"What I'm hearing is that they're looking at a clean slate and going after everybody: the drug companies, the pharmacy benefit managers, everyone", said one health care lobbyist, who spoke on the condition of anonymity to speak frankly.
"Finally, as we demand fairness for American patients at home we will also demand fairness overseas. This is a total rip off and we are ending it".
The council suggested changing trade policy to limit the "underpricing" of drugs overseas.
Trump said his plan is aimed at removing "gag" rules placed on pharmacists that prevent them from telling patients when a drug or its competitor would cost less if the patient pays out of pocket rather than going through insurance.
President Donald Trump has instructed trade ambassador Robert Lighthizer to grant the drug industry's wish of making pharmaceutical prices a "top priority" in negotiations with other countries.
But the White House plan largely drops some of the most aggressive, populist attacks Trump proposed on the campaign trail, mostly sparing the pharmaceutical industry he previously accused of "getting away with murder". He repeated those words at a Cabinet meeting in October.
The Community Oncology Alliance (COA) issued a statement saying that it "strongly supports" efforts to reduce drug prices.
Critics say that proposal is unlikely to help lower prices here in the U.S. It's an approach that could avoid a direct confrontation with the powerful pharmaceutical lobby, but it could also underwhelm Americans seeking relief from escalating prescription costs. The budget request also included a provision moving some drugs covered under Part B to Part D to leverage private plans' negotiating power.
"A lot of what they focus in on is not really the price of pharmaceuticals, as much as the out-of-pocket payments of the patients at the pharmacy", said Craig Garthwaite, an associate professor of strategy at Northwestern University's Kellogg School of Management.
While Trump and Azar delivered tough remarks, it did little to scare the industry.
Public outrage over drug costs has been growing for years, because Americans are being squeezed in a number of ways: New medicines for cancer and other life-threatening diseases often launch with prices exceeding $100,000 per year. That trend, coupled with several high-profile cases where drug manufacturers significantly raised the price for common, decades-old drugs, have thrust the issue into the national spotlight.
Still, administration officials ratcheted up the rhetoric ahead of Mr. Trump's speech.
Azar and other Trump officials have described the pricing problem in stark terms and promised bold action.
After more than a year of waiting for a clear policy direction from Trump's ominous statements on drug prices, the industry is worked up. Top drug companies have donated millions to campaigns and candidates so far in the 2018 election cycle, according to Federal Election Commission (FEC) records.
In a quick follow-up, HHS Secretary Alex Azar raised one specific proposal that aimed at shaming pharma companies by forcing them to include the price of the drugs they promoted in advertising.
But experts are skeptical the US can pressure foreign governments to pay more for drugs.
One novel proposal in the president's grab bag is meant to actually raise prices - not in the USA, but in other developed countries. Would the drug's price similarly fade into the background?
That idea has always been supported by Democrats but is a non-starter for drugmakers and most Republicans in Congress.
Trump was speaking as his health deputies released a series of proposals to address high drug costs.
Those include requiring insurers to share rebates from drug companies with Medicare patients and changing the way Medicare pays for high-priced drugs administered at doctors' offices.
"This is a major restructuring of a huge portion of the US economy".
The result is that the US spends more on medicines than any other nation. Prescription-drug spending in the US grew 1.3 percent in 2016, to $328.6 billion, according to the Centers for Medicare and Medicaid Services. That compares with $756 for Canada and $497 for the United Kingdom, both of which have government measures to control drug prices. "We need a vital and vibrant generic industry and generic drug market", he said.
Other nations, also struggling with high drug prices, scorned Trump's advice on this issue.
Drugmakers argue that list prices do not reflect actual cost after discounts and rebates. Those price concessions are nearly never disclosed and it's unclear what portion actually flows back to consumers. Another proposal would do away with rebates altogether to encourage more upfront discounts in Medicare.
"I think the mood, just generally, across the health sector is 'watch and wait, ' " said Mark Merritt, president of the Pharmaceutical Care Management Association, the lobby for pharmacy benefit managers.
Patents last longer in the USA than most countries, typically giving companies a dozen years of competition-free marketing after a drug launches.
Reducing drug costs in Medicaid is also under consideration. This effectively blocks the development of generic versions because generic drugmakers must test their products against the original medicine before they can win FDA approval.