Two weeks after President Trump signed an executive order "Lowering Drug Prices By Putting America First," the White House still hasn't released the text of the order. The unorthodox move is apparently a leverage play, an attempt to squeeze drug companies into offering concessions, but so far there's little indication Trump is getting the deal he was after.
Trump had American flags and women in white lab coats behind him, his big presidential sharpie marker in hand when he signed the order July 24.
"This one will go into effect on Aug. 25 if we don't make a deal," Trump said at the time as he held the order up for the cameras.
It was the fourth order he signed that day. Language for the other three was posted online quickly and published in the Federal Register. But this order remains something of a mystery. The basic idea is that in other countries, prescription drugs cost less than they do in the United States. So under Trump's plan, for drugs administered in a doctor's office or hospital setting, Medicare would start paying the lowest price in the world. He calls it "favored nations" pricing.
"No more will we have to suffer by saying, 'Gee, why is it so much cheaper for the exact same drug in some other country?' " Trump said.
But first, Trump said, he was going to give drug companies a chance to come up with a better idea. "They don't like 'favored-nations' clauses," Trump said a few days later. "I understand that."
This isn't how the process normally works.
"I can't think of any case where the president has signed an executive order publicly and then not put it in the Federal Register," said Tara Leigh Grove, a professor of constitutional law at the University of Alabama.
Grove said the process for executive orders varies from administration to administration, but publishing the order is the one big step no one skips, because that's what makes it real.
"Usually if a president is going to issue an executive order the president wants the people who are supposed to abide by the executive order to know what they're supposed to do, and you can't really know what you're supposed to do if they don't tell you," Grove said.
Asked what's in the executive order or how it would achieve what Trump is promising, the White House just points back to a vague fact sheet and the president's remarks.
So, Lori Reilly, chief operating officer at the Pharmaceutical Research and Manufacturers of America, the pharmaceutical industry trade group, said its members zoomed in on a picture of Trump holding up the executive order to try to see what was in the text.
"There is an AP picture where there is some language, that we were able to see some, but there's a page missing and so that leaves questions," she said.
In fact, when NPR zoomed in on the photo, it discovered the obscured second page must have contained all of the details about what the proposal would actually do and how.
Reilly said the industry would be willing to talk about other ways of bringing down drug prices, but this proposal, as it's understood, is a nonstarter.
"We recognize there is a desire by many to find ways to lower costs for American consumers, but we're steadfastly and strongly opposed to the idea that they have with regards to allowing foreign governments to dictate prices in the U.S.," she said, calling the president's proposal a distraction from battling the coronavirus.
Multiple sources said some quiet conversations are happening now, but it's not clear how serious they are. In an earnings call, the CEO of Pfizer said if implemented the executive order would lead to American job losses and said he didn't see much need for a White House meeting.
The lack of urgency may come from experience. Trump has been talking about variations on this idea for nearly two years. He rolled out something called an " international pricing index" with much fanfare right before the midterm elections in 2018.
"This is a revolutionary change," Trump said at the time. "Nobody's had the courage to do it, or they just didn't want to do it."
But then it languished. Nine months later, it still hadn't gone into effect, and Trump said he would be "announcing something very shortly, a 'favored-nations' clause."
Now, another year later, Trump signed that executive order, but he's telegraphing that he's open to alternatives.
"The Trump administration is all bark and no bite on drug pricing," said Chris Meekins, director of Washington health care policy at Raymond James Financial. "And despite the barks getting louder with executive orders, the bite is no harder."
Meekins served in the Department of Health and Human Services in the first two years of the Trump administration. He said there's clearly a reelection motive here. Trump and his campaign want to be able to say they've done something on drug prices, an issue about which polls show voters care.
"I think it's just more noise," Meekins said. "As I describe it to clients, Trump on drug pricing feels a little bit like Charlie Brown, Lucy and the football.
"Where the administration is Lucy, hey we're going to do these drug-pricing executive orders. We're going to do these drug-pricing executive orders and everyone, the media, investors run up assuming the football is going to be there to be advanced. And then at the last minute, it gets pulled out."
Even if Trump moves forward with the executive order, that would just mark the beginning of what would likely be a lengthy process that could be further stalled or halted all together by drug industry lawsuits.
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