In President Donald Trump's final State of the Union address of his first term, he told Congress he would swiftly sign bipartisan drug-pricing legislation if lawmakers sent a bill to his desk.
But Trump stopped short of a full endorsement of a major bipartisan drug-pricing deal brokered by Senate Finance Chair Chuck Grassley (R-Iowa) and ranking member Ron Wyden (D-Ore.). While he called upon Congress explicitly "to pass Senator (John) Barrasso's highway bill," by contrast Trump's comments on drug pricing left some wiggle room.
"I have been speaking to Senator Chuck Grassley of Iowa and others in the Congress in order to get something on drug pricing done, and done properly. I am calling for bipartisan legislation that achieves the goal of dramatically lowering prescription drug prices," Trump said.
The statement is emblematic of the White House's approach to healthcare policymaking in Congress so far in 2020 — to support bipartisan progress broadly, but to hold back from exclusively endorsing major bipartisan legislative packages that stalled in December. Some observers and congressional staff see the approach as leaving room for bipartisan dealmaking, while others worry that vague calls for action will not be enough to break through stubborn gridlock.
White House spokesman Judd Deere said that Trump has clearly stated he wants Congress to address drug pricing and surprise medical billing legislation, and that Democrats "ducked completing work on key healthcare priorities" last year.
"Many excellent provisions are being considered on Capitol Hill and the White House remains in close contact with Members as we work to move a solution forward that advances the President's priorities," Deere said in a statement.
Grassley is working to build support for the Grassley-Wyden drug-pricing package among Senate Republicans and to mitigate concerns about a provision that would require drugmakers to pay back Medicare for price hikes that outpace inflation.
The White House endorsed the Grassley-Wyden package last year, but Trump did not offer a full-throated endorsement during the State of the Union address. But the next day, Vice President Mike Pence touted the Grassley-Wyden deal in a television appearance.
"We've got legislation that's bipartisan legislation. Chuck Grassley, Ron Wyden have worked on in the United States Senate. I've been in meetings in the West Wing where we've talked about this, and the president said pass the bipartisan bill," Pence said on Feb. 5.
By contrast, the president's budget, released Feb. 10, called for bipartisan drug-pricing action with federal cost savings similar to preliminary estimates for the Grassley-Wyden legislation, but did not name the bill specifically.
Russ Vought, acting director of the White House Office of Management and Budget, said that the Grassley-Wyden proposal has "a lot of life," though the budget did not call exclusively for the bill's passage.
"This budget provides a little less specificity in the area of this issue because we realize there is a House bill and a Senate bill and we want—ultimately want to get a bill to the President's desk," Vought told reporters.
Grassley said on Feb. 13 that he hopes to get 25 Republican co-sponsors for the Grassley-Wyden legislation. Around 11 GOP senators have publicly supported it so far. Since the State of the Union and budget release, Grassley picked up a notable endorsement from Sen. Martha McSally (R-Ariz.), who is running a tough reelection race. But Grassley's fellow GOP senator from Iowa, Joni Ernst, on Feb. 11 co-sponsored a different drug-pricing legislation compiled by House Republicans.
A Senate Republican aide said that the White House's reticence to take an unequivocal stance promoting the Grassley-Wyden legislation could hurt the package's chances, as Senate Republicans would need cover to vote in favor of inflationary reimbursement caps for pharmacy drugs. The budget was silent on the divisive policy.
Grassley has previously called for more vocal support from Trump and said Senate Majority Leader Mitch McConnell's opposition has made it difficult to procure co-sponsors, but he took responsibility for rallying support on Feb. 13.
"I'm not going to put the burden on McConnell," Grassley told reporters. "If I don't get this up, it's my fault."
Chris Holt, director of healthcare policy at the right-leaning American Action Forum, said it makes sense strategically that the White House might want to leave lawmakers flexibility to come to a bipartisan consensus, but that Grassley will likely have difficulty getting to 25 GOP co-sponsors without Trump's full support.
"When they are taking tough votes, Congress needs cover from the White House, and that may need to be more specific than 'get something done,' " Holt said.
Surprise medical bills
The debate over surprise medical billing is a different political landscape, as support for distinct proposals does not break along party lines. The White House endorsed a bipartisan, bicameral agreement between the House Energy & Commerce Committee and the Senate health committee in December, but has taken a more open-ended stance since the beginning of the year.
The president did not mention legislation banning surprise medical bills in his 2020 State of the Union address. On Feb. 11, after two House committees had put forth bills to ban surprise medical bills, the White House released a statement highlighting key differences between two leading approaches.
"The White House is encouraged by the Ways and Means and Education and Labor Committees' engagement in addressing surprise medical bills, but is concerned that a push to overuse arbitration will raise healthcare costs. We are closely reviewing the proposals and believe both measures must protect against surprise air ambulance bills," Deere said in a statement.
The House Ways & Means bill is the only one of the three House proposals that leaves out a monetary threshold for arbitration between providers and insurers and does not ban air ambulance companies from balance billing patients.
However, the Ways & Means arbitration-only proposal also appears to be the closest to the approach favored by 39 conservative House Republicans, who in a letter dated Feb. 10 asked House Speaker Nancy Pelosi (D-Calif.) not to advance a surprise billing fix with a benchmark payment mechanism. Hospitals and providers also prefer the arbitration-only approach.
On Feb. 12, Trump tweeted that he wanted all four committees to work together to put bipartisan legislation on his desk without mentioning a preference for any single approach.
"Ending surprise medical billing moving ahead in Congress! Thanks to Ways & Means and Education/Labor Committees for your work on Bills to protect patients and end medical bill ripoffs!" Trump tweeted.
A Senate Republican aide said the White House's seemingly open approach to bipartisan legislation on surprise billing could leave lawmakers room to come to a consensus proposal. But a Senate Democratic source argued if the White House supports the bicameral surprise billing proposal and the Grassley-Wyden drug-pricing bill, its messaging should be "clear and consistent."
"Congressional Republicans are paralyzed because they are not clear what the President's position is, and this confusion coming from the White House is holding up efforts to get these priorities done," the Democratic source said.
Congressional observers and staff agreed that the impasse on both issues has been persistent, and Trump may be the only actor with the leverage to compel Congress to act on major healthcare legislation ahead of a May 22 deadline to fund some expiring Medicare and Medicaid programs.
"President Trump's support for a specific policy on surprise billing or drug pricing could be the key to unlock months of gridlock on these challenging issues," said Shea McCarthy, a senior vice president at Thorn Run Partners. "For now, that key might as well be hidden under a mattress somewhere."