October 29, 2026 — No Patient Left Behind (NPLB) wrote to the United States Trade Representative to prioritize addressing foreign government policies that allow wealthy countries to free-ride on American biomedical innovation.
Dear Ambassador Greer,
No Patient Left Behind (NPLB) appreciates the opportunity to submit comments for the 2027 National Trade Estimate Report on Foreign Trade Barriers (NTE Report). We urge the Office of the United States Trade Representative (USTR) to prioritize addressing foreign government policies that allow wealthy countries to free-ride on American biomedical innovation. Rather than importing foreign price controls that would undermine innovation at home, the United States should use its trade-negotiating and enforcement tools to ensure wealthy trading partners pay their fair share for medicines that benefit patients worldwide.
NPLB is a community of biotech innovators, investors, researchers, healthcare professionals, and patient advocates committed to improving patient access while preserving incentives for continued biomedical innovation. We believe that patients should be able to access the medicines of today and tomorrow.
Foreign free-riding harms American innovators and patients:
America leads the world in biomedical innovation. This leadership is made possible by a U.S. market-based system that recognizes the extraordinary value of new medicines and provides the financial incentives needed to fund the extreme risk and cost of biomedical research and development. Medicines developed under the U.S. system benefit patients in the United States and around the world. This benefit continues in perpetuity, even after prices drop drastically due to generic and biosimilar competition at patent expiration.
Other wealthy countries have long benefited from American innovation, but they have not contributed their fair share to sustaining this critical ecosystem (1). Unlike the United States, where competing insurers negotiate independently with manufacturers, many wealthy countries rely on government-controlled pricing and reimbursement systems that dictate how much they are willing to pay for new medicines. Manufacturers are then forced to choose between accepting an artificially low price or forgoing those markets entirely. The result is a global system in which American patients and taxpayers disproportionately support the financial incentives that drive biomedical research while other wealthy trading partners benefit from breakthroughs but do not adequately fund them.
Flawed foreign assessments of medicines' value compound this problem. Many foreign governments rely on outdated health technology assessments (HTAs) that fail to capture the full value medicines deliver to patients and society, including productivity gains, reduced caregiver burden, scientific spillover, and the fact that drugs go generic and fall in price, among other benefits. These flawed formulas create artificially low reimbursement rates for American products, delay patient access to life-saving treatments, and reduce incentives for future innovation.
The solution is stronger trade policy, not importing foreign price controls:
There is a right way and a wrong way to address foreign free-riding, and NPLB has written extensively on proposed solutions and the potential impacts and consequences of various approaches, summarized below:
Importing approaches foreign governments use to impose price controls, such as Most Favored Nation (MFN) and other international reference pricing policies, does not address the underlying problem. These approaches risk undermining American leadership in biomedical innovation by slowing pipelines, gutting American biotech companies, and depriving American patients still awaiting treatments of access to breakthroughs, all while failing to get foreign governments to pay more.
Instead, NPLB has consistently called for trade-centered solutions to foreign free-riding. USTR should use America's trade leverage to require wealthy trading partners to pay their fair share for biomedical innovation. This approach requires foreign governments to contribute their fair share to innovation while protecting the market-based incentives that have long fostered America's pro-innovation ecosystem and led to some of the greatest scientific breakthroughs in human history.
Specifically, NPLB urges USTR to make foreign pharmaceutical free-riding a broader trade priority, including by pursuing the following objectives with wealthy trading partners:
Eliminate non-tariff market access barriers that delay or deny patients access to innovative U.S. medicines, including unnecessarily restrictive reimbursement requirements and flawed HTA processes.
Secure fairer contributions to biomedical innovation by encouraging wealthy countries to align spending on new medicines with their economic capacity and recognize the full value those treatments deliver to patients and society.
Protect timely access to new medicines by ensuring foreign governments do not use restrictive reimbursement and pricing practices to delay adoption of innovative treatments.
Establish meaningful, enforceable trade commitments that prevent countries from undermining negotiated improvements through additional mandatory rebates, discriminatory pricing policies, or new market access restrictions.
In the past year, we have seen USTR employ similar strategies successfully with key trade partners, including in the U.S.-U.K. pharmaceutical pricing arrangement. By committing to increased spending on new medicines, improved reimbursement, and reduced rebate burdens, the United Kingdom agreement offers an encouraging example of what constructive trade engagement can achieve.
NPLB commends USTR for its work on this agreement and encourages the agency to pursue similarly meaningful commitments from Germany and other wealthy trading partners, with clear implementation and accountability measures to ensure those commitments deliver lasting results. Specifically, the Section 301 investigation initiated on June 18, 2026, into Germany's persistent underpayment for innovative pharmaceutical products provides an opportunity to examine how the country's reimbursement policies burden U.S. commerce.
The 2026 NTE Report highlighted concerns about Germany's pharmaceutical pricing and reimbursement policies, including demanding evidence requirements, low-cost comparators, and assessments that can fail to recognize innovative medicines' benefits. Importantly, low German reimbursement levels influence prices in other markets through international reference pricing, constraining opportunities for U.S. medicines beyond Germany. Further, recent legislation increasing mandatory manufacturer rebates threatens to further reduce Germany's contribution to biomedical innovation. We encourage USTR to address these barriers through its ongoing Section 301 investigation and document their impact on U.S. innovation and competitiveness in the 2027 NTE Report.
Similar scrutiny should extend to other wealthy trading partners whose policies enable foreign free-riding.
Biomedical innovation is a shared global responsibility. Americans should not have to carry a disproportionate share of this burden alone. The United States has the opportunity to strengthen its leadership in biomedical innovation by opening foreign markets, demanding fairer contributions from wealthy trading partners, and preserving the incentives that make the development of new medicines possible.
We appreciate USTR's leadership in addressing this imbalance and encourage continued efforts to ensure that all wealthy countries contribute fairly to collaboration against our one universal adversary: disease.
Sincerely,
Priscilla VanderVeer
Executive Director
No Patient Left Behind
1 As NPLB has previously highlighted to USTR, an analysis of international pharmaceutical spending suggests that wealthy countries pay approximately 30% of U.S. net prices for branded medicines, compared with a GDP-adjusted benchmark closer to 74%.