Somewhere inside the Centers for Medicare and Medicaid Services, an actuary ran the final numbers on a rule the administration had spent most of a year promising would do something large. The version proposed in December 2025 carried a projected savings of nearly $12 billion. The version published on September 30, 2026 carried $440 million. Same rule, same window, 96 percent less money. The math had not failed. The rule had been rebuilt around it.
The rule has a name built for a press release: the Global Benchmark for Efficient Drug Pricing, or GLOBE. It is one of two mandatory pilots inside President Trump’s most-favored-nation plan, the policy sold as the end of the oldest arithmetic insult in American medicine, that a patient in Phoenix pays several times what a patient in Paris pays for the identical vial. The mechanism is clean enough. For certain clinician-administered Part B drugs, the kind infused in an oncology suite or a rheumatology clinic, Medicare would measure its rebate against a benchmark drawn from nineteen comparable countries, from Canada and Japan to France and Germany, and claw back the gap. “Medicare Part B patients and American taxpayers have paid significantly more for prescription medications than people in comparable countries,” said CMS Administrator Mehmet Oz, announcing the finalized model. He is right about that. Americans have underwritten the rest of the world’s medicine for years, and the price gap is not in serious dispute: other governments negotiate hard and refuse the launch prices the United States accepts without a fight.
Then came the other half of the policy. While CMS drafted a mandatory rule to force rich-country prices onto drugmakers, the same administration was signing voluntary deals with those same drugmakers, trading price concessions for a way out from under the rule. Sixteen agreements had been struck by the time the dust settled, Pfizer and AstraZeneca and Eli Lilly among them, some cutting headline prices by as much as 85 percent. And the final GLOBE rule exempts any company that signed one. By the deadline, nearly every major manufacturer had.
The model is mandatory. Almost no one has to follow it.
What remains is a pilot that applies, by the administration’s own accounting, to 4 companies. The firms that cut a deal walked. The holdouts stayed on the hook. Thomas Hwang, a Harvard researcher who had modeled GLOBE’s reach, told STAT the collapse was in line with the estimate he had already run once the exemptions were counted. The 96 percent surprised no one who does this math for a living. It was the predictable arithmetic of a rule built to let its targets out the back door.
The structure around those four is narrower still. GLOBE covers only separately payable Part B drugs and biologics, and it exempts orphan-only drugs, plasma-derived products, certain cell and gene therapies, and any biologic once a biosimilar competitor reaches the American market. It runs in randomly selected ZIP codes covering about a quarter of people on Original Medicare. The model begins January 1, 2027. The first patient might see a smaller copay by that April. The ambition was advertised; the enforcement was reserved for the few who declined to deal.
Set the two tracks beside each other. The voluntary deals were the carrot, the mandatory rule the stick, and in practice the carrot swallowed the stick. A manufacturer that signs a deal buys its way clear of the only enforceable price control on the table, and promises in return the sort of concession that is harder to audit and easier to walk back than a federal rebate formula. That is not a hard trade to accept. Most of the industry accepted it.
None of this makes the most-favored-nation idea wrong. The idea is the correct one, and it polls across every faction because voters of all stripes are tired of subsidizing the rest of the world’s pharmacy. America First on drug prices would mean the government using its leverage as the largest buyer on earth. The final rule shows that leverage traded away for voluntary gestures, with the teeth saved for four companies that would not play along. Mehmet Oz, who spent two decades selling the American public on supplements and television segments before he ran the agency, now signs his name to a rule that promises lower prices and delivers, on his own actuaries’ page, about four percent of what it first advertised. The $12 billion was the honest number. Someone decided the $440 million would be easier to sign.