President Trump was apoplectic about drug prices once again. A Wall Street Journal story in early January, picked up by Fox News, reported that prices on hundreds of drugs were going up — a slap in the face to a president who had campaigned on lowering costs and accused the pharmaceutical industry of “getting away with murder.”

At a Jan. 6 Camp David meeting, Trump fumed about Health and Human Services Secretary Alex Azar, whom he had charged with lowering drug prices, according to three people with knowledge of the conversation. Two days later in the Oval Office, a nervous Azar, who had just returned from vacation, detailed the intricacies of what he was doing to lower prices, leaving the president bored and impatient, according to people close to the situation.

“I don’t understand a word you’re saying,” Trump interrupted. “And no one else will, either.”

As Trump presses to make health care a central plank of his 2020 reelection bid, such episodes point to his mounting frustration with those he thinks are thwarting his ability to deliver on a major campaign promise: lowering drug prices. That has included Azar, a former drug executive who until very recently pushed back on proposals to import lower-cost drugs from Canada and negotiate drug prices in Medicare.

Now, though, under intense pressure to deliver campaign talking points, Azar has reversed his long-standing opposition to ideas traditionally espoused by Democrats and reviled by most Republicans and the drug industry.

“Inspired by the president’s passion, Secretary Azar has been pushing FDA to go even bigger and broader on importation,” a senior administration official said Monday. The official declined to detail specific policy changes.

Acting White House chief of staff Mick Mulvaney described the president’s anger as focused on news coverage of drug prices. In an interview Tuesday, he said that Trump was pleased overall with Azar’s performance — particularly the Food and Drug Administration’s record approvals of generic drugs.

By all accounts, drug prices are a fixation for Trump, who frequently sends advisers news clippings and summons them to the White House to rant about the issue. “The guy likes to make money, and he thinks they make too much money,” said one former senior administration official. Yet even as Trump ratchets up pressure on Azar and others to deliver wins on an issue he sees as key to his base, sharp clashes within the administration over approach have jeopardized attempts at lowering prices, which polls as a top voter concern, according to more than a dozen current and former administration officials, Capitol Hill aides and lobbyists.

A senior administration official said there was frustration at a lack of executive branch tools to lower drug prices and that some of Trump’s ideas were ambitious but unworkable. Disagreements over how to proceed have created a policy free-for-all as different advisers — and the president himself — pursue what appear to be ad hoc and sometimes dueling approaches. Trump entertains proposals usually pushed by progressive Democrats one moment and free-market GOP ideas the next.

The president has embraced a proposal by Florida Gov. Ron DeSantis (R), for instance, to import lower-priced drugs from Canada — much to the chagrin of Azar, who described such ideas as a “gimmick” last year and who must sign off on any such plan as safe and money-saving. At an Oval Office meeting in May, Azar got into a heated argument with DeSantis, saying that importing drugs would be ineffective in bringing down prices and lead to safety problems because there would be no way to ensure counterfeit drugs from other countries are not routed through Canada. Trump ended up favoring the proposal after DeSantis contended it would deliver lower prescription drug prices in a key electoral battleground state, according to officials briefed on the meeting. Florida must still send the proposal to the Department of Health and Human Services for Azar’s approval.

“All options are on the table, and we will work with Democrats and Republicans to make this happen,” HHS spokeswoman Caitlin Oakley said in response to questions.

White House spokesman Judd Deere said that “there’s no daylight between the White House and HHS as we work to implement the president’s important priorities . . . To suggest otherwise is patently false.”

The White House’s seemingly contradictory approaches are particularly evident on Capitol Hill, where Azar is advising the Senate on a modest bipartisan package of legislation that aims to lower health-care costs by addressing surprise medical bills, promoting greater transparency and making it easier for generic drugs to get to market.

But officials from the White House — eager to strike a bold deal that would give Trump a high-profile signing ceremony — are in talks with House Speaker Nancy Pelosi’s office about allowing Medicare to negotiate the prices of select drugs, according to Hill aides and lobbyists. Republicans and Democrats alike say they are skeptical such a deal can be struck with the presidential campaigns already underway.

“Democrats are not incentivized to have progress before the election,” said Dan Mendelson, a Democratic health policy expert who founded Avalere Health, a Washington-based consulting firm.

Allowing the government to negotiate Medicare drug prices probably would not win support from leading Senate Republicans, such as Finance Committee Chairman Charles E. Grassley (Iowa), who argue the government should not interfere in the marketplace and that such efforts would limit access to medicine.

A senior administration official played down talk of competing, or uncoordinated efforts, saying Azar, White House domestic policy director Joe Grogan and White House legislative affairs director Eric Ueland speak three times a week about what is happening on Capitol Hill.

But with such drastically different proposals under discussion, it remains unclear to advisers, lawmakers and industry officials which ideas the administration is prioritizing.

“There’s not a clear path forward, and I’m not sure there will be,” said one lobbyist briefed on discussions between HHS and the White House. “That’s part of the tension — they’re trying to figure out how do we actually do what the president wants to do. They don’t have all the tools they need to make an impact, so they’re trying a lot of different things to see if it will work and if the consumer will feel it.”

Azar, who served in the administration of George W. Bush and is a former president for the U.S. division of Eli Lilly, has been unable to move the needle, meanwhile, on what most consumers pay for drugs with his own more free-market-oriented proposals, emphasizing ideas such as price transparency and competition. Few of those initiatives have even taken effect because of a glacial rulemaking process and, in some cases, administration infighting.

“Nobody is fighting harder than Secretary Azar to deliver on President Trump’s priority to lower prescription drug prices for the American people,” said Oakley, the HHS spokeswoman. “The secretary has proposed many bold ideas, which, if enacted, would lower drug prices and reduce patients’ out-of-pocket costs.”

Azar has championed a proposal to eliminate lucrative drug manufacturers’ rebates to insurers that he says would reduce drug prices for Medicare participants. But mounting tension between him and Grogan, a fiscal hawk, is said to be hampering its progress. Grogan has opposed its nearly $180 billion estimated price tag over a decade. Grogan, who once worked for drugmaker Gilead, is not entirely opposed to the rule, which is still under review at the Office of Management and Budget, according to officials close to the situation. But he does not view it as central to the administration’s drug-pricing efforts, as Azar does.

Azar also advocated a rule slated to take effect this month that requires drugmakers to include the list price of their medicines in television ads, which several companies, including Eli Lilly, have sued to stop. Azar has said the rule would give consumers more information about health-care costs and enable them to make more informed decisions.

Just before the midterm elections last fall, he and Trump announced a more controversial proposal to base the price of some Medicare drugs on the lower costs paid by other countries. The proposal seeks to balance Trump’s desire to put U.S. prices on a par with cheaper ones overseas with Republicans’ opposition to the federal government actually negotiating drug prices in Medicare. HHS sent the proposal, opposed by key Senate Republicans and the drug industry, to the Office of Management and Budget for review about two weeks ago.

“We are charging ahead. We are getting drug prices down, and much more is coming,” Azar said recently on Fox News.

In an interview with ABC News last month, Trump said he would unveil a “phenomenal” health-care plan in coming weeks that would be taken up by Congress in 2021, when he said he believed Republicans would control both the House and Senate. Lawmakers and congressional aides do not know what the plan entails, and there is little appetite by congressional Republicans right now to revisit health policy changes after repeatedly failing to repeal and replace the Affordable Care Act during Trump’s first year in office.

A senior administration official said the administration would announce a number of health-care initiatives in coming months.

This story first appeared July 2, 2019, in The Washington Post | by Yasmeen Abutaleb, Josh Dawsey and Laura McGinley