Although MFN policies are designed for the US, they shift pricing and policy risk onto ex-US health systems, turning traditionally stable markets into sources of global exposure. Future access, predictability, and investment will depend on how ex-US payers and policymakers adapt their pricing, HTA, and innovation frameworks in response.

As international prices and benchmarks become more closely linked to US outcomes, ex-US health systems are finding that decisions taken within national pricing and reimbursement structures can carry wider consequences. Markets once valued for stability and predictability are now exposed to new forms of external risk, driven not by domestic policy choices but by how prices and assessments are used elsewhere.

How Risk Cascades from US MFN Policy

Understanding how MFN creates cascading effects across global markets is essential for strategic planning. The diagram below illustrates how US policy decisions flow through reference countries, creating ripple effects that ultimately shape ex-US market responses and long-term access outcomes.

The scale of this interconnection is striking. Over 70% of global markets reference prices from MFN basket markets, either directly or through secondary IRP chains. This means pricing decisions made in basket markets do not simply affect US benchmarks – they cascade outward through layers of international reference pricing, ultimately shaping reimbursement in markets that have no direct connection to the US at all. Europe is particularly exposed: major European markets are heavily referenced by others, placing them at the top of a hierarchical structure where price changes propagate rapidly through the system.

How Ex-US Markets May Respond

Ex-US payers and policymakers are unlikely to remain passive. MFN exposure is prompting a reassessment of how national systems manage imported risk. This may include tighter managed entry agreements, outcome-based payment models, changes to reference baskets, or increased use of alternative value frameworks to limit external exposure.

While such responses may help protect local affordability and policy objectives, they also risk increasing complexity and uncertainty across the global system. Measures designed to shield individual health systems can create knock-on effects elsewhere, reinforcing the interdependencies that MFN policies expose.

These pressures also raise practical questions about policy design and governance. Historically, simple and consistent frameworks helped health systems manage decisions predictably, while preserving confidentiality of net prices. In a more interconnected environment, however, applying the same rules everywhere can mask where risks really sit and where strategic priorities differ between health systems.

Regional Policy Directions

For Europe, MFN adds urgency to an already crowded policy agenda. If US pricing policy is reshaping global incentives, the EU faces a clear question about how it remains competitive for innovation while safeguarding affordability. Recent and ongoing reforms – including the EU Pharmaceutical Legislation, the proposed Biotech Act and Critical Medicines Act, and the introduction of EU-level HTA – all have a role to play.

Their impact will depend on whether they genuinely reduce regulatory and bureaucratic burden, improve clinical trial efficiency, protect intellectual property, and support timely access, rather than adding further rigidity. Recent national signals, such as changes to cost-effectiveness thresholds in the UK, suggest some payer willingness to adapt, but they are unlikely to be sufficient on their own.

At the same time, other ex-US markets are moving quickly. China is actively reforming its pharmaceutical regulatory and access policies to simplify market entry, speed approvals, and support innovation, making it a more attractive early-launch market for global companies. This divergence in policy direction highlights the competitive pressure facing Europe as global launch strategies evolve in response to MFN-driven risk.

Longer-Term Implications

Beyond immediate pricing effects, the redistribution of risk has longer-term implications. If MFN-driven pressures influence launch timing, geographic prioritisation, or investment decisions, ex-US patients and health systems may ultimately experience delayed access or reduced availability of innovation. These outcomes are rarely the stated aim of affordability policy, but they remain part of the wider risk landscape.