CAGW Files Comments With the Center for Medicare and Medicaid Services on GLOBE and GUARD Models

BEFORE THE

Department of Health and Human Services

Centers for Medicare & Medicaid Services

In the Matter of

Global Benchmark for Efficient Drug Pricing (GLOBE) Model

and

Guarding U.S. Medicare Against Rising Drug Costs (GUARD) Model

Comments of

Thomas A. Schatz

President

Citizens Against Government Waste

February 20, 2026

Citizens Against Government Waste (CAGW) is a private, nonprofit, nonpartisan organization dedicated to educating the American public about waste, fraud, abuse, mismanagement, and inefficiency in government.  On behalf of CAGW’s more than one million members and supporters nationwide, I am writing to express our strong opposition to the “Most Favored Nation” models proposed by the Center for Medicare and Medicare Innovation (CMMI) under the Centers for Medicare and Medicaid Services (CMS), identified as the Global Benchmark for Efficient Drug Pricing (GLOBE) model in Medicare part B and the Guarding U.S. Medicare Against Rising Drug Costs (GUARD) model in Medicare Part D.

We urge the agency to immediately suspend and permanently withdraw these misguided proposals.

CAGW raised strong concerns in 2020 when CMS advanced a similar proposal to link drug prices paid in Medicare to those set in other developed nations.[i] Experience since then only serves to reinforce our opposition to the resurrection of this idea in the current proposals. CAGW opposes the GLOBE and GUARD models for the following reasons:

GLOBE and GUARD Advance Socialized Medicine and Government Intrusion in Healthcare Instead of Empowering Patients and Strengthening Competition and Choice.

Both GLOBE and GUARD seek to implement so-called “Most Favored Nation” (MFN) price controls that tie U.S. drug prices to those set by foreign governments. Government health authorities in the countries referenced in GLOBE and GUARD oversee healthcare systems built on rationing, delayed access, and limited treatment options. Importing their price-setting mechanisms into Medicare would move the United States toward the same outcomes of more government intrusion and less patient access.

Through GLOBE and GUARD, CMS is opening the door to government-run healthcare based on socialized models. In his 2020 State of the Union address, President Trump promised his administration “will never let socialism destroy American healthcare.”[ii] We urge CMS to remain true to this commitment by recognizing the danger of importing price controls from nations with socialized healthcare systems and withdrawing these misguided proposals.

Government price-regulation schemes, no matter how well-intended, inevitably end up costing more than they save and creating significant unintended consequences for consumers. For example, in Japan, price controls “work to the disadvantage of consumers … many of the most effective drug therapies for cancer, heart disease, and other conditions are simply unavailable.”[iii]

Unlike the government-run schemes in other countries, the U.S. relies on empowered patients and consumers and market competition. This system does a far better job at giving patients a choice of treatment options, while at the same time holding down overall treatment costs. An August 2025 analysis of international and U.S. prices found that when comparing prices across medicines’ competitive life cycle (in which prices fall due to competition from other brand medicines and then generics) drug prices in the U.S. are 18 percent lower on average than those among our peer countries.[iv] The fact is, the U.S.’s market-based, competitive structure works well in giving consumers an informed choice, driving fast adoption and lowering prices for generic medicines.

GLOBE and GUARD Represent a Fundamental Abuse of CMMI’s Statutory Authority.

The GLOBE and GUARD proposals represent a profound expansion of federal power over healthcare policy through an agency that was never intended to serve as a substitute for Congress. CMMI was created under the Affordable Care Act to test limited, targeted demonstrations that might improve care or reduce costs. Instead, it has evolved into an unaccountable policymaking body capable of imposing sweeping, mandatory national policies affecting millions of Americans without a single vote in Congress.

These proposals would continue and accelerate this mission drift. The price controls and other policies embedded in GLOBE and GUARD will negatively impact patients, seniors, caregivers, providers, innovators, and taxpayers across the country. They will reduce access to medicines, slow the pace of medical advancement, and undermine the long-term financial structure of Medicare.

Importantly, these models are not narrowly targeted pilots. They are mandatory, coercive, and expansive. Patients and providers would be swept into government experiments with no meaningful ability to opt out, disrupting established care relationships and personal treatment decisions.

Decisions of this scope and consequence should not be made by unelected officials operating through administrative demonstrations. Prerogatives over the nation’s healthcare policy belong to Congress. Lawmakers can debate tradeoffs openly, consider unintended consequences, and be held accountable by voters. CMMI’s ability to impose sweeping changes by administrative fiat, especially by mandating a destructive policy like MFN, creates instability and uncertainty for patients and providers alike.

GLOBE and GUARD Threaten Continued Medical Innovation as the Engine for Better, More Affordable Healthcare in the U.S.

Price controls do not eliminate costs; they shift them. By undermining the market incentives that drive medical research and development, MFN policies threaten future innovation and reduce the availability of new treatments, particularly for patients with serious and chronic conditions. Developing new medicines requires years of research and billions of dollars in private investment, with no guarantee of success.[v] Government price-setting erodes the foundation that makes such innovation possible.[vi]

Government price-setting is penny wise and pound foolish, trading away ephemeral short-term price cuts for the long-term improvements in patient health and healthcare spending that can be achieved by continued medical progress and healthcare innovation.

In response to President Trump’s September 11, 2020, Executive Order (EO) on importing price controls from foreign countries, CAGW stated, “Adopting foreign price controls from ‘most favored nations’ (MFN) for drugs sold in the United States will be an unmitigated disaster.  As CAGW said along with 79 signatories to an August 11, 2020, coalition letter expressing ‘grave concerns’ with the MFN Executive Order, ‘price controls will slow medical innovation, threaten American jobs, and undermine criticism of single-payer systems.’  The letter reminded President Trump of his pledge to ‘never let Socialism destroy American health care,’ yet this is the direction in which the EO will take the country.”[vii]

CMMI Should Not Be Allowed to Build on its Track Record of Failed Proposals and Wasteful Spending.  

If CMMI had demonstrated success over the past 15 years, there might be a stronger case for reforming and entrusting it with a mandate for testing and identifying ways to improve healthcare. The record shows the opposite.

The gap between the Congressional Budget Office (CBO)’s original estimates for savings through CMMI and the costs that CMMI have instead incurred are significant but unfortunately not surprising. In 2010, CBO estimated CMMI would save taxpayers $2.8 billion between 2011-2020.[viii]

Instead, CMMI lost $5.4 billion, and CBO estimated it would lose another $1.3 billion by 2030 based on optimistic assumptions of unproven improvements in its models while still receiving $10 billion per decade in mandatory taxpayer funding.[ix] A June 2021 analysis of 174 CMMI models showed “only four models have met the statutory criteria of lower spending or improved quality and been expanded—or introduced—to the Medicare program nationwide.”[x]

Adopting the tools of socialized medicine is no antidote to the federal government’s well-documented inability to innovate. GLOBE and GUARD exacerbate these failures by vastly expanding the reach of a program that has not proven it can improve care, save money, or operate with adequate transparency or accountability.[xi]

Further, we are concerned that the misuse of federal power under CMMI will serve to reinforce current distrust of public healthcare institutions rather than restoring the trust that has been lost over the past decade. Broad, mandatory policy changes like GLOBE and GUARD fail to maximize quality improvement, prevention, patient empowerment, and public transparency. Public agencies that are unaccountable are ipso facto wasteful, and CMMI is no exception.

The Path Forward: Restore Accountability and Stop the Overreach

CAGW urges CMS to suspend and withdraw the GLOBE and GUARD proposals. After 15 years of failure, CMMI has not earned the authority it continues to claim. GLOBE and GUARD would import government price controls and exemplify why CMMI must be reined in before further harm is done.

 

[i] Elizabeth Wright, “Most Favored Nation Policy: Unfavorable to U.S. Pharmaceutical Research,” Citizens Against Government Waste (CAGW), September 19, 2020, https://www.cagw.org/most-favored-nation-policy-unfavorable-to-u-s-pharmaceutical-research/.

[ii] The White House, Remarks by President Trump in State of the Union Address, February 4, 2020, https://trumpwhitehouse.archives.gov/briefings-statements/remarks-president-trump-state-union-address-3/.

[iii] John E. Calfee, “The Unintended Consequences of Price Controls,” American Enterprise Institute, January 2, 2001, https://www.aei.org/articles/the-unintended-consequences-of-price-controls/.

[iv] Tomas J. Philipson, Deyu Zhang, and Qi Zhao, “ International Comparison for Drug Prescription Prices,” Unleash Prosperity, August 2025, https://committeetounleashprosperity.com/wp-content/uploads/2025/09/044_UP_Drug-Prescription-Prices.pdf.

[v] Congressional Budget Office (CBO), “Research and Development in the Pharmaceutical Industry,” April 2021, https://www.cbo.gov/publication/57126.

[vi] Joseph H. Golec and John A. Vernon, “European Pharmaceutical Price Regulation, Firm Profitability, and R&D Spending,” National Bureau of Economic Research, November 2006, https://www.nber.org/papers/w12676.

[vii] CAGW, “Citizens Against Government Waste Opposes Using Foreign Price Controls on U.S. Pharmaceuticals,” September 11, 2020, https://www.cagw.org/press/citizens-against-government-waste-opposes-using-foreign-price-controls-on-u-s-pharmaceuticals/.

[viii] CBO, Estimate of the direct spending and revenue effects of an amendment in the nature of a substitute to H.R. 4872, the Reconciliation Act of 2010, March 20, 2010, https://www.cbo.gov/sites/default/files/111th-congress-2009-2010/costestimate/amendreconprop.pdf.

[ix] CBO, “Federal Budgetary Effects of the Activities of the Center for Medicare & Medicaid Innovation, September 2023, https://www.cbo.gov/publication/59612.

[x] Jennifer Podulka and Yamini Narayan, “Center for Medicare and Medicaid Innovation: Findings from Medicare Models to Date,” Health Management Associates, Issue Brief #1, June 2021, https://www.healthmanagement.com/wp-content/uploads/HMA-AV-Issue-Brief-1-CMMI-findings.pdf.