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ASHINGTON — Democratic presidential nominee Hillary Clinton wants to crack down on rising prescription drug costs. She has made it a pillar of her campaign, the stuff of TV ads and stump speeches. She also has ambitious plans for Alzheimer’s research and other medical science initiatives.

But, even if she wins the White House, Clinton might have to put all that on hold.

A series of setbacks to Obamacare in recent months has raised real questions about the viability of the Affordable Care Act, with three major insurers announcing that they will leave many of the law’s marketplaces next year and others requesting substantial premium increases.

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Analysts increasingly believe that Clinton, should she prevail in November, will be forced to act quickly to salvage the law — and may have to spend enormous political capital to get the job done. Getting support from the health care sector, particularly the influential pharmaceutical lobby, to smooth negotiations with Congress could be difficult if Clinton is simultaneously pursuing a plan to lower drug costs.

The challenges to the ACA “threaten the future stability of these markets and will require serious policy solutions to address,” said Caroline Pearson, senior vice president at Avalere Health, a Washington-based consulting firm. “If Clinton is elected, she is probably going to have to pursue a package of ACA fixes with Congress in early 2017.”

“Any bill that reopens the ACA will be politically complicated,” Pearson continued. “Efforts to address prescription drug prices may need to be deprioritized in order to rescue and reform the ACA.”

Clinton could try to act without Congress. But executive action on drug prices can also be difficult, as the Obama administration has found with its proposed experiment to lower Medicare payments for some medications. The industry has helped rally bipartisan criticism of the plan, and the administration has conceded the proposal might be changed.

So Clinton might have to forgo for now any major effort to deal with drug prices, at a time when many Americans feel that drug costs are unreasonable.

“I tend to think that if a Clinton White House had to use political capital to address the ACA, they’d be unlikely to then take on pharma too,” said Larry Levitt, senior vice president at the Kaiser Family Foundation.

Clinton aides disagree with that assessment. They argue that part of the problem that health plans are facing, which is helping drive them out of the ACA market, is high drug costs. Fixing one problem could help with the other, they say.

“The truth is that one of the primary reasons that plans in and outside of exchanges are struggling with costs is that they are searching for ways to moderate prescription drug prices and overall costs,” a Clinton adviser told STAT. “As such, I see these issues aligned. Addressing the prescription drug cost challenge is a part of dealing with plan affordability.”

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Some lobbyists also believe that Clinton could still act on drug prices or other health care items even amid Obamacare’s problems. But that could depend in part on what course Clinton takes in trying to fix the law.

If she’s willing to cede some ground where Democrats and Republicans can agree on the ACA (such as repealing its “Cadillac tax” on high-end insurance plans or medical-device tax), the thinking goes, a fix might pass relatively easily and she would therefore have the opportunity to pursue other items on her agenda.

But the Democratic nominee has suggested she wants to revisit one of the biggest fights left over from the original debate over the law: the public option. Many Democrats, including Clinton and President Obama, believe a government-run insurance plan would help stabilize the law’s marketplaces.

Republicans in Congress are categorically opposed to the public option — and unless a Clinton landslide sweeps a new Democratic majority into power in the House, the GOP will control at least one chamber of Congress. The public option has the makings of a major legislative showdown if Clinton wants it, one that would risk bogging down the rest of her agenda.

“This could become a very early distraction for a Hillary administration,” said one health care lobbyist, who requested anonymity to speak candidly. “It lures her into an earlier debate on a health agenda that may have not been what she started with.”

The other factor here is the calendar. As lobbyists will tell you, 2017 is loaded with deadlines that could force Congress and the new administration to act. Many are health-related: a package of Medicare provisions that needs to be extended, the reauthorization of the Children’s Health Insurance Program that Clinton prizes, and a schedule of pharmaceutical fees from the Food and Drug Administration that must be renewed.

Ordinarily, such must-pass legislation would give Clinton a chance to advance her health care agenda in negotiations with Congress. It still could. But if she is instead preoccupied with finding a way to keep the ACA afloat, she might not want to imperil those talks with something as contentious as drug price reform.

Plus there are plenty of big priorities outside of health care — like getting a Cabinet appointed, a Supreme Court vacancy filled, and a budget passed — all of which could leave Clinton with a smaller window to get to the rest of her health care platform.

“Which crisis is she going to have to choose to manage? I think it’s going to be a very crowded first 100 days,” the lobbyist said. “You’ve got a lot going on. It depends on which crisis has the most need, because Congress typically conducts itself that way.”

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  • Now Democrats may face the consequences of not having Bernie Sanders as the nominee. Single- payer was a signature issue and a Bernie presidency would have meant a virtual mandate.

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