UPDATED: Pharma loves free trade. How will it get along with a protectionist President Trump?

During his campaign, President-elect Donald Trump vowed to clamp down on trade deals and backed price-negotiating powers for Medicare. Photo by Michael Vadon.

Actual issues didn’t get much play during this year’s contentious, invective-filled presidential campaign. But when the election spotlight did focus on policy rather than personality, it spent a disproportionate amount of time on prescription drugs. The high price of prescription drugs, to be specific.

By November, the American people didn’t agree on much, but they did agree on one thing: Drug prices should be high on a new president’s to-do list, even higher than Obamacare, according to a poll by the Kaiser Family Foundation.

Now, it’s up to President-elect Donald Trump to craft that to-do list, and drug prices didn’t rate nearly as highly, issue-wise, as they did for his Democratic rival Hillary Clinton. Repealing Obamacare, on the other hand, was a signature promise. Indeed, drug stocks were up premarket Wednesday morning as fears of a government drug-pricing crackdown lifted, with Big Pharmas like Pfizer (up 9.5%) and Merck & Co. (up 5.5%) among the leaders. Mylan, at the center of the EpiPen controversy, saw shares rise 6% early in the day, and Valeant shares jumped 4.8%.

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But drug pricing action of some kind is still likely, analysts say, perhaps as part of an Obamacare overhaul. On Medicare Part D, “Trump’s position is identical to Clinton’s,” Evercore ISI Group analyst Terry Haines said via email; the president-elect believes price should be part of the equation in Medicare coverage negotiations. “Trump can make inclusion of that a condition of signing an [Affordable Care Act] reform bill.”


Related: Time for GOP to prove it has a better plan for healthcare reform


In January, Trump told a crowd of 1,000 people in Farmington, NH, that Medicare could save $300 billion a year by negotiating discounts. "We don't do it," Trump said. "Why? Because of the drug companies."

Trump favors another cost-saving move that has repeatedly failed in Congress, and could conceivably include it in ACA reform, too: drug reimportation, which would allow Americans to buy their prescription meds from other countries where prices are lower. Drugmakers are set against reimportation in the U.S.; after all, their sales have suffered from similar parallel trade within the EU.

Meanwhile, Trump’s trademark issue--trade--could have more wide-reaching effects on the pharma industry, if he follows through on his radical anti-free trade promises. The pharma market is global, heavily reliant on foreign sales and on products manufactured outside the U.S., including China, which Trump has specifically targeted. Drugmakers want more free trade, not less; just witness Big Pharma’s backing of the Trans-Pacific Partnership (TPP), a sweeping agreement that Trump has denounced as all but evil.

“These trade deals are lifeblood for the protections of the intellectual property that pharma maintains,” Dan Mendelson, president of the consulting firm Avalere Health, told Fortune in August. “When you start going in and saying we’re going to rip these up, you upset the balance.”

Presidents have far more authority to act directly in international trade than they do to push action domestically, and Congress has less power to interfere, trade experts say. Trump has pledged to walk back the North American Free Trade Agreement, which would raise barriers to pharma’s cross-border operations in Mexico and Canada. He’s said he’d withdraw from the World Trade Organization. TPP would be dead. Other open-market moves, ditto.

Theoretically, U.S. tariffs and other protective measures encourage export and discourage imports; they would incentivize companies to make their products in the U.S. for consumption in the U.S. market. It’s complicated to transfer manufacturing of any product, but for prescription drugs, the hurdles are enormous, and all manufacturing changes are regulated by the FDA.

And trade agreements are far more important in pharma than in many other industries: They’re not just about the flow of goods, but about intellectual property protections, too. Trade deals help ensure that pharma’s proprietary data and products remain so.

Pharma backed the TPP, for instance, partly because it would strengthen patents in countries where protections are weaker than they are in the U.S. Some of the fastest-growing pharma markets in the world would be covered by that deal. China was not, and nor was India, partly because it feared its own pharma industry would suffer. That's the country, after all, where officials have revoked some drug patents and, in one case, forced a Big Pharma company, Bayer, to allow a generics maker to knock off its cancer drug Nexavar. 

Trade could thus shape up to be a bigger conflict with the new president than drug pricing. While private payers will continue to put the squeeze on pharma in the pricing realm, drugmakers and their advocates will have to figure out how to work with--or against--Trump on trade. That could be touchy, Mendelson told Fortune. “Every health care group in Washington is feeling very ginger about picking its battles,” he said. “If you criticize him, you make yourself the subject of his ire.”

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