President Trump is preparing to deliver a long-awaited address on prescription drug prices as soon as next week, but advocates warn the White House may be focused more on populist messaging than swallowing bitter pills.
Trump lamented the rising cost of drugs during his campaign and last year he accused pharmaceutical companies of "getting away with murder." He blasted other countries for controlling prices and vowed to the cost of drugs in the U.S. "way down."
But based on more recent statements from the president as well as remarks made by members of his administration — many of whom previously worked for drug companies — few expect Trump to offer up major changes in the address.
"We are not hopeful, but we'd love to be wrong," said Peter Maybarduk, director of Public Citizen's Global Access to Medicines Program. "The signals are pointing mostly in the wrong direction."
Studies show the increase in drug prices are having a big impact on American households. An AARP report last year found the average annual price of drugs widely prescribed to seniors increased to $12,951 from $6,425 five years ago.
Health and Human Services Secretary Alex Azar, a former executive at drug maker Eli Lilly, said this week that Trump wants to go "much further" on the issue, but offered few specifics. An unpublished proposal on drug pricing recently submitted to the White House by HHS was marked as having little economic impact, an indication the administration is not contemplating fundamental changes.
The White House had previously said Trump would use the speech to ask HHS for ideas to address the problem. The speech was scheduled for April 26 but was delayed when Azar was hospitalized with diverticulitis. A White House spokesman did not respond to questions about the contents of the upcoming address, or its timing.
"I'm not expecting significant changes," said Rachel Sachs, a Washington University law professor who blogs about drug policies. "One of the things to watch for in the speech is what the administration says it can do on its own and what it needs Congress' help with."
Trump has already put pressure on the drug industry in ways that even some critics have applauded. The Food and Drug Administration has sped up approval of generic drugs, injecting more competition in the market. The president's proposed budget floated the idea of giving some states leverage to negotiate prices in Medicaid.
And the White House has proposed requiring pharmacy benefit managers, which act as middlemen between drug companies and insurers, to pass along to Medicare beneficiaries the savings they negotiate by buying large quantities of drugs. That idea wouldn't lower the price of medicine, but it could reduce out-of-pocket costs for patients.
The administration has also been scrutinizing lower prices paid in other countries, a favorite issue for the president. White House economic advisers recommended this year that the administration use "enhanced trade policy" to pressure other nations against negotiating prices that are far lower than what U.S. patients and insurers will pay.
Analysts say many of those proposals could have an impact, but they will take time to implement — and may affect a small number of patients.
"These are all tweaks around the edges," Sachs said.
What the president is unlikely to do is allow Medicare to negotiate drug prices. Trump embraced that idea during the presidential campaign but has not pursued it since taking office. Azar said this year that allowing negotiations would limit the choice of drugs available to seniors.
Less clear is whether the administration will step up enforcement of anti-competitive practices. In the case of price gouging, for instance, federal law allows the government to override patent protection in exchange for compensation. The Bush administration came under pressure to consider that move with the anti-anthrax treatment Cipro in 2001, but drug maker Bayer decided to voluntarily reduce its price instead.
FDA Commissioner Scott Gottlieb has hinted that Trump's address will focus at least in part on those practices. Gottlieb told a conference in Washington on Thursday that the administration wants to "dismantle many of the provisions that shield parts of the drug industry from more vigorous competition."
Trump's rhetoric on drug prices has reflected public apprehension on the issue. Just more than half of Americans believe passing legislation to address drug prices should be a "top priority" for Washington, according to a Kaiser Health Tracking Poll in March.
And the added pressure from the White House has also intensified finger pointing within the labyrinth of industries involved in prescriptions. Pharmaceutical companies blame insurers and pharmacy benefit managers. Those groups counter that it is the drug makers that decide how much to charge for their product.
"The problem is the price," said Will Holley, a spokesman for the Campaign for Sustainable Rx Pricing, which represents insurers and large PBMs such as CVS Health. "At the end of the day there's one player that sets the price of drugs."
Holly Campbell, a spokeswoman for the trade group Pharmaceutical Research and Manufacturers of America, said patients are struggling to afford medicine "because insurers and PBMs have been shifting more of the costs to them for years."