Politico: Why Trump might cut a drug pricing deal with Democrats

President Donald Trump is already signaling one area where he might reach across the aisle if Democrats take the House.

"If there is anything bipartisan, it's lowering drug prices," Trump said last Wednesday as he signed two drug price transparency bills.

Fresh off a bitter Supreme Court fight and a bruising campaign season, 2019 may not scream the year of big bipartisan compromises. But the drug price issue has broad populist appeal, motivating Republican and Democratic loyalists, as well as swing voters. It also appeals to male voters as few health care issues do, making it particularly attractive to Republicans, said Celinda Lake, a Democratic pollster.

"If you wanted to pick the No. 1 issue that united the Trump voters and Bernie [Sanders] voters," drug pricing would be it, Lake said.

That engagement by voters across the political spectrum is only expected to intensify as new cancer treatments priced at $500,000 a pop come on the market and consumers face ever-higher deductibles before their insurance coverage kicks in.

Which doesn't mean politicians are close on a breakthrough. Almost no health policy expert believes an agreement to allow the government to negotiate Medicare drug prices is possible next year — despite Trump's endorsement of the idea on the campaign trail and House Democrats' championing such negotiations as part of their "A Better Deal" agenda.

Far more likely to win bipartisan support are incremental reforms that require drugmakers to disclose their list prices in advertisements, or force greater transparency around their relationships with pharmacy benefit managers to ensure the companies aren't colluding to keep prices high, said Tara O'Neill Hayes, deputy director of health care policy at the center-right think tank American Action Forum.

Other proposals that could win cross-aisle support would increase Medicaid penalties on companies that raise their list prices above the inflation rate, and prevent brand drug companies from abusing FDA safety programs to block cheaper competition.

Still, Trump remains something of a wild card. His campaign dalliance with more controversial proposals usually identified with progressive Democrats, such as permitting the import of cheaper overseas drugs and government price negotiations, ended with his election. But he has shown a willingness to put the squeeze on allies, including his own advisers, when it suits his purposes.

"For some of the Republicans who work at HHS and people in Congress, their concern is doing a deal with the Democrats [that] might split the Republican Party," said James Capretta, a health policy fellow at the conservative-leaning free-market think tank American Enterprise Institute. "But for Trump, that might be worth it to get some deal on the table and get points on something he campaigned heavily on in 2016."

Poll results could also spur Trump to shift away from more traditional Republican approaches to return to his campaign pledges. A September POLITICO/Harvard poll found a majority of likely voters — and more than a quarter of Republicans — think Trump's much-touted blueprint to lower prices, which relies mostly on modest steps or policies it says still need further study, will have no effect on drug costs.

An August NORC University of Chicago/West Health Institute poll found that less than half of Republicans approve of Trump's handling of drug costs. Yet that same NORC poll found more than 82 percent of Americans support government drug price negotiations.

Either way, House Democrats hope the president's engagement on drug pricing will give cover to at least some Senate Republicans to oppose the powerful pharmaceutical lobby, even if it's on smaller reforms like banning a practice called pay for delay, where brand drug companies pay generic drugmakers to keep cheaper copycats out of patients' hands.

"I think you can see a dynamic where you have a Republican president, a Democratic House and a very split Senate with some Republicans wanting to show they are willing to take on PhRMA actually lead to some sort of progress in an area that is always extremely difficult to make progress," said Chris Jennings, who advised Hillary Clinton on health policy,

Trump being on board "creates a dynamic where it's hard for [Republicans] to say no," Jennings said.

Rep. Lloyd Doggett, a Texas Democrat who has garnered 100 co-sponsors on his drug price negotiations bill, said he is optimistic the president will work across the aisle.

"This is a very good area for him to work on because he was so strong in what he said," Doggett said.

Factors that will determine just how much gets done include how many new members, both Democratic and Republican, make it into the House. "PhRMA is very, very powerful and PhRMA has ties to Democrats and the Republicans. ... If you are an incumbent, you are often bought off on the issue." Lake said.

Who controls key committees will also play a role: Sen. Chuck Grassley is first in line to lead the Senate Finance Committee, replacing retiring Sen. Orrin Hatch, if the Iowa Republican agrees to give up the Judiciary Committee. This would give Grassley, one of the few Republicans willing to take on PhRMA, leadership of the Senate committee that handles Medicare and Medicaid policy. It would be a big departure from Hatch, one of the drug industry's biggest allies. Grassley has long sponsored pay-for-delay legislation and other bills that crack down on anti-competitive practices in the drug industry.

On the House side, the leaders chosen for Energy and Commerce will determine how hard Democrats go against the drug industry. New Jersey Democrat Frank Pallone would likely control the full committee under a Democratic majority and is interested in working on drug pricing. California's Anna Eshoo, who represents the industry-heavy Silicon Valley region, could likely helm the committee's health work. Eshoo, who has taken more in lifetime contributions from the pharmaceutical and health products industry than any other sitting House member, could block some of the progressive Democrats' agenda. She did not respond to a request for comment for this story.

But any bipartisan compromise likely has to happen quickly, experts caution. The closer it gets to 2020, the more Democrats may be more inclined "to hold the issue," rather than give the president something he can take credit for to voters, AEI's Capretta said.

Another stumbling block may be lawmakers' unwillingness to stick their necks out for reforms unlikely to be felt by most consumers. The FTC estimates the drug industry's pay-for-delay practices cost the U.S. about $3.5 billion annually, for instance — just a fraction of the $450 billion the country spent on drugs in 2017.

"A lot of people won't feel that." said Steven Knievel, director of the Access to Medicines program at the left-leaning Public Citizen.

This could make it trickier for lawmakers worried about upsetting the powerful drug lobby to cast their votes.

"It would be a kind of crazy approach for someone to say, ‘I'm going to take a controversial vote on something and it won't have a serious impact,'" said Ezekiel Emanuel, a health policy professor at the University of Pennsylvania and a former top adviser to President Barack Obama.

Emanuel thinks voter frustration over drug pricing will have to get worse before lawmakers are willing to take hard votes against an industry with so much clout.

"I think we are going to need some more time, more anger … probably a few more scandals," he said.

One tipping point could be a drug priced at over $1 million. If that happens, he said, "then you've broken a barrier."