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One of President Joe Biden’s big, under-recognized achievements has been an effort to make prescription drugs more affordable. And that effort is continuing into the eleventh hour, even as he prepares to hand over the presidency to Donald Trump. 

On Friday morning, the Department of Health and Human Services announced the names of 15 drugs that will be subject to Medicare’s new negotiation power, meaning the federal government will bargain directly with manufacturers to lower the prices of those medications.

It’s the second time that the federal government is engaging in the process, which will take about eleven months to complete. The big headline is that this year’s batch includes Ozempic and Wegovy, the breakthrough, popular — and expensive — weight-loss drugs used to treat diabetes and heart disease. Securing a lower price would save money for both the federal government (which has to finance Medicare) and individual seniors (who have to pay premiums for their drug coverage and then cover co-pays at the pharmacy).

None of this would be happening without Biden, because it was his signature legislative achievement, the 2022 Inflation Reduction Act, that gave the federal government the negotiation power. And that’s not all it did to make prescription drugs more affordable for the people on Medicare.

The sweeping climate and health law, which Democrats in Congress passed on party-line votes, introduced a $35 monthly limit on insulin and penalties on manufacturers who raise prices more quickly than inflation. It also put in place a $2,000 annual cap on total out-of-pocket expenses for drugs, which by itself could make a significant difference for seniors and people with disabilities who have especially high drug costs.

Together, these policy changes represent a big chunk of Biden’s domestic policy legacy, one that top officials in the outgoing Biden administration are using these final days to highlight.

“It’s been some of the most meaningful moments of my last couple of years here,” Chiquita Brooks-LaSure, outgoing administrator at the Center for Medicare and Medicaid Services, told me in a phone interview. “Just talking to so many people who are on really expensive drugs, so many spouses who have stayed in the workforce to pay for their husbands or their wives’ drug coverage, the relief they have that they can now retire, they don’t have to worry about their spouse, even younger generations.”

But Brooks-Lasure won’t be around to make sure this happens, and neither will Biden. Carrying out these drug pricing initiatives is about to become Trump’s responsibility, assuming he and the Republicans in Congress don’t decide to wipe them off the books altogether. And while there are good reasons to think the reforms will prove resilient, there are also good reasons to think they won’t.

Why These Programs Are Politically Vulnerable

One of those reasons is timing. The first round of drug negotiations wrapped up in August, resulting in lower prices for popular drugs to treat blood clots, diabetes and some cancers. But the new prices won’t be in place until 2026, meaning the billions in projected savings won’t register with any individual seniors until then. (Similarly, Ozempic and Wegovy prices wouldn’t come down until 2027.)

That long delay may help explain why the drug pricing reforms don’t seem to have registered with the public. Surveys showed these reforms were quite popular, meaning that people responded favorably when pollsters asked about them. But surveys showed just as consistently that, without the prompt from pollsters, relatively few people knew about the reforms that were in place.

Maybe the most striking findings came (again) from KFF, which in the summer polled seniors, the group that presumably would be paying the most attention because they were the ones who stood to benefit most directly ― and because, in general, seniors pay more attention to politics than other groups. 

Only 48% of seniors knew about the new drug negotiation power, with even fewer aware of the out-of-pocket caps or inflation penalties, according to the survey. The only feature a majority recognized was the insulin cap, and then only barely. (In the survey, 52% said they knew about it.)

That lack of awareness will make it tougher to defend the drug pricing initiatives if Republicans go after them, as plenty seem inclined to do. 

Conservatives have long been hostile to the whole idea of having the government using its leverage to force down drug prices, because a bedrock principle of conservatism is that markets ― that is, competition among private companies ― work best when the government does the least. Among the warnings Republicans and their industry allies have made is that, even if these reforms make drugs a little cheaper now, they will lead to fewer breakthroughs by reducing the financial incentive to invest in innovation.

Last year’s budget proposal from the Republican Study Committee, which represents conservatives in the House and drives its policy agenda, called for repealing the new prescription drug reforms. So did Project 2025, the Heritage Foundation document designed to serve as a governing agenda for Trump’s second term. 

Sen. Mike Crapo (R-Idaho), who as chair of the Finance Committee would preside over legislation to roll back the drug provisions, told Axios back in September he was hoping to do that. As for implementing the law, that would fall to HHS, an agency Trump has said he wants Robert F. Kennedy Jr. to lead. Kennedy is no friend of the pharmaceutical industry, but he’s also not an experienced administrator who has shown an ability to drive an agenda on anything beyond attacking vaccines.

Especially when it comes to the many more technical decisions about managing the drug negotiation process, Kennedy is likely to be at the mercy of other administration officials with more expertise. That could include conservative advisers at the White House.

It could also include Mehmet Oz, whom Trump has tapped to take over as Medicare administrator and whose ties to the pharmaceutical industry have already drawncriticism from consumer advocates.

Why These Programs Might Prove Resilient

But there are some other factors at play, too, including Trump’s own unpredictable feelings on drug pricing.

He’s been more critical of the drug industry than many Republicans, in particular seizing on the fact that the U.S. doesn’t get the same low drug prices as other countries where the governments negotiate over the prices of all pharmaceuticals. He’s also not above taking credit for his predecessors’ achievements, once they turn out to be popular.

It may not be a great idea to bank on Trump having a genuinely strong feeling about health care policy, let alone his acting on that. But he is famously sensitive to public opinion, especially among his constituents. And while the drug pricing reforms haven’t gotten a lot of public attention so far, that could change if Republicans try to undermine them or wind them back.

Trump should know this as well as anybody, because he was a key player in a recent, vaguely parallel episode. It was back in 2017, when Trump and the Republicans tried to repeal the Affordable Care Act ― the signature accomplishment of his then-predecessor, Barack Obama ― and thought they’d succeed because polls showed little enthusiasm for the law.  

That changed suddenly once the public realized that taking away the law would mean millions losing coverage, and the end of guaranteed insurance for people with preexisting conditions. That shift in public opinion was a big reason why repeal failed, and why Republicans took big losses in the midterms.

Brooks-LaSure said she’s seen this pattern before, with other health care initiatives: “With implementation it takes time, and it takes many years for the importance of these programs to be fully realized.” And while that belated recognition may not do much politically for the elected officials who did the labor to enact big reforms, it can insulate the programs themselves when opponents try to gut them.

But this process doesn’t play out automatically. In the case of the Affordable Care Act, for example, it almost certainly took organizing, educating and rallying by the program’s defenders to grab the public’s attention. That may be what needs to happen again. The big changes to drug pricing, a huge piece of Biden’s legacy, can still survive. But only if the public realizes that their future is at stake.