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Health and Human Services Secretary Alex Azar. Photo: Chip Somodevilla/Getty Images

The Trump administration is rolling out the policy specifics for a central promise in its plan to lower drug prices — taking on the system's middlemen.

The big picture: Health and Human Services Secretary Alex Azar has long had his eye on pharmacy benefit managers and the rebates that are their bread and butter.

  • The proposal HHS unveiled yesterday would essentially ban those rebates in Medicare and Medicaid, forcing PBMs to collect a flat fee for their work.

How it works: Today, drug companies set a price for their products and then PBMs negotiate a discount in the form of a rebate, on behalf of insurance plans. PBMs keep some of that money for themselves and the insurers use some of it to help lower premiums across the board.

  • HHS wouldn't allow that any more under the proposed rule, but it would permit discounts that flow directly to patients at the pharmacy counter.

Winners: In the short term, this would largely move money around. Patients would pay less at the pharmacy — which is good news for seniors who take a lot of expensive drugs.

  • The trade-off is that Part D premiums would increase, which in turn increases the government's costs.
  • HHS expects the savings from lower out-of-pocket costs to exceed the increase in premiums.
  • Politically, the pharmaceutical industry would be a winner here, too: Pointing the finger at PBMs is a big part of its strategy to stave off tougher controls on its own prices.

In the long term, HHS is hoping this will change the pharmaceutical industry's pricing practices.

  • For example, drug companies will sometimes agree to steep rebates in exchange for PBMs giving their drug preferred treatment over a competitor.
  • Without the rebate structure in place, the hope is that those types of deals simply won’t be possible, and pricing negotiations will center more heavily around drugs’ sticker prices.

The bottom line: This is a major shakeup in the way we pay for drugs. It's in the weeds, and it’s not a cure-all (nothing is), but it's big.

Go deeper: The drug pricing maze

Go deeper

$1.2 trillion "hard" infrastructure bill clears major procedural vote in Senate

Photo: Kevin Dietsch/Getty Images

The Senate voted 67-32 on Wednesday to advance the bipartisan $1.2 trillion infrastructure bill.

Why it matters: After weeks of negotiating, portions of the bill remain unwritten, but the Senate can now start debating the legislation to resolve outstanding issues.

Fed chair says he isn't concerned by Delta surge

Fed Chairman Jerome Powell at the G20 finance ministers and central bankers meeting in Venice last month. Photo: Andreas Solaro/AFP via Getty Images

One of the country's most influential economic officials doesn't anticipate that surging coronavirus cases will knock the reopening recovery off course.

What he's saying: "There has tended to be less economic implications from each [coronavirus] wave. We'll see if that's the case for the Delta variety," Federal Reserve Chairman Jerome Powell told reporters today.

Updated 4 hours ago - Economy & Business

Ubisoft workers demand company accountability in open letter

Photo: Frederic Brown / Getty Images

Close to 500 current and former employees of “Assassin’s Creed” publisher Ubisoft are standing in solidarity with protesting game developers at Activision Blizzard with a letter that criticizes their company's handling of sexual misconduct.

Why it matters: Ubisoft and Activision Blizzard workers are framing the actions as part of a bigger movement meant to have lasting change in the industry and its culture.