Trump, Fight Big Pharma? Nah.
GOP Candidate Abandons Historic Rx Price Controls, Doubles Down on Hate. Donald Trump and Health Care, Part 2
In his first term, Donald Trump proposed the most aggressive prescription drug price controls in U.S. history. This isn’t obvious in media health care coverage, but he did.
For months his campaign has promised to revive those proposals if he’s elected. Two weeks ago, however, Trump abruptly abandoned his most far-reaching proposal: linking Medicare drug prices to the lowest prices paid in other countries. To date, Trump still supports stockpiling large amounts of “essential” drugs and medical devices and trying to force drug companies to manufacture both the final products and “critical inputs” in the U.S. However, Trump will face pressure to abandon it as he did “most favored nation” pricing.
Doing so reduces GOP health care policy to the party’s longstanding opposition to abortion, hatred of trans people and immigrants, empty partisan criticism of the Affordable Care Act and an awkward embrace of the anti-vaccine movement. Here’s a look at the rest of former President Donald Trump’s agenda.
Category 4: Exercise federal power to control drug prices.
“Most-Favored Nation” Medicare Drug Pricing: According to a Rand Corporation study, U.S. drug prices are 256% higher than a weighted average of prices in 33 other countries belonging to the Organization for Economic Cooperation and Development (OECD). In the second year of Trump’s term, the Centers for Medicare and Medicaid (CMS) gave notice that they were working on a rule to link the prices Medicare pays for drugs administered in doctors’ offices (known as “Part B” drugs) to the average prices paid in OECD countries.
The Trump Administration dragged its feet for two years, then in spring 2020 escalated in a series of last-minute Executive Orders. Trump ordered CMS to have Medicare pay only the lowest price that drug companies receive in a group of OECD countries for most drugs. The order expanded to cover the 250 most expensive drugs, both doctor-administered Part B drugs and retail drugs covered by private insurers in Medicare’s privatized pharmacy benefit program (“Part D”).
Trump’s Administration handled the issue with typical incompetence. With the election approaching, they tried to rush through regulations for the Part B drugs, claiming that the public health emergency allowed them to skip the normal public notice and comment process for new rules. Federal courts rejected the emergency idea and blocked the regulations on procedural grounds as Trump lost the White House.
However, the substance of the regulations was never tested legally and until two weeks ago, Trump had pledged to revive his proposals. In a video statement at the campaign website headlined “Protecting Americans by Taking on Big Pharma and Ending Global Freeloading”, Trump said:
Under my policy, the United States government will tell Big Pharma that we will only pay the best price they offer to foreign nations, who have been taking advantage of us for so long— the United States is tired of getting ripped off.
Follow the link today and you get:
Fans of regulatory detail should read Rachel Sachs’ excellent rundown of the twists and turns of the most favored nation proposal in Health Affairs, written shortly after the 2020 election.
It would be a more interesting read if Trump remained committed to the policy. The attempt to introduce international reference pricing, as badly botched as it was and with real implementation flaws described in Sachs’ article, represented the first sweeping attempt to rein in drug prices in U.S. history. Upon taking office, President Joe Biden rescinded the Executive Order and, with congressional authorization, began negotiating prices for 10 Part B drugs. Those negotiations concluded with great fanfare last month, but the prices won’t take effect until January 2025, and then only if the law survives industry lawsuits.
“Essential Medicines” Stockpiles and Domestic Production: On August 6, 2020, Trump issued Executive Order 13944, “Ensuring Essential Medicines, Medical Countermeasures, and Critical Inputs Are Made in the United States.” With the public concerned about pharmaceutical supply disruptions during the pandemic, EO 13944 sought to rebuild the U.S. stockpile of drugs, medical devices and supplies needed to address public health emergencies and replace foreign manufacturing of those items with domestic production.
The EO outlined three key steps:
Define essential medicines, “medical countermeasures” for public health emergencies including chemical, biological and nuclear attacks, and the critical manufacturing inputs needed to make them.
Require the federal government to stockpile these items.
Require federal agencies to buy stockpile materials - including the “critical inputs” - from American sources, unless the head of the agency buying them could certify that there were no domestic sources.
On October 30, 2020, the FDA issued its list of 227 drugs and 96 devices, their active ingredients and other “critical inputs” that the agency believed are “medically necessary to have available at all times” to meet the Executive Order’s emergencies. The list was set to grow as other agencies, including the Pentagon, had yet to weigh in with their list of essential medicines.
In late November after Trump’s defeat, his Trade Representative Robert Lighthizer sent a proposal to the World Trade Organization (WTO) to withdraw the listed drugs, inputs and devices from coverage under the WTO’s Government Procurement Agreement. The GPA and other free trade agreements require countries to open some of their government procurement to competition from international suppliers. The EO instructed the Trade Representative to clarify with parties to those agreements that the essential medicines and inputs are not covered by those requirements.
“Critical inputs” include foundational chemicals and biological materials needed for production. Domestic content legislation usually just requires that products be finally assembled in the U.S., with the majority of the content sourced domestically. By specifying domestic sourcing for the critical inputs, Trump was trying to reduce U.S. dependence on critical chemicals extracted and manufactured overseas.
As of this writing, Trump remains committed to these policies to combat what he calls “Biden’s pharmaceutical shortages.” (If readers follow the link and find the video and statement have disappeared, please alert Healing and Stealing in the comments).
“Buy America” policies are popular, at least according to polling conducted for manufacturers who stand to benefit from them. The two major parties compete to champion American manufacturers and manufacturing workers. Biden did not directly rescind the essential medicines EO, but according to the global trade blog of the corporate law firm Sheppard Mullin, he withdrew the request to remove the FDA list from WTO GPA coverage in April 2021. The effect, according to the firm, was to “gut the Trump Executive Order of any meaningful impact.”
The maneuvers around the essential medicines Executive Order reflect a broader divide within U.S. politics over trade. Project 2025 couldn’t even gather consensus recommendations on trade from its 100+ NGO coalition. Rather than policy proposals, the chapter on trade consists of two essays debating whether or not free trade agreements are a good thing. And when faced with Trump’s proposal, Biden chose to quietly “gut” it rather than challenge trade partners. The unraveling of the bipartisan trade consensus in Washington is a major trend within U.S. politics deserving of in-depth reporting. But not in Healing and Stealing. Or at least not today.
Category V: Finessing Abortion
Since the start of the 2024 campaign, the leader of the party that has been home to the anti-abortion movement for fifty years has tried to position himself as a moderate, pro-democracy candidate when it comes to abortion.
Donald Trump seeks full credit for appointing three justices who solidified the Supreme Court’s majority overturning Roe vs. Wade. However, he frames the decision primarily as a victory for democratic decision-making rather than in traditional anti-abortion terms. In his debate with Vice President Kamala Harris, Trump celebrated the fact that “states are voting on …an issue that that’s torn our country apart for 52 years.”
Trump publicly defines “pro-life” to include access to birth control and in-vitro fertilization, while critical elements of his party’s activist base are hostile to both. Trump regularly touts his support for exceptions for pregnancies that result from rape or incest or threaten a mother’s life in any state abortion ban.
With reproductive freedom apparently a winning issue for Democrats since the Dobbs decision, Trump’s campaign has worked hard to impose discipline on the GOP activist base. According to the New York Times, when Trump and his campaign rammed their draft through the Republican Platform Committee without any changes, one reason they took away committee members’ cell phones and surveilled them was to prevent anti-abortion activists from organizing opposition. The final platform contains only a single abortion paragraph - unquestionably Trump’s. It neither claims that abortion is murder nor calls for a federal ban on abortion.
Trump has had difficulty maintaining his position during intense state-level struggles over reproductive rights. Strict state abortion bans are endangering women’s lives across the country, with some states not only banning virtually all abortions, but even attempting to stop pregnant women from traveling across state lines to receive care.
In February, when the Alabama Supreme Court ruled that fertilized eggs are people and state medical facilities suspended in-vitro fertilization treatments, Trump told CNN “I strongly support the availability of IVF for couples who are trying to have a precious little beautiful baby,” adding “today I’m calling on the Alabama legislature to act quickly to find an immediate solution to preserve the availability of IVF in Alabama.”
When the Arizona Supreme Court ruled on April 9 that the state could enforce an 1864 law banning all abortions except for those endangering a mother’s life, Trump said the court “went too far” and urged the state legislature to “act as fast as possible.”
Arizona has repealed the law, but Arizona voters will decide on Proposition 139, which would amend the state constitution to allow abortions without state interference until a fetus is viable, and later to protect a mother’s life or health. For Trump, however, that’s too far. Having first opposed the Civil War-era law, Trump now opposes the constitutional amendment, using false and exaggerated claims about ninth-month abortions and infanticide.
The same dynamic played out at the end of the summer in Florida, where current law prohibits abortions after six weeks of pregnancy, but the ballot includes an amendment to overturn current law and enshrine reproductive rights in the state constitution. On August 30, Trump said he thinks six weeks is too restrictive and suggested he’d vote for the amendment. The next day, facing criticism from anti-abortion leaders, he reversed himself, saying he still believed that six weeks is too short but that the amendment would open the door to Democrats “radical” approach, including infanticide.
Trump carried his uneasy balancing act into the September 10 debate with Vice President Kamala Harris [transcript here]. When asked about his sudden flip on the Florida law, Trump first repeated the party’s false talking points about infanticide in West Virginia. Then he praised the Supreme Court for allowing states to make democratic decisions on reproductive health care policy, pointing out that abortion-rights ballot initiatives in Ohio and Kansas had results that were “[m]uch more liberal than people would have thought.”
When Harris insisted that Trump “will sign a national abortion ban” because Project 2025 calls for one, Trump responded “[i]t’s a lie. I’m not signing a ban.” When moderator Linsey Davis pressed him specifically on whether he would veto a national abortion ban as President, Trump didn’t say “yes” or “no,” just that he wouldn’t have to because no bill would ever reach his desk.
Reporters and Democrats have portrayed that answer as Trump evading the question. After the issue came up in the recent Vice Presidential debate, Trump took to Truth Social, saying he “would not support a federal abortion ban, under any circumstances, and would, in fact, veto it.”
Category VI: Erasing Transgender Identity and Criminalizing Gender-Affirming Health Care
Former President Trump and the entire conservative movement are all-in on a national gender identity panic.
Trump’s campaign arguably reserves its nastiest rhetoric (a high bar indeed) for the subject. Although frequently criticized for failing to offer substantive policy proposals, Trump has issued a detailed proposal entitled President Trump’s Plan to Protect Children from Left-Wing Gender Insanity. It begins “President Trump today announced his plan to stop the chemical, physical, and emotional mutilation of our youth.”
Trump promises to take aggressive action immediately upon re-occupying the White House, and to pursue legislation to permanently embed his ideas in statute. Key proposals from an extensive list include:
revoking the Biden Administration’s interpretation that the Affordable Care Act’s gender discrimination language protects against state laws restricting gender-affirming health care.
Passing rules to terminate any hospital or other provider who prescribes drugs to or conducts surgery on minors as part of gender transition from participating in Medicare and Medicaid.
Issuing an Executive Order banning all federal agencies from even mentioning the idea of gender transition.
Proposing legislation to outlaw any gender-affirming care for minors, ban publicly-financed health insurance programs from paying for it, and declare that the federal government only recognizes two genders, male and female, assigned at birth.
People who identify as transgender occupy a central place among the groups of people demonized by the GOP, along with undocumented immigrants and criminals. As the campaign enters its final weeks, Trump brought all three together in ads criticizing Harris for funding health care that includes gender reassignment surgery for people in prisons. “Hard to believe, but it’s true. Even the liberal media was shocked Kamala supports taxpayer-funded sex changes for prisoners and illegal aliens.” The ad concludes:
“Kamala’s for they/them. President Trump is for you.”
Trump’s plan reflects a visceral hatred of the very idea of transgender identity. Other writers are better equipped to go deep on the subject, but two details of Trump’s proposed enforcement illustrate the party’s ferocity from the health care policy perspective.
First, termination from Medicare and Medicaid is nuclear law enforcement. Hospitals are virtually never kicked out of these programs. Health care justice activists (including yours truly) have for years encouraged or demanded that the federal government strip hospitals that price gouge or abuse patients of their right to receive federal reimbursement. No general hospital can survive long without participating. To threaten annihilation over trans health care and not over corporate behavior like the profit-driven understaffing that contributes to thousands of deaths a year is a clear statement of priorities.
The GOP platform also “support[s] the creation of a private right of action for victims to sue doctors who have unforgivably performed these procedures on minor children.” This is among the more darkly comic positions any politician has taken in Healing and Stealing’s many years observing U.S. politics.
Stopping juries from imposing big financial penalties on corporations found guilty of wrongdoing has long been a bedrock of Republican policy, especially in health care. GOP legislators have pursued caps on damages and other policies to limit patients’ ability to sue hospitals and doctors at the federal and state level for years. Now the very concept of fluid gender identities has Republicans scrambling to create an entirely new category of “malpractice” and write patients’ rights to sue doctors and hospitals into federal law. It’s a nearly unimaginable turnaround.
The notion that there is lavishly funded health care in prisons and immigration detention centers is ludicrous, made clear in a 2019 New England Journal of Medicine article. Yet, in the end, prisoners including immigration detainees have a nominal right to government-financed health care, which includes provisions for sex reassignment and other care for transgender prisoners, as it should. These rights were won through epic advocacy campaigns on behalf of some of the most vulnerable people in the United States.
Without a doubt, many of the people at whom Trump’s ads are targeted likely would find other reasons to vote based on fear of others, but the fact remains that nearly 40% of American adults of all genders skip health care due to cost each year as thousands of people die for want of treatment and millions face debt and bankruptcy. In a political environment in which nearly every voter has a family member, work colleague or friend who has suffered at the hands of the health care system, a right to “free” health care for anyone, no matter how venomous or distorted the description, can sound unfair to some voters. More on the “right” to health care in our look at Vice President Harris.
Category VII: End Vaccine Mandates
As President during the first year of the COVID-19 pandemic, Trump built his entire policy around the hope for rapid vaccine development. The Biden Administration doubled down, relaxing other prevention measures once widespread vaccination was underway.
As with abortion, Trump is trying to straddle a political fence around vaccination. On the one hand he takes credit for the rapid development of the COVID-19 vaccines during his Presidency. On the other, he now opposes requiring vaccination and the GOP has entered an awkward dance with the broader anti-vaccination movement. Trump has promised to cut off federal funding for school districts that require vaccination. According to The Hill, “I will not give one penny to any school that has a vaccine mandate or a mask mandate”
To the extent such a policy includes childhood immunizations against infectious diseases like polio, measles, mumps and rubella, it could potentially unwind decades of successful public health intervention and ultimately threaten thousands or even millions of lives. Measles cases have risen this year, although the overall number of cases remains small and the Centers for Disease Control and Prevention hasn’t attributed the rise to a significant reduction in vaccine coverage.
Trump’s campaign staff has claimed that he is talking only about COVID vaccines, but a review of 17 Trump speeches by KFF Health News reporter Darius Tahir found that Trump himself has not made that distinction. When Robert Kennedy Jr. endorsed Trump in July, a leaked phone conversation between them included a recording of Trump describing having seen a child get sick from vaccination then immediately develop autism. The original paper suggesting a link between measles vaccine and autism was retracted by The Lancet 14 years ago.
Healing and Stealing has generally avoided weighing in on what we consider significant failures of our public health system during the COVID-19 pandemic under both Trump and Biden, including a tendency to oversell - at least by implication - the value of the vaccines in preventing the spread of the virus. That story requires much deeper reporting than we have done to handle responsibly. Regardless, those failures would not justify conflating public frustration with COVID policies with discredited criticisms of critical public health measures dating from before the pandemic.
The dance with the anti-vaccine movement suggests that one of Trump’s unique proposals might end up as a platform for vaccine criticism rather than a serious investigation of critical health issues. Trump has proposed to create a Presidential commission to investigate the rise of chronic illnesses especially among children:
In recent decades, there has been an unexplained and alarming growth in the prevalence of chronic illnesses and health problems, especially in children. We’ve seen a stunning rise in autism, auto-immune disorders, obesity, infertility, serious allergies, and respiratory challenges.
It is time to ask: What is going on?
Is it the food that they eat? The environment that we live in? The over-prescription of certain medications? Is it the toxins and chemicals that are present in our homes?
Every year, we spend hundreds of billions of dollars to treat these chronic problems rather than looking at what is causing them in the first place. Too often, our public health establishment is too close to Big Pharma—they make a lot of money, Big Pharma—big corporations, and other special interests, and does not want to ask the tough questions about what is happening to our children’s health. If Big Pharma defrauds American patients and taxpayers or puts profits above people, they must be investigated and held accountable.
Real government attention to these questions is long overdue, and Trump would be a surprising investigator, particularly of the chemical industry. His first administration, according to the New York Times, rolled back more than 100 environmental regulations.
The language of the full announcement focuses more attention on “Big Pharma” as the cause of chronic illness than other industries. The pharmaceutical industry deserves plenty of scrutiny, but Trump’s embracing of the anti-vaccine movement suggests his commission, if ever formed, might end up with a narrow focus or pre-determined answers. Trump’s rhetoric suggesting Big Pharma’s culpability rings particularly hollow since his abrupt, unexplained abandonment of aggressive Medicare prescription drug price controls.
Next Up: Vice President Kamala Harris and the Democrats’ concepts of a plan.