WASHINGTON — President Donald Trump has made his executive order tying prescription drug prices in the United States to the prices paid in Europe and other developed nations — and the ensuing war that has broken out with the pharmaceutical industry — a centerpiece of his campaign for reelection.

The problem: No such executive order has been released.

A month after a big White House signing ceremony, where Trump stood in front of a mock pharmacy and promised to “end global freeloading on the backs of American patients and American seniors,” the text of his directive remains largely a secret.

He has boasted of his efforts in campaign advertising, on the official White House website and on Twitter. But despite the president’s vow that he would issue the order on “August 24th at 12 o’clock” if the drug companies did not act on their own, the public’s only glimpse has come from an Associated Press photographer, who captured its first and last pages.

A White House spokesman declined to comment on the missing order.

The directive, which Trump refers to as a “favored nations clause,” was one of four executive orders announced at the signing ceremony July 24. They are all aimed at lowering drug prices in various ways.

The first three have been made public but require the Department of Health and Human Services to undertake a lengthy rule-making process before they will have any effect on drug prices. Trump described the fourth order, the one linking U.S. drug prices to those in other nations, as “the granddaddy of them all.” But he said he would postpone carrying it out in order to give the pharmaceutical industry time to negotiate.

Advertising

The president also said he would meet with executives the week after the signing ceremony. Such a meeting never occurred. However, one person familiar with the issue said the White House had been meeting with the pharmaceutical manufacturers trade association to try to come to terms on a joint statement.

In the meantime, Trump has been boasting about his plans as if they were in place and drastically affecting drug prices. His campaign has spent $668,000 over 11 days on a new advertisement suggesting that his Democratic opponent, former Vice President Joe Biden, is the favored candidate of the drug industry, attacking the companies and Biden in one fell swoop.

“Here’s what President Trump’s plan really does,” the ad says. “Reduces Medicare and prescription drug prices. Reduces the cost of insulin. Cuts the cost of lifesaving medicine. That’s why Big Pharma is attacking President Trump. They liked it better with Joe Biden.”

In a recent tweet, the president also claimed — inaccurately — that the “favored nations clause” order had already lowered drug prices. (It also inaccurately described the timing of the signing.)

At the ceremony on July 24, Trump promised that he was “doing something that is going to be incredible for the American public,” taking a worn page from old Democratic playbooks, which have had that party’s candidates campaigning on drug prices for years. Trump in 2016 embraced a Democratic plan to allow the federal government to negotiate drug prices. But in the face of opposition from his party, his promise took a novel turn: He would allow European countries, many of them social democracies, to negotiate prices, then latch on to the price points they secured.

While the president has implied that his “favored nations” order would affect all pharmaceuticals, in reality it would affect only a small fraction of drugs: those, like chemotherapy infusions, that are administered in a doctor’s office. Even to do that, an order alone would not be enough to change policy; that would require notice-and-comment rule-making that could take months or longer.

Advertising

Sections of Trump’s document visible in the photograph, and transcribed by a reporter at Modern Healthcare magazine, make reference to this need for “rule-making.”

“It’s very frustrating to see the president tweeting as if this has already happened, because it has not,” said Rachel Sachs, an associate professor of law at Washington University in St. Louis, who studies pharmaceutical policy.

Phillip J. Cooper, a professor of public administration at Portland State University and author of “By Order of the President,” a book about presidential documents, said that federal law required signed executive orders to be published in the Federal Register. No “favored nation” order has appeared, so the missing order either violates the law or is incomplete.

“If it was publicly signed, I have no idea what the ground would be for withholding it,” Cooper said.

Trump has embraced the issue of high drug prices since his 2016 campaign, promising that he would fight the powerful pharmaceutical industry to deliver relief to American consumers. But the administration has delivered little policy on drug prices. The courts overturned its effort to require drugmakers to publicize the list prices of medications. Other efforts, like the one to establish an international price index for certain drugs, were proposed and shelved.

The president has spoken intermittently about his desire to peg the price of prescription drugs to the prices paid by other countries, which are typically lower than those in the U.S. An earlier proposal from HHS would have established a pilot program where certain drugs were priced based on an average of foreign prices. Trump’s remarks suggest that he now prefers a policy where drugs would be priced according to the lowest price paid by peer nations.

Advertising

The pharmaceutical industry has always opposed the policy.

“The ‘most favored nation’ executive order is an irresponsible and unworkable policy that will give foreign politicians a say in how America provides access to treatments and cures for seniors and people struggling with devastating diseases,” said Nicole Longo, a spokeswoman for PhRMA, the largest industry trade group.

The industry’s opposition to international index pricing is shared by many Republicans in Congress, who say they think adopting drug prices from countries where prices are set by the government is effectively importing socialism. Joel White, a Republican strategist, called it “really bad policy,” because it amounted to “importing other countries price controls,” and “misguided” because it was targeted at medicines given in doctors’ offices or hospitals.

“People are concerned about what they pay for pills at the pharmacy counter,” he said.

Polls have consistently shown that the public trusts Democrats more than Republicans on matters related to health care. Democrats rode their emphasis on health care to control of the House in 2018, and they expect to make it a major issue again this year.

At the end of 2019, the House passed a bill aimed at lowering all drug costs by empowering the government to negotiate with pharmaceutical manufacturers — a policy Biden has embraced — but the bill stalled in the Senate.

The House bill would also link prices for up to 250 common drugs in the U.S. to prices overseas. It would also apply the bench marking more broadly, to include retail drugs and to apply to drugs bought by people with private insurance, not just those in Medicare.

“This is a winning issue for us because we have a track record of delivering, and Republicans have a track record of taking health care away,” Rep. Cheri Bustos, D-Ill., chair of the Democratic Congressional Campaign Committee, said in a recent interview.