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Insulin for $35 a month. A limit of $2,000 a year in out-of-pocket drug costs for older Americans. Billions of dollars in savings for Medicare resulting from drug negotiations.
Whether these policies expand or, in the case of the negotiations, survive at all may be determined by the election in November.
Vice President Kamala Harris, the Democratic nominee, has vowed to extend President Biden’s policies to more drugs and more Americans. She plans to use savings from expanding negotiations to help pay for a sweeping new proposal that would cover long-term care at home for people on Medicare.
Former President Donald J. Trump, the Republican nominee, is a wild card. He has offered few specifics about what he would do on drug pricing.
Last week, he reversed his position on a policy he had proposed in his first term that rattled pharmaceutical companies: tying drug prices to what other wealthy countries pay. In a second term, he would face pressure from some Republicans to undo Mr. Biden’s Medicare negotiation program — although he once promoted the same thing.
Drug pricing has not featured prominently in a presidential campaign that has been dominated by immigration, abortion and the economy. Mr. Trump, in particular, rarely talks about the issue. Nor is it top of mind for many voters.
“Health care costs have shifted to a second-tier issue in the election,” said Robert Blendon, a health policy expert at Harvard.
Most industry observers say Ms. Harris is more likely to pose a greater threat to drugmakers’ profits, but they don’t rule out the possibility that Mr. Trump could also be bad for their interests.
Here’s where the candidates stand on key issues in drug pricing.
Lowering the government’s drug costs
The 2022 Inflation Reduction Act, Mr. Biden’s signature legislative achievement, changed pricing practices to lower drug costs for older Americans and the federal government. Both Democrats and Republicans like to note that Ms. Harris cast the tiebreaking vote on the legislation. No Republican lawmakers voted for it.
One of the law’s most contentious provisions allowed Medicare to negotiate prices directly with drugmakers. The federal government stands to save billions of dollars by pushing prices down, but the program has encountered fierce opposition from the drug industry and some Republicans who have said they want to repeal it.
New prices for the first 10 medications picked for negotiations go into effect in 2026, with up to 20 drugs added in subsequent years. Mr. Biden called for expanding the program to “up to 50” drugs a year, and Ms. Harris has also advocated speeding up the pace of negotiations.
Mr. Trump’s campaign declined to comment on whether he would repeal the program. If his administration wanted, it could weaken the program without repealing it, by being less aggressive in negotiations with drugmakers.
If he and Republicans were to repeal the program, they would most likely want to replace it with something else to reduce drug costs for the government and older people, said Joe Grogan, who was a senior Trump administration official.
“I do not believe that Trump would want to repeal it in isolation,” Mr. Grogan said.
In his 2016 campaign, Mr. Trump endorsed empowering Medicare to negotiate drug prices but dropped the proposal as president. His running mate in this election, Senator JD Vance, said in 2022 that he favored it too, “so that our seniors aren’t paying through the roof.”
Paying no more than other rich nations
As president, Mr. Trump proposed a different mechanism for lowering drug costs: Medicare would pay no more than certain other wealthy countries for drugs given at a clinic or a hospital. The theory is that other rich countries would foot more of the bill for drugs.
This idea, known as a most favored nation pricing model, never took off, though it unnerved drug companies and many conservatives. Mr. Trump has not been talking about the idea on the campaign trail, but he recorded a video last year touting it.
In the video, Mr. Trump said that foreign nations “have been taking advantage of us for so long — the United States is tired of getting ripped off.”
Last week, the Trump campaign walked back the proposal, saying that there was no push to renew it but that Mr. Trump would still seek to lower drug prices. The video has been taken down.
Analysts at Capital Alpha Partners, a policy research group, cautioned against reading too much into Mr. Trump’s policy change. “We highly doubt he’s reached any conclusion on what he would or wouldn’t do on drug pricing if he’s re-elected,” the analysts wrote in a note to investors.
Offering $35 insulin
For years, insulin was the poster child of high drug prices, with some patients rationing the life-sustaining product because they couldn’t afford it.
But the situation has largely improved in recent years, with credit due to both Mr. Trump and Mr. Biden. (Mr. Trump claims he deserves full credit.)
In Mr. Trump’s first term, his administration created a model for capping some Medicare patients’ out-of-pocket costs at $35 per month. Under the Biden administration’s Inflation Reduction Act, Democrats expanded that cap to all Medicare patients on insulin.
The insulin cap in Medicare is broadly popular, including among drugmakers, and faces little risk of repeal regardless of who’s elected. Ms. Harris proposes expanding the cap to make it mandatory for people who get their insurance through an employer, though insulin manufacturers have already instituted voluntary $35 caps in that market.
Capping out-of-pocket costs
Under the Inflation Reduction Act, older Americans will pay no more than $2,000 out of pocket a year for the prescription drugs they take at home under Medicare’s Part D program, starting in January.
Mr. Trump has supported similar spending caps in the past: In his first term, he endorsed a bipartisan bill that would set a $3,100 annual limit on out-of-pocket costs in Medicare.
As they criticize other parts of the Inflation Reduction Act, Mr. Trump, other top Republicans and the drug industry are not calling for doing away with the $2,000 cap.
“There’s no natural enemy to the Part D cap,” said Stacie Dusetzina, a drug pricing expert at Vanderbilt University.
Ms. Harris proposes extending the cap to people with private insurance, a small fraction of whom have very high out-of-pocket drug costs. Compared with older people on Medicare, working-age people are healthier and take fewer drugs.
Health policy experts say Ms. Harris’s proposal would have a hard time getting through Congress.
If employers were required to cap out-of-pocket drug costs for their workers, they would most likely pass down that added expense by increasing premiums or co-pays or by raising deductibles, in which patients must pay some of their medical bills before their coverage starts.
“The Harris proposal would provide relief for people with high drug costs, though it could end up costing patients more for other types of health care,” said Larry Levitt, a health policy expert at KFF, a nonprofit health research group.
Ms. Harris’s campaign declined to provide more detail on the proposal.
In the case of the $2,000 cap in Medicare, the Biden administration spent $5 billion to avoid spikes in premiums for older Americans next year.
Cracking down on drug middlemen
In recent months, lawmakers, regulators and attorneys general have increased their scrutiny of pharmacy benefit managers. Hired by employers and government programs, P.B.M.s negotiate prices with drugmakers, pay pharmacies and help decide which drugs are available to patients at which price.
P.B.M.s are supposed to keep a lid on drug costs. But they have been accused of prioritizing their own profits, inflating drug prices and driving independent pharmacies out of business.
On the campaign trail, Ms. Harris has vowed to “demand transparency from the middlemen who operate between Big Pharma and the insurance companies, who use opaque practices to raise your drug prices and profit off your need for medicine.” Ms. Harris is also proposing financing her home care plan in part by finding savings from cracking down on benefit managers and their business practices which drive up drug costs.
Mark Cuban, the billionaire who runs an online pharmacy that offers low-cost drugs whose prices have been inflated by the big P.B.M.s, has been advising the Harris campaign.
“I have talked to them about P.B.M.s and the pharmaceutical and health care industry,” Mr. Cuban said in an interview. “I’ve been adamant about the plight of independent pharmacies, and they’ve listened very intently.”
Mr. Trump has not been talking about P.B.M.s on the campaign trail. In 2018, his administration proposed a sweeping change that would have threatened the benefit managers’ business model and would have remade how the government pays for prescription drugs. The proposal was never enacted.
Republican officials are divided in their views of P.B.M.s. A number of conservative state attorneys general have sued them, and some federal and state lawmakers have proposed new limits on their business practices. But other Republicans say the P.B.M.s are not to blame for high drug prices.
Replacing Obamacare
Ms. Harris’s campaign has focused much of its health policy messaging around warning voters that Mr. Trump and Republicans would try to repeal the Affordable Care Act, the 2010 law that expanded health insurance and drug coverage to millions of Americans. The campaign argues that one result would be many more uninsured people, who would have to pay out of pocket for their drugs, if they could afford them at all.
It’s unlikely that Republicans could muster enough votes to repeal the law. The more likely scenario is that Republicans would steadily chip away at the law, ultimately covering fewer people. That could mean that some people no longer have drug coverage and that the people who would stay covered might have to pay a greater share of the costs of their drugs.
Karoline Leavitt, a spokeswoman for the Trump campaign, said the Harris campaign was lying. She said Mr. Trump was aware of “the high price of health care and insurance that hardworking families simply cannot afford” and would expand access to “new affordable health care and prescription drug options.”
On the fate of the Affordable Care Act, as with other drug pricing policies, the makeup of Congress may dictate more of what happens than either candidate’s convictions.
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