Even Brown agrees that it’s unlikely pharma companies would specifically target rural regions for cuts.

“Manufacturers are unlikely to single out rural regions for cuts, but tighter margins that result from Trump’s Most Favoured Nation policy would intensify the structural pressures already shrinking rural drug access,” he said. “Beyond access to specific drugs, patients in rural areas suffer most because the pharmacy infrastructure is already in crisis, with a significant number of US pharmacies closing over the last decade.”

But Basey argues that it’s high drug prices that have put the strain on rural and community pharmacies, as well as uncompetitive pricing practices that favour larger chains. Lowering prices across the board could actually help these pharmacies be more competitive.

And, of course, the age-old argument: that pharma will offset tighter margins by reducing innovation. This was the core argument of a paper recently published by University of Chicago researchers, who calculated that MFN pricing would reduce global R&D spending by 48%, resulting in the loss of 21 new drugs per year.

But there too, there’s reason to doubt. A study this year from Bentley University showed that R&D spending has actually increased since the passage of the Inflation Reduction Act.

For one thing, it’s no longer mandating that the US pay the lowest price for drugs, but instead that it match the average net price among the United Kingdom, France, Germany, Italy, Canada, Japan, Denmark, and Switzerland.

This change was driven by a sensitivity to the potential effects on innovation, according to Director of Medicare and Deputy Administrator of CMS Chris Klomp.

“Now, the President could have directed us to go to the poorest country on the planet and find the cheapest price for every single drug and bring that back to the United States and use the might of the government to insist that that's the price we pay,” he said at a White House event announcing the first MFN deal with Pfizer. “That might have worked, actually, for just a little bit. But very quickly, it would have utterly destroyed innovation in pharmaceuticals.”

By rooting the pricing in the principle of fairness, Klomp continued, “It allowed us to do what has not been done before, which is to call on manufacturers and ask them to be fair. It allows us to go to countries and ask them to pay their fair share in the battle against global disease. That is the unlock for this great deal.”

But there are hiccups. In many cases, this average net price might not actually be lower than what Medicaid already pays. In a piece by STAT, research firm Capstone argued that MFN pricing could actually be beneficial to drugmakers in those markets by helping them avoid 340B exposure.

The other new piece to MFN in its current incarnation is the direct-to-patient platform TrumpRX, and the promise that MFN prices will be available there as well as via Medicare and Medicaid. This could also potentially offset the risk to rural communities.

And TrumpRx is similarly nebulous at the moment.

“Well, we have a website [that] I think says coming January 2026,” Alice Valder Curran, a partner at Hogan Lovells, said on a recent pharmaphorum podcast. “But how it's going to work, whether it's going to have its own links to direct to patient options, whether it instead is just going to take patients to manufacturers or some other third parties, is hard to know.”

It will likely be a while before we know the true impact of the policy. But, Brown points out, it’s worth noting that MFN doesn’t exist in a vacuum, and the Trump Administration has already made a lot of damaging policy decisions for rural healthcare.

“For example, NIH funding cuts result in funding gaps for research and termination of clinical trials, limiting physician specialists who administer and order specialty drugs,” he said. “Medicaid cuts under the ‘One Big Beautiful Bill’ are expected to lead to more uninsured (which would mean those individuals would find little benefit from Medicare/Medicaid drug price controls). His tariff threats and confusion could limit investment in pharmaceutical and medical device innovation and worsen supply chains. And finally, the general chaos at the FDA has reduced predictability in innovators' commercialisation plans. All said, Trump's healthcare policies are likely to be harmful to patients in the US.”