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Donald Trump started his presidency with a pledge even more audacious than Obamacare repeal: He was going to bring down drug prices.

But four months in, with his policy agenda weighed down by Congress's health care debate, not to mention assorted other distractions, it's fair to wonder whether Trump will ever get around to fulfilling his pledge.

Trump notably elided a big opportunity today to lay down an ambitious marker on drug prices: His budget, a document that is in reality nothing more than a wish list, doesn't include any of the major drug pricing overhauls he has supported in the past.

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Despite the huge — and politically untenable — spending cuts in Trump's budget, effectively none of the savings come from the drug industry.

"Indeed, they have proposed huge cuts to get the budget to balance without touching drug pricing at all," Len Nichols, a health policy professor at George Mason University, said in an email.

The budget doesn't ignore the industry entirely. It calls for reopening negotiations on the funding drugmakers provide to the Food and Drug Administration, a move that will surely rankle industry and Congress, and nods to encouraging more contracts that pay drugmakers for the value their treatments provide, not just the list price companies set.

But given the blank slate of his budget, Trump skipped the enterprising reforms — like direct Medicare negotiations of drug prices — that he has touted before, back when he claimed drugmakers were "getting away with murder."

Lobbyists and other sources who track the drug pricing debate made two points worth considering after Trump's budget landed.

1. This budget likely reflects White House budget director Mick Mulvaney's priorities more than Trump's.

It notably cuts Medicaid and Social Security Disability Insurance, after Trump promised repeatedly as a candidate not to touch those programs. Mulvaney, an archconservative when he was in the House, is a spending hawk; Trump is not.

The same principle could be applied to drug prices, several sources told me.

"I don't think Trump himself feels any need to pull punches with drug pricing, and my instinct is to chalk it up to Mulvaney and those guys preparing the budget and they probably don't care about it," one lobbyist said.

Or as another put it more bluntly: "There’s only one person in the administration who truly cares about drug pricing, and he’s busy doing other things (firing Comey, leaking to Russia, etc.). There’s simply no one else in the administration who wants to cross pharma."

A related implication here is that Trump isn't ready to expend much political capital or attention to the issue — which most observers think is necessary for any meaningful changes.

2. Trump is still hell-bent on Obamacare repeal, so he can't rock the boat with Republicans on drug prices.

The president's rhetoric on drug prices made him very unorthodox for a Republican; the party prefers to talk about increasing competition rather than direct government intervention.

There may be a political calculation in the White House's decision to forgo a debate on drug prices, even in a symbolic document like the budget. Passing the American Health Care Act proved unexpectedly difficult in the House, and the Senate might be equally tough.

No need to muddy the health care discussions further by simultaneously pushing for contentious pharmaceutical reforms.

"I think with AHCA in the balance, they weren't gonna rock the boat with Republicans on any issue," a third health care lobbyist said.

Trump could still return to the drug pricing issue — it has a way of surfacing when the president needs a populist mantle.

More incremental reforms might be simply more practical; there are plenty of doubts about whether something like Medicare negotiations would actually achieve the savings its supporters believe. It's really hard to say which policies would actually help to lower costs, a point most experts on the topic readily admit.

"It could be that drug prices is a populist campaign issue but hard to actually address," Caroline Pearson at Avalere Health told me. "The policies affecting drug prices are complicated, and finding market-friendly solutions may be more difficult than the administration anticipated."

Whether it's politics or pragmatism driving Trump at the moment, the experts tracking this issue aren't ready to put it to bed just yet. Another legislative debate that demands spending cuts, or even the need for the Independent Payment Advisory Board to find Medicare savings, could still lead to action.

"Either way, I don't think we can assume drug pricing policy is off the table," Pearson said. "It could resurface during legislative debate if they are looking for offsets. It could also be pursued through administrative action or as a result of the IPAB being triggered."

But for now, Trump seems to be taking his foot off the industry's neck.

Chart of the Day

The stunning Medicaid cuts in Trump's budget. Remember: Medicaid is the single biggest insurer in the country, and the president promised more than once not to cut the program. Read more from Sarah Kliff here.

Kliff’s Notes

Your daily top health care reads, with research help from Caitlin Davis

Today’s top news

"Price pushes Congress to follow Trump plan for more FDA user fees" : “The request, made in a letter to Senate HELP ranking Democrat Patty Murray, could threaten deals the agency already struck with name-brand, generic and biosimilar manufacturers, as well as device makers, by forcing the industries to ante up more than they committed. The user fee legislation would cover payments from fiscal 2018 to fiscal 2022.” —Sarah Karlin-Smith, Politico

“The request, made in a letter to Senate HELP ranking Democrat Patty Murray, could threaten deals the agency already struck with name-brand, generic and biosimilar manufacturers, as well as device makers, by forcing the industries to ante up more than they committed. The user fee legislation would cover payments from fiscal 2018 to fiscal 2022.” —Sarah Karlin-Smith, Politico "Trump wasn’t always so linguistically challenged. What could explain the change?" : “Research has shown that changes in speaking style can result from cognitive decline. STAT therefore asked experts in neurolinguistics and cognitive assessment, as well as psychologists and psychiatrists, to compare Trump’s speech from decades ago to that in 2017; they all agreed there had been a deterioration, and some said it could reflect changes in the health of Trump’s brain.” —Sharon Begley, STAT

“Research has shown that changes in speaking style can result from cognitive decline. STAT therefore asked experts in neurolinguistics and cognitive assessment, as well as psychologists and psychiatrists, to compare Trump’s speech from decades ago to that in 2017; they all agreed there had been a deterioration, and some said it could reflect changes in the health of Trump’s brain.” —Sharon Begley, STAT "Trump wants to cut health research. This Republican won’t let him.": "In the administration’s first comprehensive budget proposal, out today, Trump is expected to call for a $5.8 billion trimming of the National Institutes of Health’s budget as part of an effort to curtail spending while increasing America’s already gigantic defense budget and expanding tax cuts. But that request will likely be dead on arrival in Congress.” —Julia Belluz, Vox

Analysis and longer reads

"The last clinics" : "Across the country, the number of abortion clinics has been declining for years, and after another clinic closed in West Virginia in January, seven states have just one abortion provider left. (An eighth, Arkansas, has only one full-service provider offering both medication and surgical abortions.)" —Allison McCann, Vice

"Across the country, the number of abortion clinics has been declining for years, and after another clinic closed in West Virginia in January, seven states have just one abortion provider left. (An eighth, Arkansas, has only one full-service provider offering both medication and surgical abortions.)" —Allison McCann, Vice "6 States Hoping to Revamp Medicaid in the Trump Era": "governors on both sides of the aisle are anxiously awaiting to see what happens. In the meantime, some are trying to make their own changes to the health-care system in their state — and have the best chance of doing so in years." —Mattie Quinn, Governing

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