The future of one of President Joe Biden’s most important domestic policy achievements — getting Medicare to negotiate drug prices — could either become part of the Biden administration’s legacy, be rolled back by the incoming Congress or weakened by President-elect Donald Trump’s administration.

Trump has remained relatively bullish on the drug pricing provisions of the 2022 reconciliation law, and its future looks even bleaker now that Republicans will control both the House and Senate.

“The Trump campaign did not express a position on drug price negotiation specifically, but congressional Republicans are not fans of this program and introduced legislation to repeal the IRA in its entirety,” said Juliette Cubanski, deputy director of the Medicare policy program at KFF, a health research organization, referring to the law with its nickname, an abbreviation for the Inflation Reduction Act.

Trump will find himself responsible for administering the program after the Jan. 20 inauguration. While he supported Medicare price negotiations in the past, it’s unclear where he stands on the issue now. His campaign backed a similar proposal that would tie drug prices paid in the United States to prices paid by other countries.

Medicare drug price negotiation was passed as part of the 2022 reconciliation bill, which allows the administration to negotiate with drug companies on the prices of 10 high-priced drugs starting last year. The Biden administration said the negotiated rates, which go into effect Jan. 1, 2026, would have saved Medicare $6 billion if they were in effect last year.

More than a dozen lawsuits targeting the program are also still pending in the courts, and the Trump administration’s Justice Department must decide whether it will continue to defend it. Should it decide not to, the strategy would mirror that of the Trump administration decision 2018 failing to defend the 2010 health care law in a lawsuit filed by the Republican attorney general.

Trump has also shown a willingness to downplay the policy accomplishments of his predecessors, including his handling of the 2010 health care law during his first term that saw enrollment declines compared to the Obama administration.

“It’s really unclear at this point where the incoming Trump administration will take the Medicare price negotiation program,” Cubanski said.

Trump’s transition team did not return a request for comment.

Congressional reaction

While it’s unclear how Trump feels about Medicare price negotiations, congressional Republicans loathe it, likening it to “government price controls” that reduce pharmaceutical companies’ research and development of new drugs.

Some have vowed to repeal it, but Senate Republicans, who will control the chamber starting next year, do not have a majority that can clear the 60-vote threshold.

But they could likely use reconciliation — a budget maneuver to avoid the 60-vote requirement used by Democrats to pass the law in the first place.

But repealing the drug pricing regulations could be difficult because it saves money — the Congressional Budget Office estimated that the negotiated provisions alone would reduce the deficit by $25 billion by 2031.

Rep. Earl L. “Buddy” Carter, R-Ga., who serves on the House Energy and Commerce Committee, said in an interview that he would like to see the committee work to undo the drug price bargaining provisions in the next Congress.

“My hope is that it will be eliminated,” he said. “In 10 years in the state legislature and 10 years in Congress, this is the worst piece of legislation I’ve ever seen.”

But Democrats have fought for the program. Senate Health, Education, Labor and Pensions Chairman Bernie Sanders, I-Vt. has appeared with Biden to present the achievement.

If the drug pricing regulations were to be rolled out, said Sen. Tina Smith, D-Minn., “it would be a huge gift to Big Pharma.”

Cubanski warned that the Trump administration may not have much flexibility in how the regulations are implemented.

“There’s a lot of detail in the statute about how the program is going to be implemented that in many ways doesn’t give the administration a lot of leeway,” Cubanski said.

Implementation of the law

Still, the administration will have the ability to issue guidance about how the negotiations will work, including how many meetings will take place between the government and drug manufacturers.

The Trump administration will face some important deadlines shortly after the inauguration on January 20.

By February 1, the administration must select up to 15 drugs for which Medicare will negotiate prices. It’s possible the Biden administration will select these drugs before Trump takes office, but the new administration would likely want to revisit that, said Jeffrey Davis, health policy director at McDermott+, a health lobbying, advocacy and policy strategy firm. “It’s a pretty quick deadline,” he said.

“Legally, they are required to implement the Inflation Reduction Act,” he said. “But even if they have to, they can delay implementation or say they need more time.”

He added that the Trump administration could decide to deprioritize the program by shifting staff and resources away from it toward other priorities, just as he similarly deprioritized the administration of the 2010 health care law.

He unilaterally suspended payments to insurance companies intended as reimbursements to reduce cost-sharing for patients. The insurance companies sued and won. But it is not clear who would have the right to sue over the drug negotiation program.

Project 2025 — the blueprint for a second Trump term that was denounced by the campaign but written by many of his former and current advisers — calls for the program to be repealed.

“Until the IRA is repealed, an administration charged with implementing it must do so in a manner that is careful with its authority, minimizes the harmful effects of the Act’s policies, and avoids even worse unintended consequences,” the plan states.

While negotiation is popular in pollsit is still not widely known among the public, and Republicans can claim the election results as their broad mandate to repeal it.

“An effort to lower drug prices is incredibly popular, so I think there would be a lot of questioning whether they would try to roll back measures that would result in higher drug prices,” Eugenia Pierson, chair of the Legislative and Public Policy practice group at the law firm Arnold & Porter, said in an interview with CQ Roll Call.

Part D pilot program

Trump will also have to decide on a demonstration program launched by the Biden administration this year aimed at preventing premium increases in Medicare Part D that were triggered by the law shifting more drug costs to insurers as it capped beneficiaries’ out-of-pocket costs. .

The stabilization program will cost $5 billion and involve a $15 per member per month subsidy to plans and a $35 per year premium increase cap on a plan’s total Part D premium.

Republicans have called the $5 billion pilot an “uncontrolled taxpayer-funded bailout to paper over the deficiencies in the Inflation Reduction Act.”

When Trump takes office, it will be too late for him to roll back the first year of the pilot. But he could easily wrap it up before the next open enrollment period, which typically begins in October. That would likely lead to premium increases for patients, Cubanski said.

“Without these additional subsidies (to plans), one could imagine a scenario where these premiums increase significantly above current levels,” Cubanski said.

Pierson pointed out that there are drug pricing provisions in the law that will more immediately lead to lower costs, pointing to the provision that caps out-of-pocket costs at $2,000 starting Jan. 1.

Pierson said that if Vice President Kamala Harris had won the election, the central question would be whether to push CMS to be more aggressive in drug price negotiations.

“That’s changing now … as we expect a Trump administration,” she said.