Seventeen of the biggest pharmaceutical companies have now signed MFN deals with Washington, and the formula behind them takes the second-cheapest price in a basket of eight countries and turns it into America's benchmark. At the same time, Brussels is about to make launching in Europe a legal obligation, and China has just brought more new drugs to market than the US for the first time. Neil Grubert has watched global pricing and access for 25 years, and he joined me on The Pharma Perspective to explain why these developments point at the same conclusion: Europe can no longer assume that the drugs will simply arrive.

The world's medicine bill has been split the same way for thirty years. America pays top dollar while everyone else haggles, and the industry lives with it because the American cheque funds the laboratories. Europe's seat at this table has been comfortable so far. We wait our turn and bargain hard, and the drugs arrive anyway. They always arrive.

Neil Grubert has spent 25 years watching how this game is played, first building up the market access business at Decision Resources Group and, since 2014, as an independent consultant on global access and policy. When I asked him about Europe's position, he didn't reach for a diplomatic phrase. The danger, he told me, is "a certain level of complacency in Europe". The drugs always arrived, so we assume they always will. Here are the three reasons to stop assuming.

In the autumn of 2025, letters went out from Washington to the seventeen biggest pharmaceutical companies in the world. Every one of them has since signed an MFN agreement¹. The premise is the freeloading charge: America supplies around half the industry's revenue from new medicines and three quarters of its profits, while paying several times European prices for the privilege.

The terms are closely guarded, but Neil reads four commitments in the company statements and White House fact sheets. MFN prices go to state Medicaid programmes now, and to every future launch in every sector of the market, including the commercial sector, the part Neil calls the crown jewel, where Washington has until now left prices alone. Companies move into direct-to-consumer selling through TrumpRX, a government-branded shop window that stocked around 74 branded medicines when Neil last counted. And any extra money earned from higher prices abroad flows back to cut prices in America, "repatriated", as the White House puts it, as if the money had merely been on holiday.

Refusal has a price too, and the price is a 100% tariff at the border.² The UK bought itself a full exemption with a dedicated pricing deal, while the EU stands at 15%.³

Strip away the politics and MFN is a simple machine. Take eight countries, the G7 without America plus Switzerland and Denmark, find the second-cheapest price in that row, adjust it for purchasing power, and that number becomes America's benchmark, first for Medicaid and then for every new launch.⁴

The radical part is which price gets measured. Countries have copied each other's list prices for decades, which is like valuing houses by the asking price in the estate agent's window. Everyone knows the real numbers are lower, and nobody outside the room knows by how much, because discounts of 50% or more are routine everywhere. The US now wants the real number. Companies are to self-report their net prices, clawbacks and managed entry agreements included, and the deadline is tightening: Neil watched the reporting window shrink from nine months to two between drafts of the rulebook.

Let’s follow one discount on its journey to understand this better. Suppose a company halves its price in Germany to win reimbursement. Under the old rules, that number lived and died in Germany. Under MFN, it crosses the Atlantic and reprices the company's biggest market. Anyone who thinks companies will absorb that arithmetic politely has never sat in a pricing committee. Several CEOs have already promised, in public, to do whatever it takes to protect their US prices, and Neil hears growing reports of launch hesitancy in Europe.⁵ The optimistic reading says this is a wobble that ends once the rules are clear. Neil doesn't buy it, and his words are worth repeating: there has always been this assumption that the drugs will come to Europe before too long, and "I question whether we can afford to continue to take that for granted."

Europe's answer arrives in October this year, when the revised pharmaceutical legislation is expected to get its final signature. Inside it sits Article 56a, the launch obligation.⁶ Any member state can request a new drug within a year of approval, and the company then has three years to supply that market properly or start losing exclusivity there.

Of course, the diagnosis behind it is correct, because the access gap across the EU is real and indefensible. A patient in Sofia can wait years for a medicine that Munich gets in months. But you can close a gap from either end, and Neil's worry is the one Brussels doesn't want to hear: instead of everyone getting the drug sooner, everyone gets it at the same time, which turns out to mean later, or not at all. A company staring at the MFN arithmetic may find it safer to skip Europe than to launch on schedule at prices that poison its American benchmark. Brussels is making European launches compulsory at the exact moment Washington is making them expensive. Something has to give, and it won't be Washington.

While Washington and Brussels argue over who pays for innovation, the number that I found most stunning actually came from Beijing. In 2015, China originated two of the world's 76 newly approved innovative drugs, which is little more than a rounding error. By 2024, the tally in Nature Reviews Drug Discovery stood at 39 for China against 41 for the US.⁷ And according to Neil, China has recently overtaken the US in terms of new drugs approved. Does that mean we see a shift in who claims the spot for the most important pharmaceutical market in 2026?

The machinery behind this change moves at a speed Europe should study. China prices its entire public reimbursement list in a single weekend. Company teams sit at the table, step out to phone headquarters, then walk back in and make a deal. They call it “soul bargaining”, the average discount is around 60%, and the prize is a market of 1.4 billion people. Some Western companies have walked away from that table, but fewer do each year. And in December 2025, China unveiled its first commercial insurance list, 19 higher-priced products with room to breathe on price, including five CAR-T cell therapies the public list had repeatedly refused.⁸

The door to the West is opening too. Lawrence Tallon, chief executive of the UK's MHRA, said it plainly this spring: Western countries "can no longer afford to reject Chinese data, otherwise they will cut themselves off from the most innovative drugs."⁹ Neil's frame for all of this is the question every European policymaker should have pinned above their desk: is China's rise a risk, a threat or an opportunity? His answer is all three at once. A threat to the multinationals, a risk of depending on Chinese supply in an unstable world, and an opportunity to buy real innovation at prices the current system won't offer. And if Western companies hesitate at Europe's door, Chinese companies will not wait to be asked twice.

I ended by asking Neil what he would change tomorrow about how the world pays for medicines. He didn't name a mechanism. Instead, he spoke about empathy, and its harder-nosed cousin, realism. Our industry needs to see what payers see: ageing populations and defence bills competing for money that is finite. Policymakers need to count what a research industry brings beyond the price of a pill, from skilled jobs to the security of making your own medicines on your own continent. Both sides are defending their own line in the budget while the ground between them moves.

Nobody will announce the end of Europe's second wave. It will show up as a gap in a launch calendar, then another, and by the time it's undeniable it will be habit. So watch where companies put their next three launches, because that's where this argument gets settled.

Has MFN changed a launch conversation you've been part of? I don't mean predictions, I mean something you've actually seen: a sequencing decision revisited, a European submission that slipped down the priority list. If it's business as usual where you sit, that's just as useful to hear, because the gap between the headlines and the day-to-day is exactly what I want to map.

Hit reply and tell me what you're seeing.

Across 12 domains, the HEOR roadmap is a quick self-assessment against the 120 core skills of the field. Download it for free in less than 30 seconds, or spend 10 minutes customising it for a personalised breakdown of your gaps and what to work on next.

P.S. — Pharma Radar is written by Mirko von Hein. I help pharma and biotech teams navigate HTA submissions, cost-effectiveness modelling, and market access strategy across the UK, Ireland, and Germany. After a decade across IQVIA, Parexel, and Gilead, I'm now taking on selected engagements through Von Hein Consulting.