On May 12, 2025, President Donald Trump issued an executive order reviving his controversial “Most Favored Nation” (MFN) drug pricing policy—an aggressive attempt to slash Medicare costs by pegging U.S. prices to those paid in countries like Canada, Germany, and the United Kingdom. Though pitched as a bold move to take on Big Pharma, this policy risks causing more disruption than relief—and, once again, overlooks the real culprit behind many of America’s skyrocketing drug prices: pharmacy benefit managers (PBMs).
There’s no denying that prescription drug costs in the U.S. are too high. Millions of Americans are forced to make impossible choices—skipping doses, delaying refills, or foregoing treatment altogether—because they simply can’t afford their medications. This is a real crisis, and it demands urgent, thoughtful solutions. But the MFN approach, while headline-grabbing, is the wrong tool for the job.
The premise of the MFN policy is simple: if other developed nations pay less for drugs, the U.S. government should get the same deal. But drug pricing is never simple, and trying to import foreign price controls into a fundamentally different healthcare system is a recipe for unintended consequences. That’s exactly what happened when this policy was first introduced in 2020—and what is likely to happen again if implemented now.
By slashing Medicare reimbursement rates for a select group of costly Part B drugs—those administered by physicians in hospitals and clinics—the MFN rule threatens access to care for seniors and people with chronic illnesses. Providers, especially smaller oncology practices and rural clinics, would be forced to offer these treatments at a loss or stop administering them entirely. That means patients could lose access to life-saving medications or face delays and long travel distances to get care. It’s a dangerous gamble, especially when better options are on the table.
One of the most glaring omissions in President Trump’s executive order is any mention of Pharmacy Benefit Managers, the shadowy middlemen who play an enormous and largely opaque role in determining what Americans pay at the pharmacy counter. Originally created to negotiate drug prices on behalf of insurers and employers, PBMs have evolved into powerful gatekeepers that manipulate formularies, collect undisclosed rebates, and prioritize profits over patients.
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Three PBMs—CVS Caremark, Express Scripts, and OptumRx—control nearly 80% of the U.S. market. They determine which drugs are covered, how much patients pay, and how pharmacies are reimbursed. And despite their influence, PBMs operate with little transparency and virtually no accountability. They often demand massive rebates from drug manufacturers in exchange for favorable placement on formularies—but those rebates aren’t necessarily passed on to consumers. Instead, they’re pocketed by the PBMs or insurers, while patients continue paying inflated list prices.
This broken system creates all the wrong incentives. Manufacturers are encouraged to raise list prices so they can offer higher rebates, securing PBM favor. Meanwhile, patients—especially those with high-deductible plans or coinsurance—end up footing the bill based on those artificially inflated prices. It’s a shell game, and the winners aren’t patients.
Reforming PBMs wouldn’t just treat the symptoms of high drug prices—it would attack the disease at its core. That’s why policymakers from both parties have begun pushing for PBM transparency and accountability. Proposals include requiring PBMs to disclose rebate structures, pass negotiated discounts directly to patients at the point of sale, and eliminate practices like “spread pricing,” where PBMs charge insurers more than they reimburse pharmacies, pocketing the difference.
Such reforms enjoy broad bipartisan support and don’t require the blunt instrument of international price indexing to deliver real results. In fact, multiple studies suggest that cracking down on PBM practices could save the healthcare system tens of billions of dollars over the next decade—without threatening patient access or stifling pharmaceutical innovation.
Speaking of innovation, the MFN rule would send a chilling message to the pharmaceutical industry. While it’s popular to vilify drug manufacturers, the reality is that the U.S. leads the world in medical innovation precisely because it allows companies to recoup the massive investment required to develop new treatments. Tying U.S. drug prices to countries that cap pricing based on cost-effectiveness thresholds could discourage investment and delay the introduction of breakthrough therapies here at home. It’s not a question of protecting industry profits—it’s a question of protecting patients’ future options.
None of this is to suggest that the current system is acceptable. It’s not. But meaningful reform should be targeted, data-driven, and designed to promote competition, not suppress it. That means streamlining the approval of generics and biosimilars. It means encouraging direct negotiations for high-cost drugs. And it means finally dragging PBMs out of the shadows and into the light of regulatory scrutiny.
If President Trump truly wants to challenge the status quo and stand up for American consumers, he should pivot from recycling flawed policies like the MFN rule and focus instead on reining in the opaque middlemen profiting off patients’ pain.
To be clear, PBM reform won’t solve every issue in the pharmaceutical supply chain. But it strikes at the heart of the pricing distortion that has come to define the American drug market. It aligns with free-market principles by increasing transparency and competition. And it does so without risking access, undermining care, or relying on foreign pricing models that simply don’t translate to the U.S. healthcare environment.
In reviving the MFN rule, President Trump has chosen a high-risk path with uncertain rewards. It may score political points, but it’s unlikely to deliver the relief patients are desperately seeking. The real solution lies in a more nuanced, thoughtful approach—one that shines a light on PBM abuses and restores balance to the system.
Let’s hope policymakers—and the American public—demand better. Reform is overdue, but it needs to be smart, targeted, and patient-first. That begins not with recycled executive orders, but with meaningful PBM reform.
Pam McAloon is a retired Registered Nurse, specializing in critical care and oncology. Currently serving as State Committee Woman for Pinellas County and as Pinellas Chair of the FRW.
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