White House advisers, scrambling to create a health-care agenda for President Trump to promote on the campaign trail, are meeting at least daily with the aim of rolling out a measure every two to three weeks until the 2020 election.
One of the initiatives would allow states to import lower-priced drugs from Canada and other countries and another would bar Medicare from paying more than any other country for prescription drugs, according to two senior administration officials and lobbyists — controversial ideas in line with Democratic proposals. Yet it remains unclear whether the administration has the legal authority to execute some of these policies without Congress’s approval.
The White House is already facing fierce pushback on some proposals from Republicans on Capitol Hill and the pharmaceutical industry, which will probably go to court to challenge any measure it opposes.
The furious push reflects the administration’s sense of vulnerability on an issue that Democrats successfully used in 2018 to win control of the House of Representatives. White House officials are eager to inoculate the president against a repeat of that strategy in 2020 — and reduce the GOP disadvantage on an issue that pollsters say plays to Democratic strengths. Health care is already playing a starring role in the Democratic presidential debates, with most of the candidates making proposals, including Medicare-for-all plans, key to their campaigns.
“While the radical left has sweeping proposals for a total government takeover of the health system that will hurt seniors and eliminate private insurance for 180 million Americans, the Trump administration is working on real solutions that will provide Americans with the options and control they want and the affordability they need,” White House spokesman Judd Deere said in a statement.
Some doubt a flurry of executive orders and new regulations would have any immediate effect on consumers’ pocketbooks. What is clear is that the approach, which includes White House support for a bipartisan Senate bill to cap Medicare drug price increases, is putting congressional Republicans in a tough spot: Embrace Trump’s agenda and abandon conservative precepts about interference in the marketplace, or buck the president on one of his top priorities.
While Republicans have largely fallen in line with Trump on free trade and immigration even when he has blown up GOP orthodoxy, many rely heavily on donations from the pharmaceutical industry and are reluctant to sour those relationships.
One lobbyist, who spoke on the condition of anonymity, described being stunned at a recent White House meeting when Domestic Policy Council Director Joe Grogan said the administration would not let Democrats run to the president’s left on lowering prescription medicine prices.
In another tense meeting, top pharmaceutical executives were told bluntly “it wasn’t in the industry’s best interests” to block the bipartisan Senate bill backed by Trump. If it failed, they were told, they’d see “the president of the United States negotiating with Nancy Pelosi [on allowing the government to negotiate drug prices in Medicare],” said a person familiar with the meeting.
On Wednesday, as if on cue after the first of two Democratic debates in Detroit, Health and Human Services Secretary Alex Azar held a call with reporters, outlining steps that might eventually lead to the importation of some lower-cost drugs from Canada — an idea supported by Trump but opposed by many Republicans.
Those drugs could potentially include insulin — whose price rose about 300 percent from 2002 to 2013 — as well as drugs for rheumatoid arthritis, cancer and cardiovascular conditions.
“For the first time in HHS’s history, we are open to importation,” Azar said. “There is a pathway. We can be convinced.”
The plan would allow state governments, pharmacies and drug manufacturers to submit importation proposals for federal approval. However, Food and Drug Administration experts said it could take two to three years for the administration to issue a final rule. While some rules may be done faster, this one will probably be especially complicated — and the administration is months from formally proposing it.
Drug industry groups panned the idea, as did the Canadian government, which warned of shortages for its 37 million residents if the United States imports its medicines on a large scale.
White House officials are also weighing an Obamacare replacement that Congress would take up after the election, a Medicare plan to contrast with Democratic Medicare-for-all proposals, help for beleaguered rural hospitals and steps to reduce maternal death rates, according to two senior administration officials.
The health-care effort is being driven by Grogan, acting chief of staff Mick Mulvaney and the Office of Management and Budget’s acting director, Russell T. Vought. Other participants in the sometimes contentious daily meetings include Azar, the president’s son-in-law and senior adviser Jared Kushner, White House counselor Kellyanne Conway and representatives from the vice president’s office.
One senior administration official, who spoke on the condition of anonymity to discuss internal deliberations, said the White House thinks it has “tremendous authority” to write executive orders under food, drug and cosmetics laws, as well as through the Affordable Care Act, which gives the government broad power to test ways to improve health care and reduce costs in government programs.
“We think the [ACA] authority is pretty tremendous,” the official said. The administration is arguing in federal court to overturn the law, however, with a decision expected in late summer or fall.
But many health policy and legal experts disagree and are also skeptical that the steps the administration is talking about would have a tangible effect on consumers before the election.
“It’s unlikely the administration is going to be able to use an executive order that Americans are going to be able to notice before the election,” said Benedic Ippolito, a health economist at the American Enterprise Institute. “It’s an incredibly ambitious timeline.”
Others see court challenges as inevitable, noting that the drug industry has been willing to sue the administration over policies it opposes; it recently won a lower court victory against an HHS regulation that would have required drugmakers to include the list prices of their medications in television ads.
“I’m not sure they can get anything done and survive a court challenge before the election,” said Chris Meekins, a former HHS official who is now a health-care policy research analyst at Raymond James, a financial services firm.
The White House is also attempting to build support for the Senate bill written by Finance Committee Chairman Charles E. Grassley (R-Iowa) and the panel’s ranking Democrat, Sen. Ron Wyden of Oregon, that for the first time would require drugmakers to pay back the federal government if they raised the prices of medications in the Medicare program in excess of the rate of inflation. It would also limit out-of-pocket costs for beneficiaries.
The pharmaceutical industry opposes the bill, and some Republicans have derided the legislation as tantamount to negotiating drug prices or imposing “price controls” — a line in the sand for many who oppose what they see as government interference in the market. Senate Majority Leader Mitch McConnell (R-Ky.) has not said whether he will bring a drug-pricing legislative package up for a vote, but he is generally opposed to voting on health-care legislation ahead of the election.
Against the advice of many congressional Republicans, White House advisers are also working to craft an Obamacare replacement plan that Trump could campaign on, especially if the U.S. Court of Appeals for the 5th Circuit should declare the law unconstitutional this fall and catapult the issue to the forefront of the 2020 races.
Some GOP lawmakers and strategists worry about rolling out a plan that has no chance of passage in the current Congress and that Democrats could pick to pieces during a long campaign. Many also have little appetite to return to the debate over repealing Obamacare.
Nonetheless, the White House is considering a plan, put together by conservative think tanks, that would eliminate the ACA’s subsidies for low-income consumers and replace the open-ended federal commitment to Medicaid with a lump-sum payment for each state in the form of a block grant, according to a copy posted online. The proposal largely follows the outlines of a 2017 Republican bill, which the Senate never voted on because it did not garner enough support.
“We don’t have a lot of buy-in on the Hill,” acknowledged the senior administration official, “but we’re figuring it out.”
Some of the other health-care proposals under review also appear largely aspirational, for instance, a draft executive order that instructs agencies to speed development of a universal flu vaccine, first reported by Politico, but that proposes no new funding. Other efforts, such as the initiatives to reduce HIV infections and end-stage kidney disease, and double the number of transplants, contain new funding and have been widely heralded.
“Every chance we have to set or tweak a rule we are doing it,” said the senior official. “This administration has been more creative and accomplished more when it comes to health care and health than anybody has given us credit for.”
Laurie McGinley contributed to this report.