MFN and the small Pharma squeeze, is the UK about to become a prohibitive launch market?

Last time I wrote about MFN and the growing number of NICE processes getting messy, paused, stretched, or pulled.

This follow-up is the bit that keeps coming up in conversations with founders, investors, and market access leads.

MFN does not hit everyone equally.

It lands hardest on the smallest companies, the ones with one asset, one shot, one value story, and a runway that is measured in quarters, not decades.

So what is MFN really doing?

The Trump administration has been explicit about pushing US prices down toward what other developed countries pay, via a Most Favoured Nation approach, supported by the May 2025 executive order and the TrumpRx framing.  CMS has also tied this direction into programs like the GENEROUS model for Medicaid, aiming to align prices with those paid in “select other countries”, with launch timing set out for 2026.

Now ask yourself, if the US is trying to peg pricing to the lowest price seen in peer markets, what happens to the UK’s role in global launch sequencing?

The UK just became part of the MFN chessboard. Our success in negotiating some of the lowest prices in the world now becomes a detriment to patient access and new drug launches.

The UK–US pharmaceuticals agreement announced in December 2025 is basically a giant sign that the UK is now directly connected to US pricing politics.

The UK government positioned it as 0% tariffs on UK medicines exports, and around 25% more NHS spending on innovative, safe, effective treatments.  Reuters reported that, under the deal, Britain agreed to increase the net price paid by the NHS for new medicines by 25%.

Reuters also reported a material change in NICE’s value appraisal, including the QALY threshold moving from £30,000 to £35,000, applying to all new medicines.  The US Trade Representative framed this as part of ensuring UK citizens have access to the latest pharmaceutical breakthroughs, while insulating the UK from certain tariff and investigation pathways during Trump’s term.

That is an extraordinary backdrop, and it explains why companies are already testing “US price parity” in the UK.

It is not theoretical anymore

We have seen manufacturers publicly link UK launch pricing to US pricing in a way that would have been unthinkable a few years ago.

Reuters reported AbbVie planned to launch Elahere in the UK at a list price matching the US, explicitly in the context of Trump’s MFN push.

Reuters also reported Bristol Myers Squibb planned to launch Cobenfy in the UK at a similar list price to the US, and signalled it may reconsider if NICE and the NHS do not recognise the value.

So yes, the UK is already feeling MFN gravity.

Why small companies take the biggest hit

This is where the Euractiv angle really matters, and it aligns with what EUCOPE has been saying publicly.

EUCOPE represents small and mid sized innovative biopharma companies, and it has been warning that MFN and tariffs could influence launch strategy and investment decisions.

In a post summarising an interview with EUCOPE’s Secretary General, Alexander Natz, the point is blunt: smaller companies are now under pressure to do what bigger manufacturers have done with MFN-style deals, and they are already working on this intensively.

Here is why the “outsized impact” is real.

1. One product portfolio has no shock absorber

If you have one key product, your global price is your company valuation.

EUCOPE’s study shows its membership includes early-stage innovators with very small portfolios, and a meaningful share of companies without centrally approved products yet; this is not a world of diversified revenue streams.  If MFN turns low ex-US pricing into a direct hit to US revenue, a one-asset biotech has far less flexibility than a big pharma with 20 brands and multiple therapeutic areas.

2. Big portfolios can trade, small portfolios cannot

A large company can make trade-offs across a portfolio, indications, and contracting structures.

The MFN agreements pattern described in legal analysis is effectively portfolio-based. One summary notes agreements may involve giving state Medicaid programs access to agreed prices across portfolios, and guaranteeing MFN-style pricing for newly launched innovative medicines.

If you are a small company with one product, you do not have “portfolio give” to unlock “portfolio get”.

3. The “offset with US investment” card is not available to small biotech

Some MFN-related agreements have been tied to major US manufacturing or investment commitments, numbers that are simply not credible for most small and mid-caps.

If the informal deal space becomes lower prices plus US investment plus tariff relief, small companies are structurally disadvantaged before they even walk into the room.

4. Net price exposure is existential for small companies

One of the most toxic aspects of MFN for Europe and the UK is not the list price, but the fear that confidential net prices leak into the MFN calculation.

Cornell’s health policy analysis notes a key concern: feasibility, gaming, and uncertainty in how MFN is defined and operationalised, including approaches that reference manufacturer-reported net prices.  Natz has also flagged how sanctions and disclosure pressure could force net price visibility, and that would change how European discounts are structured, even pushing new contracting approaches.

Small companies do not have the same contracting infrastructure, legal bench strength, and data plumbing to build MFN resilient arrangements fast, especially across multiple markets.

5. The rational response is to delay, and the evidence is already pointing there

The most obvious defence against MFN is protecting the US price anchor by delaying lower-priced launches.

EUCOPE’s study explicitly models this risk; if MFN links US prices to the lowest prices abroad, it can force companies into a choice between US revenues and launching in Europe, leading to delayed or withdrawn launches. The survey results show large majorities considering delay or withdrawal in response.  Le Monde reported similar concerns, including expectations of “US first, Europe later” sequencing and warnings that companies may delay or avoid launches in EU member states as spillover effects of MFN.  Reuters also captured this dynamic in analysis, including investor views that Europe could see longer delays depending on how MFN plays out.

Translate that to a small biotech board meeting, and the logic becomes brutal.

If launching in the UK creates any risk of pulling down the US net price, you do not “solve” that with clever comms.

You solve it by not launching in the UK yet.

What this means for UK launch planning for small companies

I think we are heading into a world where, for many small and mid-sized companies, the UK becomes one of three things.

A later market, after the US price is established, and after the MFN rules of the road are clearer.

A higher list price market with heavier reliance on confidential mechanisms, outcomes-based agreements, and carefully structured discounts, because visible low list prices are now globally dangerous.

A partner market, where you license, co-promote, or outsource market access capability to a player with the infrastructure to handle MFN risk, and the stamina to negotiate.

None of those outcomes are great if your goal is fast UK patient access to the next wave of innovation.

But they are very understandable if you are running a small company and your survival depends on US pricing integrity.

Or, could a form of outcome guarantee mechanism provide the solution? It’s effectively a discount without legally being a discount. It relies on guaranteeing and putting a value on the benefit, and it de-risks market entry. What are your thoughts?

If you are in a small or mid-sized biotech, or you advise them, how is MFN changing your UK launch sequencing, your NICE strategy, and your appetite for early discounting?

Are you going US first, UK later, or are you trying to build an MFN-proof UK approach from day one?