DONALD TRUMP MADE A BIG, SPLASHY ANNOUNCEMENT at the White House on October 16, when he revealed that a key fertility drug manufacturer had agreed to lower some of its prices. There are two important things to know about this development. The first is that the agreement really could help some people. Knocking down the price even incrementally would be no small thing for people scraping together the money to pay for a process that health insurance frequently does not cover at all. The second is that the agreement falls way short of making IVF free, which is what Trump had promised as a candidate. A single course of IVF—which isn’t guaranteed to work—can cost anywhere from $10,000 to $30,000, with drugs typically accounting for less than a quarter of that total. The rest comes from expenses like physician services and lab fees that the agreement on drug prices won’t touch.¹ It’s not even clear how many people will really save from the pledged drug-price reduction. Trump administration officials boasted that EMD Serono, the Merck subsidiary lowering the price of the fertility medication, would start selling its drugs by as much as 84 percent less than the list price. But drug list prices are a bit like sticker prices on the car dealer lot, with the manufacturers negotiating reductions with insurers (or pharmaceutical middlemen) and frequently offering direct discounts to people without coverage, based on need. All of those negotiations are confidential, including the prices, and the Trump administration—as it is wont to do—has released few additional details. “For some people who are on the margin of being able to pay for treatment, this extra lower cost could make a difference,” Stanford University economist Maria Polyakova, who has studied fertility treatment pricing and access, told me. “But then for people who are really priced out of this procedure, I don’t think this is going to be enough.” Presidents fail to deliver on campaign promises all the time, of course. But the free IVF pledge had served an especially important function for Trump while on the trail. It was his way of reassuring supporters anxious about access to fertility treatments following a 2024 Alabama court ruling that IVF’s destruction of unused embryos—those created for IVF procedures but not implanted, and left frozen in IVF clinics—violates that state’s abortion ban. The October 16 announcement makes clear that Trump has backed off the free IVF pledge—at least in part, as the Washington Post has reported, because of objections from anti-abortion groups. That position is not universal among conservatives. The Catholics who have been a major force in the anti-abortion movement oppose IVF on moral and theological grounds. But the evangelical Protestants who form an important MAGA bloc generally support IVF. If Trump were serious about living up to his campaign promises, he could find a way to put together a coalition for passing legislation that would truly make IVF available to all—or, at least, to many more people than it is now. But that would require him to engage with a policy issue at more than a superficial level—and to patiently manage the legislative process rather than lunge for easy PR spectacles promising lots of “Trump babies.” In other words, it would require Trump to be the sort of president he has never been. TRUMP OBVIOUSLY DOESN’T think about policy in the way his predecessors have. He governs on instinct, with a heavy emphasis on self-aggrandizement and self-preservation plus an undisguised disdain for detail. But every once in a while Trump’s instincts take him to interesting, unexpected places. If you go back and listen to or read Trump from twenty or thirty years ago, you’ll find him talking up Canada’s national health care system—“If you can’t take care of your sick in the country, forget it,” he said in a 1999 interview—and expressing pique that Americans were paying so much for prescription drugs while the citizens of other countries were paying so much less.² By the time Trump was running for president, he cared more about trying to undo Barack Obama’s signature legacy (the Affordable Care Act) than making health care a universal right. But he kept decrying the high drug prices in the United States, just as he kept pointing out that Germans, Swedes, Brits, and others were getting a better deal than Americans. That’s not surprising, given how neatly this problem lines up with his belief that other countries are taking advantage of the United States, or at least getting deals Americans aren’t. Prescription drugs are cheaper in other countries because governments negotiate prices directly with manufacturers. And though Republicans have traditionally opposed the idea that the U.S. government should do the same, Trump argued for it during the 2016 presidential campaign—and won. Democratic leaders—longtime champions of the idea—remembered Trump’s vow when they won back control of the House in 2018. Eventually, they passed legislation to give the federal government some negotiating power, with hopes he would pressure the Senate to get behind it. But Trump balked, allowing GOP leaders to kill a bipartisan bill that was working its way through committee. The idea languished until Democrats got full control of the government in 2021, when Joe Biden and Democratic leaders took up the cause and succeeded in passing legislation that—finally—gave the federal government direct leverage over some drug prices. The negotiating process got underway last year, for the first time, and resulted in agreements lowering the prices of costly, commonly used drugs for conditions like cancer, diabetes, and inflammatory disease. Exactly how much money people are saving as a result is unclear for the same reason the potential savings from Trump’s IVF announcement are unclear: All the confidential private-sector transactions make it difficult to pinpoint what people were paying before or after. But early estimates suggest the savings are real, and likely to increase over time as the list of drugs under negotiation grows. The initiative seems to be politically resilient, too. No major proposals to roll back the legislation have made headway in Congress, even though the drug industry wants to kill it and plenty of Republicans would happily do just that. ANY DAY NOW, the Trump administration will announce the result of this year’s annual negotiations. When it does, don’t be surprised if the president brags about what a great deal he’s gotten for the American people—which would be, at least implicitly, validation of what Biden and the Democrats did. But there’s still tons more to do. Biden and his allies had to limit the reach of their reforms in all kinds of ways, like restricting the policy to prices that Medicare pays. They did so, in part, to win over the many Democratic lawmakers who were as beholden to the drug industry as their GOP counterparts. If Trump were serious about continuing to bring down the price of drugs, he could try to strengthen the Biden-era reforms. He could, for example, seek to expand the number and type of drugs subject to price negotiation. He could also push to make the negotiation power broader, so that it affects not only what Medicare (and its beneficiaries) pay for drugs but also what private insurers (and their beneficiaries) pay. Trump could also push an idea he’s long favored: linking prices in the United States directly to prices abroad. Wonks call this “international reference pricing.” Trump calls it “Most Favored Nation pricing” and during his first term he tried to introduce a limited version of it through executive action. The drug industry was able to block that in court, taking advantage of the fact that the Trump administration had crafted its initiative in a hasty, sloppy way that violated rules for how the executive branch is supposed to write new regulations. But Trump this year has promised to try again if drug companies don’t agree to drop prices on their own—in effect, using the threat of his Most Favored Nation idea to badger the pharmaceutical industry into unilateral concessions. That has led to a series of announcements of voluntary price reductions, much like the October 16 IVF announcement. Pfizer and AstraZeneca executives recently appeared at their own, equally splashy White House events to unveil voluntary commitments that they said would make drugs more affordable. These events followed a series of executive orders Trump had issued, including one that he vowed would bring down drug prices by 30 percent to 80 percent—”almost immediately.”³ But as with the IVF announcement, the voluntary commitments by Pfizer and AstraZeneca appear less impressive upon closer inspection.⁴ The companies agreed to sell their drugs to Medicaid programs for lower prices, but the companies already give Medicaid programs a deep discount so it’s not clear how much bigger the savings would be. And whatever the incremental difference, it won’t affect beneficiaries directly because Medicaid already fully covers drugs for them. The companies also offered to drop the price of drugs available directly to consumers through a new website, TrumpRx, that the administration plans to create. But here too it’s tough to know what that really means, given that neither the companies nor the Trump administration have disclosed specifics. And that’s to say nothing of the biggest question hanging over the new voluntary agreements: how long the agreements will last, given that the companies can walk away from their commitments at any time. That’s why the most enduring way to bring down drug prices would be to pass legislation. And while Trump might have trouble finding allies in his own party to do that, he’d find plenty among the Democrats, many of whom have already indicated their support for the idea. An early version of the drug-pricing legislation they ultimately passed under Biden actually had a form of international reference pricing.⁵ But to get that support, Trump would have to ask. He would also have to start governing like a normal president. That’s not how he operates, which is why the real news about his announcements on drug pricing is less about what they will accomplish and more about what they likely won’t. 1 The Trump administration also announced it would write regulations making it easier for companies to offer workers health insurance to cover IVF. But officials once again offered few details, and there’s little reason to think tweaking regulations would have much of an impact. 2 Trump’s 2000 bestseller The America We Deserve also called for universal health care. Dave Shiflett, the book’s ghostwriter, once told me Trump had conveyed the impression that he just “liked the idea of everybody having insurance. He didn’t sit around thinking about policy. I just think that, instinctively, he figured it was the right thing to do.” 3 Trump at times has made even more audacious promises—including the time he said his plan would “be reducing drug prices by 1,000 percent—by 900, 600, 500, 1,200.” Evidently he hopes not only to go after high drug costs but also to repeal the laws of mathematics. 4 A recent episode of WBUR’s On Point had a terrific overview of the recent announcements and their possible implications. 5 At least some Republicans might be interested as well—among them, Missouri Senator Josh Hawley, who has cosponsored a bipartisan bill that would use a form of international price indexing. The Democratic cosponsor is Vermont Sen. Peter Welch, a longtime champion of giving government more power over drug prices. You’re a free subscriber to The Bulwark—the largest pro-democracy news and analysis bundle on Substack. 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