President Trump's upcoming speech on drug prices will probably stick to small-ball ideas. But small-ball doesn't necessarily mean no impact.

Reality check: There are a lot of legitimate ways to bring down drug costs; there are also a lot of empty gestures masquerading as real change. Here's a guide to the kinds of ideas and the odds that they'll actually happen.

Bucket 1: Move the costs around

The big picture: These proposals could reduce what patients pay for drugs, but not necessarily what the health care system as a whole pays.

How it works: The gist here is to rearrange existing discounts within the drug supply chain, usually by targeting the various middlemen between drug companies and patients.

• One idea is to make pharmacy benefit managers, who negotiate big discounts on behalf of insurers and employers, pass more of those savings on to patients at the pharmacy counter.
• The administration has already announced changes to a program that provides discounted drugs to hospitals, and Congress may go even further.

Threat level: This is where the administration has been most active so far, and politically, there’s a lot of low-hanging fruit in this set of policies.

What they’re saying: All of this fits with the industry’s larger worldview, which is that new drugs are worth the money, but patients should have to foot less of the bill on their own. Consumer advocates don’t oppose these policies, but they say this bucket doesn’t get at the heart of the problem.

Bucket 2: Increase competition

The big picture: Some conservatives want to tackle the underlying price of drugs, but they want to do it by fostering a more competitive market, rather than through price controls.

How it works: New drugs are entitled to five to 12 years of sales, depending on the type of drug, before a generic version can come to market. That window usually ends up being longer, though, because of drugs’ patent protections.

• The FDA has largely cleared out its backlog of generic drugs waiting for approval, and commissioner Scott Gottlieb hopes to jump-start the lagging market for generic versions of especially complex drugs.
• No one formally opposes more generics, but brand-name drug makers have been accused of unfairly denying generics the samples they need to develop their products. There’s a bill in Congress to address that; industry opposes it.
• Critics also say drug companies are abusing the patent system by taking out patents on even the most minor component of a drug, then reformulating those components and taking out a whole new “thicket” of patents — keeping generics at bay even longer.

Threat level: Health and Human Services secretary Alex Azar — himself a former pharmaceutical executive — said in his confirmation hearing that he would be willing to look at patent “gaming.”

What they’re saying: The advocacy group Patients for Affordable Drugs says some of these ideas, including the bill on product samples, would make a real difference. Industry, meanwhile, will probably have to concede that some “gaming” does occur, but acceding to the most aggressive regulatory changes would cost drug makers billions.

Bucket 3: Reduce the prices

The big picture: Bucket 1 addresses who pays, but not the underlying prices of drugs. Bucket 2 tries to get the market to deliver lower prices. Bucket 3 demands them.

How it works: The marquee policy here is for Medicare to negotiate — or simply to dictate — what it will pay for drugs.

• Democrats say that would not only lower costs for seniors and Medicare, but for everyone, because private insurance wouldn’t pay much more than Medicare does. Drug companies say it would dry up innovation and research.

Threat level: Trump has endorsed price negotiations in the past, which makes industry nervous, but the policy remain very much a long shot.

What they’re saying: Traditional conservatives — like Azar, Gottlieb, Vice President Mike Pence, and congressional GOP leaders — have long hated this idea. And as much as it’s still a holy grail on the left, the advocacy groups most active on this issue are also focusing on more achievable goals.

In a phone call last year with Bibi Netanyahu, President Trump said something that shocked some of the people who helped prepare his briefing materials for the conversations. According to three sources familiar with the call, Trump asked Bibi bluntly if he actually cares about peace or not.

The details: Trump was pressing Bibi on the importance of striking a "deal" for Mideast peace. He'd read news reports about Bibi planning to build additional settlements to please his conservative base in Israel. Trump thought Bibi was unnecessarily angering the Palestinians. So, in the course of a longer conversation that was mostly friendly and complimentary, he bluntly asked Bibi whether or not he genuinely wants peace.

• When Axios shared the details of this conversation with the White House before publishing, a senior official said: "The President has an extremely close and candid relationship with the Prime Minister of Israel and appreciates his strong efforts to enhance the cause of peace in the face of numerous challenges."
• And Press Secretary Sarah Sanders added: "The President has great relationships with a number of foreign leaders but that doesn’t mean he can’t be aggressive when it comes to negotiating what’s best for America."

Between the lines: According to a host of sources familiar with the president’s thinking, Trump views foreign policy as a question of relationships. The way he crafts American foreign policy is almost entirely dependent on his personal rapport with world leaders.

• A perfect example: The United Kingdom .Though Trump has great affection for Britain (he has golf courses there, appreciates the special relationship, and has referred to himself as “Mr. Brexit”), he and Theresa May have a fraught relationship. He hits the roof when he reads that she's criticized him. So he has yet to visit America's closest ally, even after last year's terrorist bombings in Manchester, though a source privy to private discussions tells me that it's "quite likely" that Trump visits the UK before the summer.
• Another example: Trump finds Japan’s trade practices and regulations to be very irksome. But he has a great personal chemistry with Japanese Prime Minister Shinzo Abe, and would likely be going far harder on the country if their relationship were tense.

Why this matters: Trump's foreign leader interactions — often improvised, often hot and cold, often disregarding diplomatic conventions and basic briefing materials — have confounded much of the administration's national security staff.

• ​Trump freelances; he rarely refers to scripts and notes, and he disdains long briefings. Instead, he kibitzes with foreign leaders like he does with his Manhattan real estate friends.
• His ad-lib style sometimes works to his advantage — and he's established genuinely good relationships with leaders like Emmanuel Macron of France and King Salman of Saudi Arabia — but it's also at times thrown staunch allies like the U.K. and Germany off-balance. And it makes the national security establishment — many of whom have longitudinal views of these relationships — break out in hives.

A Trump briefing is completely different from those of his predecessors. He doesn't want briefing books or long speeches about policy. Besides the news of the day, he almost always asks the following questions before most foreign leader meetings:

• What is the trade deficit with the foreign country? How big is their army and defense spending, and to what extent is America picking up their tab? And, in some cases, how much foreign aid is the U.S. sending to the country? Put simply: what are we doing for them and how much are they contributing in return?

One hard lesson Trump's staff learned: Always find out whether the leader he's meeting with has said mean things about him.

• Trump was furious with his national security team for not telling him in advance of his meeting last year with Greek Prime Minister Alexis Tsipras that Tspiras said during the presidential campaign that Trump represents an "evil" ideology.
• At Trump's joint press conference with the Greek leader, Fox's John Roberts quoted the brutal things Tsipras had said about Trump. The president blew up at his team afterwards for not finding this out and briefing him about it in advance.