the policy.

Industry engagement should not be mistaken for capitulation. It reflects a strategic calculation about risk management, optics, and the relative scale of exposure. That calculus further tempers the assumption that the US is on the brink of a permanent, system-wide inversion of global drug pricing dynamics. Should the Trump administration proceed with GLOBE and GUARD or try to expand MFN to the broader US market in some way, the dynamic with industry will become much more adversarial.

So, what does it all mean?

The nightmare scenario globally is a stable, durable, nationwide US policy that forces American net prices down to the bottom of the OECD and keeps them there. That would entail not just adoption of MFN in both Medicaid and Medicare, which would take several years to consummate, but its subsistence into the next administration. However, the thing about bypassing Congress with major policy initiatives of this kind is that they remain tenuous creatures of executive power. What one administration does via executive order can be easily undone by the next with a reverse stroke of the same pen.

GENEROUS may well proceed. It is the narrowest and most defensible of the three tracks. But it is also the least economically transformative. GLOBE and GUARD are more ambitious, and therefore more vulnerable. The further they move from bounded experimentation toward structural Medicare redesign, the more likely they are to instigate their own demise. Moreover, even if the latter models were to persist, the “higher-of” methodology they employ means that in practice they will likely default to list prices most of the time, which is still impactful but not nearly to the degree benchmarking to net prices would be.

For Canada and the rest of the world, that means the probability-weighted outcome is not a sudden, permanent inversion of global pricing dynamics. It is a period of experimentation, litigation, and uncertainty inside the US. That is unpleasant but not contagious.

The more probable and practical impact of the Trump administration’s MFN announcements in drug prices in Canada and the rest of the OECD is twofold:

1. An upward convergence of list prices globally

2. Even more opacity in how net prices are negotiated

Even the US doesn’t pay US prices

You might be wondering why US list prices are so high in the first place. Any discussion of MFN needs to grapple with the reality that even the US doesn’t really pay its high list prices, which are due in large part to a rebate-driven distribution system in which Pharmacy Benefit Managers (PBMs) play a central role.

PBMs sit between drug manufacturers, insurers, and pharmacies. They negotiate formulary placement on behalf of insurers and extract rebates from manufacturers in exchange for preferred coverage status. Those rebates are typically calculated as a percentage of the drug’s list price. The higher the list price, the larger the potential rebate. Over time, this structure has created a perverse incentive: manufacturers raise list prices in order to fund larger rebates, PBMs showcase the size of the negotiated “discount,” insurers benefit from lower net costs, and the entire transaction remains largely opaque to patients.

The result is a widening gap between list prices and net prices in the US. While the net price after rebates may be closer to international levels for many drugs — especially under Medicaid — the publicly visible list price remains dramatically higher. That gap still matters. It drives patient cost-sharing in many plans, it distorts international comparisons, and it fuels the political perception that US prices are uniquely outrageous. MFN proposals target those visible disparities, but they are being layered onto a system in which the headline price is often a negotiating instrument rather than the true economic transaction price.

The politics of MFN are driven by list prices, and in particular the chasm between US list prices and those in the rest of the world. It is only natural that industry will respond to this situation by trying to narrow that disparity, and even if it could, it won’t be doing so by lowering list prices in the US. Expect sustained upward pressure on list prices in Canada and abroad for the foreseeable future.

The core problem with net prices

The fatal flaw in trying to benchmark against international net prices is that they are not publicly known. Net prices are negotiated outcomes embedded in confidential agreements. In most high-income countries, the publicly posted list price is only the starting point. The real price is a function of confidential rebates, risk-sharing arrangements, volume guarantees, or outcome-based discounts that are contractually shielded from disclosure. Those confidentiality provisions are central to manufacturers agreeing to deeper concessions in the first place. Ironically, the trend towards ever greater disparity between net and list prices internationally is a byproduct of countries seeking to tamp down drug spending by benchmarking against foreign list prices — a practice Canada pioneered in creating the PMPRB in the 1980s but which is now widespread.

The more aggressively the U.S. attempts to anchor its prices to the lowest observed net prices abroad, the stronger the incentive for other jurisdictions to ensure that their deepest concessions are no longer easily observable as “prices” at all — for example, by shifting value into side payments, bundled arrangements, or non-price concessions that are harder to benchmark. In effect, international net benchmarking creates pressure not toward transparency, but toward ever greater opacity.

The real impact on Canada of US MFN policies

There is a great deal of hand wringing happening in the somewhat insular community that constitutes Canada’s pharmaceutical ecosystem. Canada represents only 2% of the global pharmaceutical market and it already suffers from being an afterthought in the minds of most multinational drug company headquarters. The fear is that proximity to the US and relatively low list prices will further compromise our access to the latest pharmaceutical innovations if the US adopts MFN. This fear is compounded by the assumption that Canada’s public drug plans are especially effective at securing low net drug prices in the confidential deals they strike with industry under the aegis of the pan-Canadian Pharmaceutical Alliance (pCPA). There are already rumblings from industry that Canada must eradicate the PMPRB and its price referencing system if it wants to avoid becoming even more of a backwater market for new drugs.

The reality is that nothing much stands to change in the near term in Canada if the US proceeds with its GENEROUS model. It is less clear what the implications would be if GLOBE and GUARD are rendered operational and can withstand legal challenge. However, the chances of the latter are low and both models appear to default to list prices in any event. What is unavoidable regardless of how things pan out in the US is that industry will be looking to raise international list prices across the board. For all the finger pointing at the PMPRB, under its new guidelines, upward pressure on list prices isn’t particularly problematic because the PMPRB’s regulatory oversight mechanisms aren’t engaged unless the price in Canada is higher than the 11 other countries we compare ourselves to. A rising tide lifts all boats, and one can assume that PMPRB oversight will be no more relevant tomorrow than it is today, which is to say not much. Excessive price hearings are exceptionally rare and will continue to be. One can argue that the optics of having a ceiling price regulator like the PMPRB makes Canada a less attractive country to industry generally, and this matters more now because of the MFN issue, but there is otherwise no rational connection between the two.

Whether US MFN benchmarking succeeds or not, there is another way to view the pressure this may place on the pCPA. For years, Canadian drug negotiations have revolved around static price concessions — percentage volume-based rebates off a list price that are loosely based on what is known about the clinical effectiveness of the drug before it actually enters the market and becomes widely used. In The Price Is Wrong, I argue that the true value of a drug can only be known once it begins to generate outcomes in the clinical population and that public payers should reorient their agreements with manufacturers accordingly. If deeper opacity than simple rebate agreements becomes necessary to shield Canada from forensic scrutiny by the US, that could create space and political cover for the pCPA to pivot toward more sophisticated arrangements. Outcome-based agreements, risk-sharing contracts, and real-world evidence–linked reimbursement models shift the focus from theory to practice. The upside of an attempt by the US to anchor itself to other countries’ net prices is that it could push Canada toward the very kind of value-based innovation that has long been discussed but never implemented.

Keep calm but get stuff done

If MFN is not the five-alarm fire it is being characterized as in Canada, that does not mean that we should be complacent about our status quo. Never squander the opportunity of a crisis, be it real or rhetorical.

The more durable lesson from the US experiment is not about prices per se. It is about structural competitiveness. Whether or not GLOBE or GUARD survive judicial review, and whether GENEROUS delivers meaningful savings, the US is signalling that it is prepared to revisit the architecture of how it pays for medicines. Canada should be doing likewise, not to defend a price point but to modernize the system through which we make decisions.

Canada has become very good at extracting marginal price concessions through layered review processes, overlapping negotiations, and cautious reimbursement pathways. What we have been less good at is improving the speed, predictability, and administrative coherence of the system itself. That friction carries its own cost. Delayed listings, duplicative assessments, and uncertain post-listing conditions reduce Canada’s attractiveness as a launch market and complicate long-term planning for both industry and payers.

If global pricing becomes more fluid — whether because of US benchmarking or other geopolitical forces — Canada’s comparative advantage will not lie in suppressing price signals further. It will lie in reducing the friction. This is where the pressure on the pCPA and Canada’s Drug Agency could become constructive rather than defensive. More innovative agreements, linked to measurable performance in Canadian populations, and real-world evidence infrastructure, would allow reimbursement decisions to evolve based on actual utilization and outcomes rather than fixed assumptions made at launch.

If Canada wants better and faster access to new therapeutic innovation it can either embrace laissez-faire pricing or modernize and consolidate its fragmented pathway from market authorization to patient access. Everything should be on the table — not because MFN warrants panic, but because global pricing dynamics are evolving whether we like it or not. If the US is experimenting with structural change under legal uncertainty, so can we. Canada’s opportunity is quieter but potentially more durable. Let’s not squander it.