Trump on Thursday grilled Azar about the administration’s new plan to let states import drugs from Canada, with a focus on how it would affect his reelection prospects in battleground states like Florida, according to two individuals. Azar, whose job does not appear to be in jeopardy, and other officials have promised Trump that the new importation plan will play a significant role in lowering drug costs, although some experts have derided the idea as a political stunt.

Voters have consistently said they trust Democrats more than Trump to handle health care issues, a gap that widened since Republicans’ extensive efforts to repeal the Affordable Care Act during his first year in office. Trump has often defended his record on Obamacare in misleading terms, including this week when he tweeted that he “Saved Pre-Existing Conditions in your Healthcare.” Trump’s claims were roundly rejected by fact checkers, who pointed to the administration’s long-running efforts to weaken Obamacare’s protections, including its support for a lawsuit that could kill the entire law.

Since last year, the White House has worked to redefine the president’s health care agenda, touting his actions on public health as it tries to move past Republicans' failure to replace Obamacare. The administration has announced significant proposals to overhaul U.S. kidney care, boost funding to fight HIV and take other public health steps that have received bipartisan support.

Trump on Thursday also pressed Azar on the administration's new restrictions on flavored e-cigarettes, said a senior administration official. That effort, once seen as a boon to his public health agenda, has been more controversial.

The Trump administration earlier this month released a slimmed-down ban on flavored vapes, prompting criticism from public health groups and Democrats who said it wasn't enough to combat the sharp rise in youth use of e-cigarettes. The administration backed away more sweeping restrictions after vaping advocates pointed to controversial polling data that an extensive ban would harm Trump's reelection bid in battleground states.

One official briefed on Trump's call with Azar said the president was not initially in an angry mood — even if the call turned tense at times. The official said Trump wanted to check on the status of several health care initiatives he sees as key to campaign.

Azar's job is believed to be secure, said three people, particularly given the difficulties of replacing a Cabinet secretary in an election year. Azar last year clashed with the White House over multiple health proposals and was enmeshed in a high-profile dispute with Medicare chief Seema Verma. Senior White House officials instructed Azar and Verma in December to end their clash.

A White House spokesperson asked about Thursday's call said that Trump and Azar are working together on a range of health care initiatives.

"There’s no daylight between the White House and HHS as we work to implement the president’s policies and improve the American health care system for everyone, not just those in the individual market,” said the spokesperson, Judd Deere.

HHS declined to discuss the details of the call, which was first reported by the New York Times. “We do not comment on conversations or meetings between Secretary Azar and the president,” a department spokesperson said.

Trump’s frustration underscores the imperative for his administration to deliver a health-care agenda that Trump believes he can campaign on, said two people.

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Any new administration activity on drug pricing is expected to focus on a single ambitious proposal, three sources said: Controversial new regulations that would tie certain drug payments to their prices in developed countries abroad. The proposal has remained under review for months amid fierce resistance from Republican lawmakers, who view the concept as tantamount to importing price controls.

But the idea, championed most notably by Democratic presidential candidate Sen. Bernie Sanders, has support inside the White House. And Trump, who often complains about foreign countries getting better deals on their drugs, has previously expressed enthusiasm for the proposal. One administration official stressed the president is considering several policies on drug pricing, including that regulation, because he is eager to push the issue.

Health officials in favor of the foreign pricing idea are expected to make a renewed push for the proposal, multiple people familiar with the matter said. If approved, the plan could be ready to roll out within weeks.

The renewed urgency on drug pricing could prompt a second look at bipartisan legislation negotiated by Sens. Chuck Grassley and Ron Wyden, which would overhaul parts of Medicare’s drug benefit and penalize pharmaceutical companies that hike prices faster than the annual rate of inflation.

The bill has languished for months in the face of Republican opposition that includes Senate Majority Leader Mitch McConnell — even as Grassley has warned that the GOP could suffer in this fall's election if the party fails to tackle drug pricing.

“Republicans arguably lost the House in 2018 because of health care issues,” Grassley spokesman Michael Zona said. “A big issue [in 2020] is going to be prescription drug pricing and that’s why everyone needs to get it together and do something.”

