OBJECTIVES To look at the affordability of orphan medications across Europe and whether payer attitudes to high-price medications are changing in the face of rising healthcare expenditure and tighter budgets.  METHODS We conducted an online semi-quantitative survey of 10 European markets and the USA to understand how payers views and attitudes are changing in response to new treatments coming to market for rare and ultra-rare conditions. The payers selected for the survey hold or have held senior positions within their respective market institutions.  The USA was included to provide international context to the European results.  RESULTS