A bold stance on drug pricing will be a prerequisite for any candidate who wants to win the 2020 Democratic presidential nomination, but one challenge will be differentiating the contenders from each other.

The main distinction among candidates could be between those pushing bipartisan policies and those promoting more liberal ideas that currently stand little chance of enactment. But in most cases, the bills have a list of co-sponsors that could resemble a future primary debate stage.

“Any Democrat who doesn’t run on it is missing the mood of the electorate, and I think that they would be making a huge mistake,” said David Mitchell, a cancer patient and founder of the group Patients for Affordable Drugs and its political action committee.

If they’re not making it an issue, he said, “They ought not get anywhere near the nomination.”

The positioning on drug pricing plans reflects the party’s broader attempt to reject corporate influence, said Peter Maybarduk, who runs consumer watchdog Public Citizen’s Global Access to Medicines campaign.

“It’s going to play a role in people’s understanding of candidates’ philosophies and how serious they are about challenging concentrated economic power in order to make people’s lives better,” he said.

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Candidates’ positioning

So far, the potential 2020 field is comfortable rallying around drug pricing plans from Bernie Sanders, the Vermont independent who is still mulling a bid.

Sanders introduced bills intended to lower drug prices in almost every session that he’s served, starting as a House member in 1991. For many years, his proposals attracted only the most liberal Democrats — or in many cases had no other co-sponsors.

Today, Sens. Cory Booker of New Jersey, Kirsten Gillibrand of New York, Kamala Harris of California and Elizabeth Warren of Massachusetts are all original co-sponsors of a three-bill drug pricing proposal that Sanders introduced in January.

The package included a bill that would allow imports of lower-priced drugs from Canada and other industrialized countries. Another bill would require the government to negotiate directly with drug companies in Medicare’s prescription drug benefit, a central part of Democrats’ strategy and a key contrast with Republicans. Other legislation would strip away monopolies if drug companies sell products here for more than they are sold abroad.

Amy Klobuchar of Minnesota, who officially announced her bid Sunday, is backing multiple approaches to some of these issues. She backs the Sanders importation bill and the negotiation bill, but also has measures of her own. She introduced legislation that would allow Medicare to negotiate in the Part D drug program — but not require it, as the Sanders bill would. But a third negotiation bill she introduced with another potential contender — Sen. Sherrod Brown of Ohio — is even tougher on drug companies than the Sanders bill, since it would revoke patent protections when prices are too high.

She’s also leading efforts on an importation bill  with Senate Finance Chairman Charles E. Grassley of Iowa. The pair also have a bill that would prevent branded drug companies from settlements over patent lawsuits that delay generic competition.

James Love, director of the nonprofit Knowledge Ecology International, sees two schools of thought reflected in the bipartisan side of Klobuchar’s approach versus the Sanders bills.

In her bills with Grassley, Klobuchar is mostly focusing on things with “a bipartisan shot of getting through the Senate this year,” he said.

“Other people are kind of laying down markers in terms of policies and things they know are probably not going to pass this year, but they want to start a debate,” he said.

Brown, whose 26-year tenure in Congress began in the House, has a track record on drug pricing almost as long as Sanders has. Highlights include a 2016 bill that would shorten the monopoly period on expensive biologic drugs from 12 years to seven years. That approach, along with the negotiation bill he and Klobuchar introduced last week, represent the kind of changes that people like Love say is most needed.

“If you’re not willing to say that you can rein in the legal monopoly, it’s hard to do other things that will protect patients,” he said.

Track records

One distinguishing factor could be the consistency of the candidate’s record over time.

California Rep. Ro Khanna, a lead co-sponsor on the House versions of the Sanders bill, asked: “Have they been advocating and standing up for this for the past two years, or has this been something they’ve been fighting for, for the past 10 years? I think those are the things that voters will look at when the policy differences aren’t that much.”

Among the current crop of hopefuls, all have accepted campaign contributions from pharmaceutical and health products industry PACs or their employees.

Brown collected the most overall, around $599,000 since his first election in 1992, according to the Center for Responsive Politics. But that’s less than one percent of the $69 million he’s raised in total. Booker’s percentage share is highest, 1.7 percent of the $25 million he’s raised since 2013.

Booker has also taken heat for a single vote he cast in early 2017 against an amendment to a budget resolution that would have called for a system to import drugs from Canada. The amendment was rejected, 46-52, and Booker was one of 12 Democrats who voted against it.

He says he voted against it because it was a “late-night messaging amendment,” not a substantive policy. He notes that around six weeks later, he was an original co-sponsor of a more fleshed-out drug importation bill led by Sanders. A year later, in February 2018, Booker announced he would no longer accept corporate PAC money.

In early January, he continued to shed this potential baggage, appearing next to Sanders at a press conference announcing the three-bill package. And he took aim at pharmaceutical companies, which employ tens of thousands of people in his state, criticizing how they spent the money they saved in the 2017 Republican tax cut.

“Did it go into predominantly research? No. Did it go into raising wages with employees, predominantly? No. It went to stock buybacks, to push stock prices up, to game the market,” he said.

The biggest challenge might be turning their positions into a usable political tactic. Since President Donald Trump and his administration are some of the biggest cheerleaders for Congress to act on the issue, political opportunity might only exist if nothing happens this year.

“If I was going to make it a central issue in my campaign, I just would want to make sure that they don’t pass a bill after I gave five speeches on it,” said Robert Blendon, a professor at Harvard T.H. Chan School of Public Health who runs the university’s polling on health issues. “But if it’s clear they’re not going to do something, absolutely, it’s something that relates just directly to voters of every age and everything else.”