GUEST COLUMN, Robert Blancato, National Association of Nutrition and Aging Services Programs
Millions of older Americans struggle every day to afford the medications they need. Too often, they make impossible choices: splitting pills, skipping doses, or forgoing prescriptions altogether because of the price.
President Trump recognizes the problem. His administration is weighing whether Medicare should cover GLP-1 medications for weight loss, a decision that could have major implications for access and cost.
The White House has also recently worked with several pharmaceutical companies on voluntary "most favored nation" deals, which will secure more affordable access by expanding direct-to-consumer options and cutting out price-gouging middlemen.
Yet some policymakers want to sweep aside that voluntary approach and make the MFN model mandatory on a broader scale. Codifying MFN into law would trigger shortages today and choke off the breakthroughs of tomorrow.
The logic behind MFN is simple: peg American drug prices to the lower, government-set prices in Canada, Japan, and most European countries. Those countries’ artificially low prices come at a steep cost.
In other developed countries, patients often wait years for access to new medicines. Many drugs available in the United States never make it to foreign patients at all, especially treatments for rare diseases that don’t pass their strict cost-benefit tests.
Mimicking foreign price controls could import those trade-offs, and American patients -- particularly older adults -- would pay the price.
Furthermore, importing foreign price controls wouldn’t fix the structural problems that actually drive U.S. drug costs. Other countries don’t need to contend with the powerful middlemen and costly loopholes embedded in their healthcare systems.
Rather than considering mandatory MFN proposals, we need to address the root of the problem. That’s the only way prices at the pharmacy counter will come down for older adults.
Consider the most influential of those middlemen -- the pharmacy benefit managers that act as gatekeepers between drugmakers, insurers, and pharmacies, with the power to determine which medicines patients can actually access. PBMs decide which drugs insurance plans will cover, and they negotiate rebates from manufacturers in exchange for steering patients towards particular drugs.
The rebates they negotiate often don’t make it to patients. In fact, more than 50 cents of every dollar spent on prescription drugs actually goes back to PBMs and other non-manufacturing entities. PBMs even have an incentive to push higher-priced drugs onto patients, in order to generate bigger rebates and bigger profits for themselves.
When PBMs profit more from expensive medicines, their formularies -- the lists of drugs covered by insurance -- tilt toward high-priced brand-name products. That means patients often pay more at the pharmacy counter even when cheaper, equally effective alternatives exist.
Independent pharmacists have long warned that PBMs also use "spread pricing," where they reimburse pharmacies far less than they charge insurers for the same prescription, pocketing the difference. The result is a system that rewards opacity, punishes transparency, and leaves both patients and small pharmacies struggling to survive.
Reform efforts have gained traction, but meaningful change requires tackling the structural incentives that let PBMs profit from higher prices and secrecy. Congress has proposed bills to mandate rebate pass-throughs to patients, delink PBM compensation from a drug’s sticker price, and require clearer reporting on how much PBMs actually earn from negotiations.
The president should work with Congress to enact crucial PBM legislation.
Cutting these middlemen down to size would actually deliver real savings to American seniors and all other patients.
ABOUT THE AUTHOR — Robert B. Blancato is the executive director of the National Association of Nutrition and Aging Services Programs.
