How a price surge complicated its pharmaceutical plan

• “The issue is affordability. The president understands that,” one adviser told Axios.

But the path to this decision has been difficult and has shown how Trump’s uneven management style — particularly when it comes to tariffs — overshadows a White House in which policies can be made on the fly, change suddenly at the president’s whim, and then be fine-tuned as conflicts are resolved in real time.

• Trump’s cabinet secretaries sometimes operate with such independence that they encroach on one another.
• In this case, it was initially Commerce Secretary (and tariff leader) Howard Lutnick on one side and Health and Human Services Secretary Robert F. Kennedy Jr. on the other.
• Kennedy’s department negotiated with pharmaceutical companies as part of Trump’s “Most Favored Nation” prescription drug plan to lower drug costs for Americans.

Behind the scenes: Inside the White House, the conflict came to a head on September 25, at a going-away party for outgoing senior adviser Taylor Budowich.

• Around the same time that evening, Lutnick was in the Oval Office after a previously scheduled meeting on tariffs on heavy trucks and furniture.
• Trump and Lutnick then began discussing tariffs on pharmaceuticals, a source said. And at 7:24 p.m., Trump announced he would impose 100% tariffs on prescription drugs produced outside the country.

The benefits: Trump’s message caught everyone off guard: Kennedy, Medicare and Medicaid Administrator Mehmet Oz, top White House officials and the pharmaceutical companies that were negotiating with them. No one was consulted about this announcement.

• This prompted White House chief of staff Susie Wiles to have a one-on-one meeting with Lutnick to voice her concerns.
• Wiles — who has tried to avoid the chaos and drama that characterized the Trump White House during his first term — reiterated to senior officials that they must work within established processes.

“Susie has just had enough” a Trump adviser familiar with the discussion told Axios. “There is a process for the ‘most favored nations’, there is a timetable and a plan.”

• “Next thing you know, Lutnick comes along and doesn’t tell anyone this, and Kennedy and Oz saw the (Truth Social) post and were like, ‘What the fuck?’ So Susie had to get rid of it.”

The message has been received. Five days after the going-away party, Lutnick joined Trump at a news conference to announce a deal with Pfizer in which the Commerce secretary made clear the tariff plan was on hold.

• “As we negotiate with these companies, we’re going to let them complete their negotiations, because they represent the most important thing to the American people,” Lutnick said in response to a reporter’s question.
• “We stand with them, we help them and work with them,” Lutnick said, referring to “Team HHS” with praise: “We stand with them, we help them.”

Friday, Lutnick joined Kennedy in signing documents for a new deal with AstraZeneca, a British-based pharmaceutical company that has agreed to build a factory near Charlottesville, Virginia.

• Kennedy praised Lutnick for being “key in the negotiations,” as did the White House in an official statement recognizing the “influential” secretary as a crucial member of Trump’s trade and economic team that helped seal the deals with pharmaceutical companies.
• Trump also said tariffs were a “big reason” for pharmaceutical companies to come to the table, although the AstraZeneca deal predated Trump’s threat of 100% tariffs last month.

Zoom: Trump’s “most favored nation” pharmaceutical plan aims to force companies to sell prescription drugs to U.S. customers at the same price they would charge customers in other countries, where the drugs are often cheaper.

• In some cases, this has not lowered drug prices in the United States, but has led pharmaceutical companies to raise their costs for consumers abroad.

The plot: Tariffs aside, Lutnick recently got angry with his top aides when he spoke to an interviewer about his interactions with the late sex offender Jeffrey Epstein, whom he called “the greatest blackmailer of all time.”

• The message was at odds with the White House’s efforts to distance Trump and his team from Epstein.

Reality check: Lutnick is a longtime friend of Trump’s and sources say he is still well-liked by the president.

• Some see a positive side to the tariff threat Trump issued at Lutnick’s request because it “caught everyone’s attention and probably let other drug companies know we’re serious,” another administration official said.
• “It’s fair to say Lutnick overcame his skis,” the official said. “But in the end, it had no material negative effect on anything, except for a few annoyed people.”