Trump Had One Good Idea. Then He Ditched It.
It wasn't all that long ago -- though it seems that way, admittedly, with the never-ending flood of Trumpian news -- that I was prepared to acknowledge that President Donald Trump actually has a few good ideas. Or at least one.
It was Tuesday morning. The new president was about to go into a meeting with chief executives from Johnson & Johnson, Merck and a handful of other major pharma companies. During his campaign, he often said that if he were elected, the federal government would start negotiating with the drug companies over the prices Medicare and Medicaid had to pay for drugs -- something it's now prevented from doing by statute. This is an issue that resonated with most Americans, the majority of whom want the government to do something about high drug prices.
Along with The Wall and the Return of Manufacturing, this appeared to be one of his core issues. And unlike some other campaign issues, it didn't fade away after the election. Pharma companies were "getting away with murder," he said on January 10, because they "had a lot of lobbyists and a lot of power."
Which is completely true. In 2003, when Congress passed the massive Part D Medicare prescription-drug benefit, Big Pharma was able to get a provision in the bill banning the Centers for Medicare and Medicaid Services from negotiating directly with drug companies to set prices, as advanced countries tend to do.
At the time, the drug-company strategy of drastically increasing drug prices was in its formative stage. For well over a decade, Big Pharma wallowed in the profits generated by multi-billion dollar blockbusters like Lipitor and Viagra.
But as blockbusters grew scarce, companies needed to find new ways to make money and keep the stock price rising. Thus began the practice of bringing cancer drugs to market with annual price tags of $100,000 or more; buying up cheap generic drugs and turning them into expensive generic drugs; paying competitors to keep their drugs off the market to maintain monopoly prices; and so on.
Inevitably, the cost of drugs started eating up an ever larger share of overall medical costs; it's now over $350 billion annually, which is about 10 percent of what the government calls the "national health expenditure." Indeed, drug sales are close to 2 percent of gross domestic product, according to a recent report by Ravi Mehrotra of MTS Health Partners.
And all the while, the Medicare-Medicaid complex, the country's largest buyer of prescription drugs and therefore the entity with the most leverage to influence prices, has been forced to sit on the sidelines and let private insurance companies negotiate prices, which the government then has to accept.
So yes, Trump's idea of allowing the government to negotiate on behalf of its beneficiaries is a good one. Although the president appears to have pulled the $300 billion in savings out of thin air, it would indeed save significant sums. Mehrotra suggests that the government could save $16 billion if Medicare Part D prices were negotiated.
There would be three other benefits: insurance companies and consumers would save money because insurers would probably use the negotiated Medicare price as their baseline. Companies would have a harder time raising prices as much as they've done during the last decade because the government would push back harder than the insurance companies do. And there'd no longer be an absurd, opaque system of behind-the-scenes rebates and other deals that now make it impossible to know the real price of a drug.
"It wouldn't be simple," said Don Berwick, who was the Centers for Medicare and Medicaid administrator in 2010 and 2011. To cite one example, "CMS would have to have a formulary, like the insurance companies, so it could steer beneficiaries to a cheaper alternative if need be," Berwick said. Still, he added, it was something the government could accomplish if it wanted.
Anyway, back to yesterday's meeting. Trump goes into it as powerful as he'll ever be. The executives are scared of him (What if he tweets?!) The Republicans in Congress want to mollify him so they can get their tax cuts. Although both the executives and the Republicans oppose empowering CMS to negotiate drug prices, it's possible -- it really is! -- that he could make it happen if he moves quickly.
"We have to get prices down," he says at the beginning of the meeting with cameras rolling. "We have no choice."
Then the doors were closed. When they opened again, Trump had not only abandoned his promise to use the government's bargaining power to bring down drug prices, he was now totally against it!
"I'll oppose anything that makes it harder for smaller, younger companies to take the risk of bringing their product to a vibrantly competitive market," he said, according to the pool reporter. "That includes price-fixing by the biggest dog in the market, Medicare, which is what's happening." (Yes, he accused an agency that has no power to negotiate prices of "price fixing.")
And so it was that after one meeting with pharma CEOs, Trump was turned around on his one good idea and embraced instead yet another nonsensical one. Sigh. And now back to our regularly scheduled programming.
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