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A big, popular health care initiative could be on the chopping block if Donald Trump and his Republican allies win full control of the federal government in the November election.

No, I’m not talking about the Affordable Care Act — although, as noted in these pages previously, its future really would be in peril.

I’m talking about the Inflation Reduction Act, the landmark legislation that Democrats passed and President Joe Biden signed in 2022.

Most people know the IRA as a climate bill. And that’s completely understandable. Its subsidies and tax incentives for clean energy account for the largest commitment of federal resources in the legislation and could have the biggest effect on the American economy.

But the IRA also had some health care provisions. The most significant of those was a series of steps to reduce the price of drugs in Medicare.

They include a cap on the price of insulin, a limit on out-of-pocket costs and penalties for drugmakers who raise prices faster than the rate of inflation. Yet another feature authorizes the government to negotiate directly with manufacturers over the prices of some drugs.

That last feature is probably the best known ― and the most controversial politically. Vice President Kamala Harris, the Democratic presidential nominee, has called for extending those negotiations to more drugs, just as Biden has. Democratic leaders in Congress say they want to do the same.

They know they can’t count on Republican support. The IRA got zero GOP votes when it went through Congress. The drug pricing negotiations in particular are exactly the sort of regulation that conservatives hate on principle ― and that GOP allies in the drug industry see as a threat to their bottom lines.

So if Harris and the Democrats want to give the government even more leverage over prescription drug prices, they’re almost certainly going to have to do it on their own.

But the bigger question ― and one that would be great to ask Trump next Tuesday at the presidential debate with Harris ― is what happens if he and the Republicans are in charge come January. Would they let that provision stay in place? Or try to roll it back?

There are several good reasons to suspect the latter.

A Big Divide On Drug Pricing

One is the philosophical divide behind the debate.

Conservatives see the IRA’s drug negotiation provision as an unjust, counterproductive meddling with the free market.

They say it isn’t really a “negotiation” so much as the government arbitrarily setting prices in ways that are unlikely to reflect the true value of drugs. They worry in particular that by reducing drug company revenue, the negotiation process will reduce the pharmaceutical industry profits that attract investment ― which in turn is what the drugmakers use to finance research and development.

In short, that forcing down the prices of drugs today will mean fewer breakthroughs tomorrow.

Liberals counter that the existing system isn’t really a free market. The drug industry, they note, already benefits from government-funded research and government-sanctioned monopolies in the form of patents and the right to market new drugs, free of competition, for several years.

The IRA, they say, simply allows the government to act like a smarter buyer, taking into account information about drug value rather than simply taking whatever price pharmaceutical companies demand. And it applies to just a narrow set of drugs, they say, making it no real financial threat to what is arguably the most profitable industry in America.

The debate is a serious one, with thoughtful, well-informed experts on both sides. But the politics are not ambiguous.

Polling has shown repeatedly that the public overwhelmingly supports the idea of giving the federal government more power over drug prices. Even Republican voters tend to approve of the idea.

That may explain the stark difference in how the two parties have talked about IRA drug pricing reforms in the campaign. Democrats bring them up all the time. Republicans almost never do.

An Uncertain Future For The New Initiatives

That’s not to say Republicans never talk about health care, at least when it comes to seniors. On the contrary, Trump has vowed repeatedly to protect Medicare. He also has a record of criticizing the pharmaceutical industry.

As president, Trump actually took a series of executive actions designed to reduce drug prices. But these were mostly modest steps. When legislation to introduce a negotiation scheme was moving through Congress, Trump backed the Republican leaders who killed it and trashed the proposal on social media.

“FEWER cures! FEWER treatments!” he posted on social media at the time, complaining about the bill.

That’s always been the pattern with Trump. Because he’s not especially conversant or interested in the details of policy, he defers to GOP leaders on legislation. And they’ve been a bit more clear about their intentions.

The most recent budget proposal from the Republican Study Committee, which represents conservatives in the House and drives its policy agenda, calls for repealing the “price controls” on prescription drugs that Biden enacted. Project 2025, the right-wing governing blueprint for a second Trump presidency that the Heritage Foundation published last year, has a section on “legacy Medicare reform” that includes a call to repeal the IRA.

It’s not clear how pharmaceutical manufacturers would react if the IRA reforms suddenly came off the books. Some companies might decide to keep insulin prices in Medicare at $35 or avoid a quick hike in prices for the initial 10 drugs for which the negotiation process just finished, if only for a little while and only for the sake of publicity.

But in a world where the IRA reforms have gone away, manufacturers would again have a free hand to set prices as they had before. Over time, both the federal government and individual Medicare beneficiaries would be paying more, especially for drugs that would have come under the negotiation process in the future.

Just to give a sense of scale, the Department of Health and Human Services estimated that the first round of drug price negotiations would have saved the federal government more than $6 billion ― and individual seniors about $1.5 billion ― had the new prices been in place this year.

Trump has said he has nothing to do with Project 2025, even though many of his current and former aides wrote large parts of it. And it’s possible he might resist efforts to roll back the drug pricing provisions.

But given his history, and the hostility toward the provision from precisely the sort of Republicans he’s followed before, that hardly seems like a safe bet.