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 the administration has the legal authority to execute some of these policies without Congress.
The White House is already facing fierce pushback on some proposals from Republicans on Capitol Hill and the pharmaceutical industry, which will likely 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. Most of the Democratic presidential candidates have made health-care proposals, including Medicare-for-all plans, key to their campaigns. Health care is already playing a starring role in the debates and Democrats are sure to assail Trump for his attempts to eliminate coverage for millions of people by challenging the Affordable Care Act in court.
“President Trump has said we will protect people with preexisting conditions, lower drug prices, end surprise medical bills, and make sure Americans get the highest quality of care they deserve,” said White House spokesman Judd Deere. “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.”
Some, however, are doubtful a flurry of executive orders and new regulations would have an 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 to the rate of inflation, 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 the prices of prescription medicines.
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, Health and Human Services Secretary Alex Azar announced the outlines of a plan to eventually allow Americans to import certain lower-cost drugs from Canada and other countries. 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 the White House’s Domestic Policy Council Director Joe Grogan, Chief of Staff Mick Mulvaney and the White House Office of Management and Budget acting director Russ 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 believes it has “tremendous authority” to write executive orders under food, drug and cosmetic laws, as well as through the ACA, 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 currently arguing in federal court to overturn the law, however, with a decision expected late summer or fall.
But many health policy and legal experts disagree and are also skeptical 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 the drug industry has already shown a willingness to sue the administration over policies it opposes; it recently won a lower court victory against an Health and Human Servies 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 authored by Finance Committee Chairman Charles E. Grassley (R-Iowa) and ranking Democrat Sen. Ron Wyden (Ore.), 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 already 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 Fifth 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, that proposes no new funding. Other efforts, such as the initiatives to reduce HIV infections, reduce 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.”