President Donald Trump on Thursday will unveil a plan to overhaul how Medicare pays for certain drugs, attacking “foreign freeloaders” that he says have driven up costs in the U.S. The bold move addresses a Trump campaign pledge to lower drug prices, just days before the tightly contested midterm elections in which health care is playing a pivotal role.

Trump is scheduled to outline the details in a speech at HHS at 2 p.m., his first address at the health department. The proposal, described to POLITICO by three individuals with knowledge, still needs to be refined and put through a federal rulemaking process.

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The proposal, which was sent to the White House earlier this month, would use Medicare’s innovation center to test three ways to lower the costs of drugs — including negotiating for some drugs that are directly administered by doctors, in hopes of keeping them in line with the lower prices paid in many other countries. The proposal applies only to drugs administered in doctors’ offices and outpatient hospital departments — medicines like cancer treatments and injectable treatments for rheumatoid arthritis or eye conditions. It won’t affect most prescriptions purchased by patients at local pharmacies.

The Trump administration will say that Medicare could save more than $17 billion over five years, with the cost of some drugs dropping by as much as 30 percent.

HHS did not immediately respond to requests for comment.

The administration is bracing for blowback, said one official, noting that hospitals and doctors — and of course the drug companies — all have reason to be unhappy about a plan that will cost much of the health sector money. The drug industry and its allies have lots of lobbying clout; a less ambitious effort by the Obama administration to address Medicare Part B prices fizzled in late 2016.

“Nobody’s going to like this,” said the official. “It antagonizes too many people.” But Trump’s proposal could appeal to patients — who stand to benefit from lower prices — and Democrats, who have chastised the Trump administration for not using all of its regulatory power to cut drug prices, which polls have shown are a concern of Republican and Democratic voters alike.

Health care has emerged as a hot issue in the midterms, with Democrats making gains by pledging to protect Obamacare protections for people with pre-existing conditions. Those protections would have been undermined in GOP repeal bills and are now threatened by a White House-backed lawsuit brought by conservative states. Trump’s pivot to drug prices could help Republican candidates needing a winning message on health.

The administration proposal has several strands, all of which dramatically shake up the industry that right now has vast control over setting Medicare drug prices.

Under the planned “international pricing index,” U.S. drug prices would be benchmarked against 16 other nations — Austria, Belgium, Canada, Czech Republic, Finland, France, Germany, Greece, Ireland, Italy, Japan, Portugal, Slovakia, Spain, Sweden and the United Kingdom — where target drug prices are collectively 44 percent lower. Prices would slowly be lowered to international levels over five years.

The Trump administration also wants to experiment with letting private sector vendors negotiate with drug makers. That strategy is modeled on how health insurers negotiate drug prices in Medicare’s Part D program, which covers outpatient drugs for older Americans. Medicare would test this approach in certain geographic areas, where participation would be mandatory for physicians and hospitals.

Not all drugs would be included in this test. CMS would focus on drugs made by just one company (which tend to be expensive) and biologic medicines, which make up a large share of Medicare Part B spending.

Under the third branch of the strategy, officials would try changing incentives for doctors to prescribe drugs. Under Medicare’s current system, doctors often have incentives to prescribe more expensive drugs, because they get a fee based on the price. Changing that to a flat fee — instead of a percentage — could help nudge doctors to use less expensive medications.

Beyond Trump’s speech, administration officials are planning a communications blitz, with HHS releasing a report on Thursday morning that lays out the high prices with Medicare’s Part B program, and top officials deploying through the end of the week. CMS also will begin inviting comments and announce that it may propose the rule in the spring of 2019 with an eye toward starting the program in spring of 2020.

When President Barack Obama sought to test new ways to pay for physician-administered drugs, the blowback came from fellow Democrats, as well as from Republicans, doctors, hospitals and patient groups. It never got off the ground.

But Trump will tout his plan as part of his “America-first” agenda, blaming other nations for paying too little for drugs and relying on Americans to absorb the higher prices that fund new pharmaceutical innovation. The president has repeatedly demanded that other nations pay more for medicines, a move that he’s claimed would enable the U.S. to get better deals.

However, Trump’s proposal does not appear to immediately affect what other nations pay. Instead, his ideas borrow from other countries’ playbook — a gambit to align high U.S. drug prices with the rest of the world, which spends far less on the same medicines.

MIAMI — The second and final gubernatorial debate between Tallahassee Mayor Andrew Gillum and former GOP Rep. Ron DeSantis boiled down to two issues: race and corruption.



Coming in the wake of new revelations about an FBI probe that has haunted Gillum’s campaign — and a series of racial controversies and racist robocalls to which Gillum has sought to tie DeSantis — the debate spoke volumes about the state of the intense campaign for Florida governor less than two weeks before Election Day.

For an hour, the candidates sparred over virtually every topic, from school spending to taxes to healthcare to immigration to gun control. But it was all overshadowed by charges and counter-charges over radical associations, neo-Nazis and misuse of tax money

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“I’m not calling Mr. DeSantis a racist. I’m saying the racists believe he’s a racist,” Gillum said in one of the most caustic exchanges of the night, during an exchange about immigration.

Gillum — the first African-American nominee for Florida governor from any major political party — has increasingly spoken about race in recent days and accused Republicans of using racially coded attacks in criticizing him about a federal corruption probe swirling around Tallahassee, where Gillum is mayor.

The issue gained renewed attention Tuesday when a Republican attorney representing Gillum’s former friend and current lobbyist, Adam Corey, released evidence he gave to the state ethics commission that showed an undercover FBI agent provided Gillum a ticket to the musical “Hamilton.” Gillum said the ticket came from his brother, who was also on the trip. But the text messages showed Corey had told him the tickets were from the man now known as “FBI Mike.”

At the first gubernatorial debate on Sunday, DeSantis pressed Gillum to disclose who paid for the tickets. Gillum ducked the question. And on Wednesday, DeSantis said the response was a sign of deception.

“He did not tell the truth about any of that,” said DeSantis, who added that Gillum should ask the Florida Commission on Ethics to remove confidentiality programs tied to its investigation, which is separate from the FBI probe.

Gillum explained that he believed the tickets had been essentially paid for by his brother, who had compensated Corey by swapping tickets to a Jay-Z and Beyonce show. “But,” he said, “I take responsibility for not having asked more questions.”

Gillum downplayed the issue as relatively trivial.

“We got 99 problems and ‘Hamilton’ ain’t one of them,” Gillum quipped, quoting a Jay-Z lyric to applause.

He then tried to turn the table, going after DeSantis for not disclosing all the records related to $145,000 in taxpayer-funded travel he took while in Congress. The travel was first reported by the Naples Daily News.

“We knew he used some of that money to go to Fox News to run his campaign,” said Gillum of one of the trips, which came before DeSantis was a declared gubernatorial candidate. “Why don’t you set the example and release your receipts?”

Gillum also accused DeSantis of hypocrisy for using his position in Congress, from which he has since resigned, to try to block Robert Mueller’s investigation into Russian efforts to sway the 2016 election — an investigation that has netted multiple indictments and convictions, unlike the Tallahassee corruption probe.

DeSantis, a former federal prosecutor, said he was performing “oversight” and was trying to get rid of “bad apples” in the FBI.

“When I worked with the FBI, I was doing it as a prosecutor to bring people to justice. When Andrew is dealing with the FBI, he’s dealing with an undercover agent as a person of interest in an investigation,” DeSantis said.

DeSantis criticized Gillum for his support of a “radical” social justice group called the Dream Defenders, which is critical of police as well as of the state of Israel. Gillum signed the group’s “Freedom Pledge,” which is intended to oppose the National Rifle Association and private prison companies. But it also calls for spending more on social services by reducing law-enforcement funding, which police unions and DeSantis oppose.

“I’m not going to sit here and take this nonsense from a guy like Andrew Gillum who always plays the victim, who is going out and aligning himself with groups that attack our law enforcement, and attack our military,” DeSantis said.

DeSantis, however, grew testy when asked about some of his associations, specifically his attendance at conferences organized by conservative David Horowitz, who had said that “the country’s only serious race war is against whites” and had asked “if blacks are oppressed in America, why isn’t there a black exodus?”

Almost as soon as moderator Todd McDermott, an anchor for West Palm Beach’s WPBF, began asking his question, DeSantis interrupted him and said it sounded “McCarthyist.” He also questioned McDermott’s research about Horowitz.

“He never made those statements,” DeSantis interjected before McDermott cut him off to assure him they were, in fact, made at the time of the conferences where DeSantis spoke.

That’s when DeSantis lost his temper.

“How the hell am I supposed to know every single statement someone makes?” DeSantis said loudly. “I’m not going to bow down to alter of political correctness, I’m not going to let the media smear me!”

McDermott insisted that DeSantis misconstrued the question he intended to ask. He then turned to Gillum, who smirked.

“As my grandmother used to say: ‘a hit dog will holler,’” Gillum said. “Mr. DeSantis has spoken. He’s got neo-Nazis helping him out in this state. He has spoken at racist conferences. He’s accepted a contribution — and would not return it — from someone who referred to the former president of the United States as a ‘Muslim n-i-g-g-e-r.’” Gillum spelled out the racial epithet onstage, letter by letter.

That’s when Gillum said racists believed DeSantis was a racist.

DeSantis replied by noting the conferences he attended with Horowitz also featured upstanding citizens, including a Medal of Honor recipient. And DeSantis also recalled his own service in the military.

“When I was downrange in Iraq, we worked together as a team regardless of race. We had the American flag on our arm,” DeSantis said. “We wore the same uniform. And we fought for the country. And when I was a prosecutor, I stood up for victims of every race, color and creed. It’s the only way to do it in our country.”

In the run-up to the bitter exchange, the two sparred over immigration.

Gillum said he wants to abolish U.S. Immigration and Customs Enforcement and place immigration enforcement under the Department of Justice. He also noted that the so-called “sanctuary cities” that DeSantis had expressed concerns about don’t exist in Florida. DeSantis, however, said the sanctuaries will come to Florida if Gillum is governor and allows local law enforcement to not cooperate with the federal government, a charge Gillum denied.

Gillum said DeSantis supports “racial profiling” of people with brown skin or of those who “speak a language that may be [a] foreign tongue to Mr. DeSantis.”

DeSantis said Gillum “hates Trump so much” that he would allow illegal immigrant pedophiles to be released into communities rather than cooperate with the federal government to deport them.

“That child molester will re-offend. And someone’s son or daughter in Florida will end up paying the price,” DeSantis said as boos rose from the crowd.

“Shame,” Gillum said.

“It’s true,” DeSantis said.

“Shame on you,” Gillum replied.

“It’s true. The truth hurts,” DeSantis said.

Gillum said the statement showed how DeSantis won’t tell the truth: “It is consistent with the way in which Mr. DeSantis has run his campaign.”

Elections

Republican incumbents are getting pummeled after voting to scrap protections for pre-existing conditions.

For weeks, vulnerable Rep. Glenn Grothman had been getting pummeled by his Democratic opponent for voting to curb protections for people with pre-existing conditions — most recently with an attack ad depicting a little boy with an oxygen mask over his face gasping for air.

So on a conference call with GOP leaders last week, Grothman pleaded with party leaders to invest in a nationwide TV ad that could run in competitive districts like his, defending the House GOP’s Obamacare repeal bill that passed the chamber last year, according to three sources on the call.

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You’re on your own, was the response. It would be too expensive, Republican leaders told Grothman.

House Republicans are increasingly worried that Democrats’ attacks on their votes to repeal and replace Obamacare could cost them the House. While the legislation stalled in the Senate, it’s become a toxic issue on the campaign trail for the House Republicans who backed it.

Toxic and ubiquitous: Democrats have maintained an almost single-minded focus on health care in their campaign messaging. More than 54 percent of pro-Democratic campaign ads in federal races mentioning the issue between mid-September and mid-October, according to a recent study by Wesleyan University’s Media Project.

Data provided by Advertising Analytics shows that Democratic candidates and left-leaning outside groups have spent $90.3 million on health care ads this cycle. That’s 43 percent of all the total $209.1 million they’ve spent on TV ads.

Republicans have tried to fend off the attacks by accusing Democrats of lying — and by trying to claim that they’re the ones who want to protect insurance safeguards for the infirm. In a Tuesday morning tweet, President Donald Trump wrote that “Republicans will totally protect people with Pre-Existing Conditions, Democrats will not! Vote Republican.”

But those claims ring hollow given what Republicans voted for last year. The House bill allowed states to opt out of provisions protecting the elderly and the sick from higher premiums in hopes of lowering costs for everyone else.

On top of that, the Trump administration has been trying to repeal Obamacare — including its popular safeguards for the sick — through a lawsuit supported by 20 GOP state attorneys general, including two of four Republicans running in competitive Senate races who have endorsed the court challenge.

That’s given Democrats ample fodder to dog vulnerable Republicans on an issue that’s increasingly driving voters to the polls.

“I’m getting my ass kicked” for backing the House repeal plan, Republican Rep. Martha McSally, who’s running for an open Senate seat in Arizona, acknowledged to Sean Hannity this week. Though she insisted that the repeal bill is “being misconstrued by the Democrats,” it’s clear she thinks the ads are taking a toll.

“They’re trying to invoke fear in people who have family members and loved ones with pre-existing conditions,” she told Hannity. McSally is airing her own ad in response claiming that she’s “leading the fight to … force insurance companies to cover pre-existing conditions.”

Grothman represents what’s been a GOP stronghold in Wisconsin, but the health care attacks have contributed to a tightening of the race, Democrats say. Grothman has been forced to spend money parrying the attacks, and he argued during a debate against his challenger, Democrat Dan Kohl, last night that he never voted to gut protections for people with pre-existing health problems.

“I’m Glenn Grothman and I won’t take a dime from pharmaceutical companies,” Grothman said in a new ad released this week.

The video aired just a few days after Kohl’s ad depicting the sick child and asserting that “insurance companies love Glenn Grothman,” because he “does what they want, so they give thousands to his campaigns.”

“Health care is the No. 1 issue I hear about on the trail,” Kohl said in an interview Wednesday. “People here are rightfully concerned about their health care being taken away.”

Sen. Chris Murphy (D-Conn.) said in a recent interview that his party’s “turnout data tells us health care is the No. 1 issue that’s going to move low-frequency Democratic voters to the polls in a few weeks.”

While the debate over health care used to favor Republicans, a Washington Post/ABC News poll released last week found that voters trust Democrats on the matter more than Republicans by a 53-35 percent margin.

The idea of scuttling protections for preexisting conditions is unpopular across the political spectrum. More than seven in 10 voters, including two-thirds of Republicans, said it should be illegal for insurers to be allowed to charge more for coverage of individuals with earlier health problems, according to a Morning Consult poll released last month.

Senate Democratic candidates have intensified their focus on health care in the campaign in recent days, after Majority Leader Mitch McConnell (R-Ky.) said that he could take another crack at repealing Obamacare next year, depending “on the outcome of the election.” Murphy described that interest in revisiting Obamacare repeal as “a gift” to Democrats, and Senate Republican candidates are tiptoeing around the issue.

Indiana GOP nominee Mike Braun, who’s running neck-and-neck with Democratic Sen. Joe Donnelly, walked that rhetorical tightrope on Wednesday. He told reporters on a conference call that he “won’t be for [Obamacare] repeal unless we’ve got a great replacement” that addresses pre-existing conditions as well as caps on coverage that Obamacare eliminated.

“When we do repeal” Obamacare, Braun said, “we need to have something ready to go or else we will lose the trust of the public that we’ve got something that’s going to replace it.”

McConnell, for one, has praised Senate GOP candidates for being “able to deal with” the onslaught of Democratic ads slamming his party on Obamacare repeal.

“There’s nobody in the Senate that I’m familiar with who’s not in favor of covering pre-existing conditions,” the Senate GOP leader told Bloomberg last week.

Dodging the topic is tougher for House Republicans because many of them voted for repeal. The text would have allowed states to define their own “essential health benefits” rather than using Obamacare’s definition of health care services that all insurance companies had to cover. And states could decide to opt out of requirements that insurance companies charge healthy and sick people the same.

Additionally, the bill would have given insurance companies more leeway to charge seniors higher premiums; Democrats and the AARP have called that proposal an “age tax.” A recent Democratic attack ad in GOP Rep. Brian Mast’s coastal Florida district, a hotspot for retirees, highlighted the vulnerable lawmaker’s vote for the House GOP replacement plan.

“Here at home, Brian Mast’s votes could increase premiums almost $3,000 per family,” the narrator says in the ad. “Florida can’t afford to pay more for health care. And we can’t afford Brian Mast.”

House Republican are trying to argue that their failed bill would have protected people with pre-existing conditions because it also created a stopgap, or “risk pool,” to cover anyone priced out of the market. But the bill had a finite amount of funding for that: $138 billion, which some health care analysts said was way too little to work.

Democrats like Kohl are calling the GOP claim that they’re protecting sicker individuals a “flat-out lie.” And Democrats around the nation predict that Republican attempts to wiggle away from the effect of their Obamacare repeal legislation won’t pass muster with the electorate.

“Once the Titanic hits the iceberg,” said veteran Democratic strategist Jesse Ferguson, who works with multiple health care groups, “you can’t fix the problem by changing your navigation system.”

James Arkin and Adam Cancryn contributed.