On the last day of August, nine more drugmakers signed the White House’s pricing plan, and the administration counted it a win. What the signature actually bought them was a way out. By putting their names to a voluntary agreement, Alcon, Astellas, Teva, Sun Pharma and five others pledged $19.6 billion in near-term U.S. manufacturing and stepped clear of the mandatory Medicare rebate models the government is preparing to drop on every company that didn’t sign. The tally now runs to 26 companies, covering by the administration’s count about 90 percent of the drugs Americans take.
It helps to separate what the deal is from what it dodges. The voluntary agreements themselves mostly concern Medicaid pricing and a direct-to-consumer channel called TrumpRx; for most people at the pharmacy counter, they change very little. Independent modeling in JAMA put the Medicaid savings from most-favored-nation pricing at roughly $8.6 billion a year across the first 17 signers, real money, though Medicaid money, not the Medicare rebates the exemptions carve away. The Medicare piece is where the exit lives. Two proposed models, GLOBE for Part B drugs and GUARD for Part D, are the mandatory machinery: GLOBE is set to begin October 1, 2026, and GUARD on January 1, 2027, and if finalized as proposed they would force a company to pay rebates whenever its U.S. price runs above the lowest price it charges among 19 wealthy nations. A company that signs a private agreement with the White House is carved out of both. The rule is mandatory. The escape hatch is not.
An analysis put a number on the difference. The White House has projected the effort would save Medicare $26 billion over several years. Once you subtract the companies that have signed their way out, the same analysis finds the exemptions could erase as much as 80 percent of that projected savings. The discipline that was supposed to fall on the whole industry now lands, in force, mainly on the manufacturers who declined the invitation to skip it.
What the companies actually agreed to, nobody outside the room can say, because the terms are sealed. The administration has barred the drugmakers from disclosing them, which is why four senior House and Senate members wrote the president in March demanding he hand the agreements over to Congress. Set the partisan framing aside; the request is the right one. A pricing reform sold to the public as a win for the public should be legible to the public. The companies know what they got. The voters footing the Medicare bill are told to trust the number and skip the contract, because there is no contract they are allowed to read.
In the parts they have volunteered, what the signers got looks less like a concession than a portfolio. In exchange for pricing “aligned” with peer nations, they stand to collect relief from the tariffs this same administration has threatened, a retail channel through TrumpRx, and exemption from liability under the mandatory rebate models. It is a familiar shape to anyone who has watched the industry bargain: take the headline concession, secure the structural protection, and make sure the protection is what endures.
The people who study this are not sold on the headline. Harvard’s Luca Maini told TIME the design mostly tidies the program’s books rather than the patient’s bill: “The main benefit here is not to the patients using the drugs, but to the fiscal health of the program.” Even that fiscal win may not hold. Thomas Hwang of Brigham and Women’s called the long-term savings “likely illusory,” because a price pegged to the cheapest wealthy nation gives companies every reason to raise their prices abroad and reset the benchmark the U.S. is chained to. And Suhas Gondi expects the industry to blunt the effect by “delaying market entry in some other countries,” keeping the reference price high by controlling where and when a drug launches at all. A JAMA Health Forum study of 2015 to 2019 launch patterns shows how heavily the U.S. benchmark would ride on that foreign timing. Tie your price to the cheapest country, and the cheapest country stops being cheap, or stops getting the drug.
Strip the announcements down and a plainer shape sits underneath. A populist promise to break pharma’s pricing power arrived with a mandatory mechanism and a voluntary exit built beside it, and the largest manufacturers walked straight for the exit while the administration saluted each departure as an arrival. This is where health-populism parts company with partisan loyalty. A policy that lets the biggest drugmakers opt out of the discipline meant to bind them is not the industry losing a fight. It is the industry setting the terms of its own regulation, in private, and being thanked for showing up.
The White House says the deals cover 90 percent of the drugs Americans use. It has not said what it gave up to reach that number, and it has told the companies not to say either.
Sources
- STAT – Trump’s secretive pharma deals may undermine ‘most-favored nation’ pricing, an analysis suggests (Sept 13, 2026)
- TIME – What Trump’s Most-Favored-Nation Deal Means for Drug Prices (Sept 2026)
- BioSpace – 9 midsize drugmakers climb aboard Trump’s MFN train
- U.S. House Energy & Commerce Democrats – letter demanding disclosure of the secret pharma deals (March 2026)
- JAMA – Savings Under Most-Favored-Nation Pricing for Prescription Drugs in Medicaid (Aug 2026)
- JAMA Health Forum – Novel Drug Launches in Most-Favored-Nation Countries and Medicare Pricing Benchmarks (2026)