When talks failed, the president sent a letter to 17 of the largest medicine makers in the summer, accusing them of “abusive drug price practices.” He said the federal government would get involved in pricing if the manufacturers didn’t step up.

By the end of the year, the administration had agreements with more than a dozen drugmakers, though the terms of the deals were not released.

“This represents the greatest victory for patient affordability in the history of American healthcare, by far,” he said at an Oval Office event at the time.

But a closer look shows the major manufacturers are lowering prices on drugs already off patent or nearing the end of exclusivity.

One of the best examples of this is AbbVie’s “voluntary agreement” with the Trump administration to provide low prices for Humira, an anti-inflammatory drug. Formerly the top-selling pharmaceutical in the world, Humira accounted for 39% of North Chicago-based AbbVie’s revenue in 2022.

After its patent expired in 2023, Humira sales dropped 30.8%. This was even though doctors were hesitant to switch patients to generics, according to an analysis by market research firm Spherix Global Insights.

One reason was due to the lack of data for the biosimilar generic compared to the brand name. Last year, sales plummeted after CVS Caremark switched from Humira to a generic drug priced 80% cheaper.

The agreement with the Trump administration included a $100 billion commitment to U.S. research and development and capital investments. It also exempts AbbVie from tariffs and future price mandates for three years.   

Another beneficiary of Trump’s MFN policy is Pfizer. The pharmaceutical giant agreed to provide three drugs free to Medicaid patients: Eliquis, an anti-blood-clotting medication; Toviaz, a bladder spasm treatment; and Xeljanz, an arthritis pill.

A generic for Toviaz was released in 2022, and off-brand formulas for Xeljanz and Eliquis are expected in the next couple of years.

While Pfizer saw its revenue for Eliquis increase from 2023 to 2024, the last year financials were made available, Toviaz and Xeljanz haven’t been so lucky. The former is not listed among the company’s top 10 medicines, while the latter saw a $500 million revenue drop from 2023 to 2024.

Although the full terms of the deal with the Trump administration have not been released, Pfizer has received a three-year exemption from tariffs.

One advantage large firms have is their ability to secure access to policymakers, including the White House, as the much-publicized round of deal-cutting has demonstrated. This allows them the chance to negotiate exemptions on drugs with closing exclusivity windows.

Market analysts said they were not surprised that larger companies could navigate the regulatory waters better than smaller ones.

“If MFN leads to uniform pricing/margin compression, firms with diversified portfolios and global operations may be better able to adapt than smaller companies reliant on only a few products,” said Anthony Lo Sasso, a professor in the La Follette School of Public Affairs at the University of Wisconsin-Madison, in an interview. “Policymakers need to consider whether MFN could inadvertently increase concentration even as it attempts to reduce prices.”

Scholars at two Washington, D.C., Trump-aligned think tanks who were given anonymity to speak candidly conceded Lo Sasso’s point that MFN risks making Big Pharma even bigger.  

Some Republican consultants say that the potential for more market power to become concentrated in the hands of a select few, already powerful players, could ultimately become a liability within the administration, too. Vice President JD Vance is a noted antitrust hawk, while numerous other figures currently serving in the federal government are highly skeptical of Big Pharma. That introduces a potential political risk ahead of a likely 2028 Vance presidential run, and threatens the likelihood that Trump’s winning 2024 coalition will hold.

The dynamic of MFN proving navigable for Big Pharma but not for smaller competitors is already being felt across the biotech sector.

Small and medium-sized firms have said the access plus patent-gaming formula that has worked so well for the biggest companies constitutes an avenue simply unavailable to them.

The Midsized Biotech Alliance of America said its goal is to make sure there are policies in place that defend affordability, competitiveness, and long-term investment. Calling the alliance the driving force of American biotechnology, a spokesperson warned that the industry could see progress halted.

Center-right policy groups have also raised concerns about MFN’s impact on competition.

A coalition of more than 50 center-right organizations issued a similar warning about market concentration. The groups, including Americans for Tax Reform, sent a letter to Congress arguing the MFN policy would suppress innovation and reduce U.S. global competitiveness.

The groups worried that any sort of MFN policy would cause European countries to retaliate and either revoke patents or give them to other companies. That could hit smaller companies, which wouldn’t be able to negotiate with Europe.

Instead, they said lawmakers should focus on free-market reforms, along with encouraging innovation and competition, to help lower drug costs over time.

Democrats expressed concerns of their own, though it bears noting that MFN originated as a Democratic policy and congressional Democrats have shown more enthusiasm than Republicans for codifying it.

In a letter sent to the president, Sen. Ron Wyden (D-OR) and Reps. Frank Pallone Jr. (D-NJ), Bobby Scott (D-VA), and Richard Neal (D-MA) demanded the White House release “complete and unredacted copies” of the MFN deals.

“If you truly believe that the deals you struck are in the best interest of the American people and should be codified by Congress, you will promptly provide them to Congress without limitation or redaction,” wrote the quartet. “Then, and only then, can there be any discussion or debate about whether they accomplish the goal that Democrats have long championed of lowering prescription drug prices for Americans.”

What concerned them was Trump’s claims that drug prices would be slashed up to 1,500%. Critics have called this math fiction and suggested such levels would mean drug companies would be paying customers.

The lack of transparency surrounding the agreements has also introduced uncertainty into how MFN will ultimately be implemented, a dynamic that analysts say tends to favor larger firms with the resources and access to navigate shifting regulatory conditions.

The White House hasn’t said if it will make the details public, although it is sharing it with drug companies. Stat News reported the administration drafted MFN drug pricing legislative text which is similar to the voluntary deals reached with other companies.

Lawmakers have not said if they’ve seen the bill’s text.

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There is concern a drug company could come out and express support for codifying MFN. Even though companies aren’t interested in MFN, reports have suggested that opposition could wane if a major player decides to back the proposal.

MFN may reduce drug prices in the short term, but uniform pricing pressure could make it harder for smaller, research-dependent firms to survive and strengthen the position of already dominant companies.

Taylor Millard is a freelance journalist who lives in Virginia. Follow him on X @TaylorMillard.