Your question about whether international pricing models like reference pricing could inform U.S. Medicare negotiations is especially timely. Reference pricingwhere a payer sets a reimbursement level based on prices in other countrieshas been widely used in Europe to keep costs down. Strong pharmaceutical lobbying and an emphasis on innovation motivated by market forces have shaped the long-standing opposition of the United States to this paradigm. Still, given the size of the Medicare program and the passing of the Inflation Reduction Act, the mechanics of this conversation are changing. One policy alternative already being explored is international reference pricing through the "Most Favored Nation" model, which was introduced (though not implemented) under the Trump administration. The idea was to peg U.S. drug prices to those paid by other high-income countries. Adopted in some form, this might improve Medicare's negotiating strength and provide downward pressure on pricing (Feldstein & Melnick, 2023). Still, the way the American pharmaceutical market is set up presents a difficulty. Unlike many European nations with centralized buying programs, the American system is still fractured. For reference pricing to work here, we'd likely need more centralized negotiation, perhaps through Medicare Part D or a public option that sets national price benchmarks