WASHINGTON — It seems fitting that President Donald Trump — who describes himself as a master negotiator — wants a big, bold move to lower prescription drug prices by allowing the government to directly negotiate with pharmaceutical companies.

If a deal emerged between the White House and House Speaker Nancy Pelosi, D-Calif., on allowing such negotiations by Medicare — long anathema to Republicans, who view such a move as price fixing — it would be because the president wasn't satisfied with a set of smaller-bore ideas being pursued on Capitol Hill and by his Department of Health and Human Services.

Trump has promised numerous times to slash drug prices. As he looks ahead to his reelection effort, achieving something as major as direct negotiatons between Medicare and drug companies could be just the win he's looking for — especially considering the idea is favored by a large majority of Americans.

Trump, Pelosi and Senate Minority Leader Chuck Schumer, D-N.Y., must determine whether there is any potential in the highly polarized climate for bipartisan legislating before the pressures of the 2020 elections make any compromise impossible.

The White House for weeks has been engaged in talks with Pelosi's office about a range of options, including allowing negotiations between Medicare and drugmakers just for a limited set of more expensive drugs, such as drugs with no therapeutic alternatives. Whether to include drugs administered directly in physicians' offices is also under discussion, according to lobbyists.

"At the end of the day, unless there's a negotiation with the drug companies, we're not going to bring down drug prices," Rep. Donna Shalala, D-Fla., who served as HHS secretary under President Bill Clinton, told me last week. "There is no substitute for negotiations. I think the president knows that."

Medicare negotiation is the elephant in the room as Congress and the Trump administration seek ways to lower the high cost of prescription drugs. They probably could achieve some savings for the government — and put a general downward pressure on drug prices — by repealing a ban on HHS from directly negotiating lower prices for medications through Medicare's Part D prescription drug program, which covers medicines distributed by private plans.

Trump, who embraced the idea on the campaign trail, is still deeply interested in it. But it's shunned by Republicans and, naturally, the pharmaceutical industry. Opponents argue that prices for Medicare drugs are already negotiated, between the drug companies and the private insurers who administer the Part D plans. They also point to the Congressional Budget Office, which has said direct negotiations would have only a "negligible effect" on drug prices for those covered by Medicare.

It's unclear whether a deal will emerge this year. Democrats aren't united on the details of such a proposal. Wendell Primus, a top Pelosi aide, has reportedly drawn ire from the House's most liberal Democrats for favoring an arbitration approach, where a neutral party would decide on a price for select Medicare drugs — a moderate alternative to full-on negotiation.

And the first hearings on Rep. Pramila Jayapal's Medicare-for-all bill is set to be held tomorrow in the House.

Indeed, there are different approaches to giving Medicare more leverage over how much it pays private companies for their prescription drugs. Because Medicare's prescription drug program is administered by private plans, lawmakers could add in a public plan where prices would be negotiated directly. Another option is to authorize the HHS secretary to negotiate prices on behalf of Medicare enrollees who participate in the private prescription drug plans.

Under legislation proposed in February by Rep. Lloyd Doggett, D-Tex., and Sen. Sherrod Brown, D-Ohio, drugmakers would have to negotiate Medicare Part D prices with the government or risk losing their temporary rights to sell their drugs exclusively. About 100 Democrats have signed on to that bill.

Wherever that issue ends up, there's a broad expectation that Congress will do something bipartisan on drug prices this year. Pelosi's office confirmed there will be action on drug pricing bills in May. A dozen bills passed by the two top House committees with health-care jurisdiction are candidates for a floor vote.

And Senate Finance Chairman Chuck Grassley, R-Iowa, said last week he's aiming to introduce bipartisan legislation in June with the committee's top Democrat, Sen. Ron Wyden, D-Ore.

"We are writing legislation to address some of the systemic problems that make prescription drugs unaffordable for some Americans," Grassley said in a speech on Thursday. "I expect that legislation to be ready for introduction in mid-June of this year."

There's a parallel effort over at HHS, which is working on several ideas intended to shed more light on pricing and put downward pressure on what Medicare plans pay drugmakers. John O'Brien, who is serving as HHS's point person on its drug pricing efforts, will brief the group Patients for Affordable Drugs Now on Tuesday on an international index the agency is contemplating as a way to link Medicare prices to lower prices in other countries.

But those ideas are mostly changes around the edges and not fundamental shifts to the whole drug pricing system. Graduates of the Obama administration are urging Medicare negotiation — among other measures — as one of the best ways to start quickly bringing U.S. drug prices down. Andy Slavitt, who headed the Centers for Medicare and Medicaid Services, and former FDA commissioner Robert Califf named direct negotiations as one of four key actions.

"This approach works well for other countries and for the U.S. Veterans Affairs," Slavitt and Califf wrote last week in the Journal of the American Medical Association.

"Notably, the Obama administration repeatedly proposed direct negotiation between the Centers for Medicare & Medicaid Services and drug companies, but the policy gained no traction in Congress, which historically has been heavily influenced by the pharmaceutical lobby and its allies," they continued.

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