Democrats are widely expected to lose control of one or both chambers in November, and MPs are aware that today’s vote on the Inflation Reduction Act could be their last chance for a while to pass major reforms to America’s health care system.
In 2020, the party campaigned on universal health insurance coverage, whether through “Medicare for All,” a public option, or a combination of private and government programs. In 2021, Democrats pushed, and in some cases passed, bills to enact sweeping drug price reforms, permanently expand Obamacare subsidies, and expand Medicaid in the 12 holdout states that have refused to do so. make, and pay hundreds of billions in home health care for the elderly and disabled and add dental, vision and hearing benefits to Medicare.
But in 2022, in order to win over a handful of more conservative Democrats in the House and Senate, they’ve had to drastically scale back their ambitions, dropping everything but drug pricing and ACA grants and cutting both so that only a few medications are submitted. to negotiations in several years, and the grants end in 2025.
These political sacrifices could have political consequences.
Democrats plan to spend the next three months campaigning for their health policy victories, but nearly everything in the bill that voters would have felt immediately has been deleted. Negotiations on drug prices mandated by the bill will not begin until 2026 and will initially cover only 10 of the most expensive drugs that have already been on the market for nearly a decade. And while the Medicare out-of-pocket spending cap will save many seniors thousands, if not tens of thousands, of dollars, it won’t take effect until 2025.
“Democrats will have a hard time selling this to voters because they won’t have much tangible to show yet,” said Larry Levitt, executive vice president for health policy at the Kaiser Family Foundation. “So they will have to sell it primarily as a historic victory over Big Pharma and ask the public to trust them on the positive changes to come.”
The bill’s extension of the Affordable Care Act’s enhanced tax credits will take effect immediately, preventing millions of people’s monthly health insurance premiums from rising by the end of the year. Democrat Legislation Passed in 2021 made the grants more generous and allowed more middle-income people to qualify. But voters won’t see new benefits or cheaper insurance, and Democrats will have to hope their message — that it could have been worse — will resonate with a public that routinely tells pollsters that the costs of care of health are too high.
“While Democrats have avoided a big political headache, it’s not like insurance premiums are going to go down,” Levitt noted. “Legislators are going to have to convince people that it would have been terrible had they not acted and that the status quo itself is a victory.”
More difficult still for members, especially progressives who dreamed of universal coverage, is that they may not be able to mount another major health reform effort for years, especially if they lose their majority this fall. It’s been more than a decade since the Affordable Care Act — the party’s last major health care reform — and Democrats have had to fight through those intervening years to regain control of Congress and the White House and defend the law against repeated repeal attempts.
representing Lauren Underwood (D-Ill.) told reporters this week that Friday’s vote is a “once-in-a-generation opportunity.”
But that doesn’t mean the party can’t build on what it passed this week for years to come.
“They might not have another bite at the apple for a long time. But once you’ve created policy leverage, it’s always easier to expand it than to create a new one,” said Benedic Ippolito, senior fellow at the American Enterprise Institute. “This could be a recurring payout for Democrats. They could increase the number of drugs negotiated here or there, from 20 to 22 drugs for example, or skip a year here or there on the time until the start of the negotiation.
Yet the long track of implementing the bill carries other risks. Not only are Republicans likely to try to turn public opinion against it while voters wait to feel its effects — as they successfully did with the Affordable Care Act — but drug companies and other industries about to take a hit are already planning legal challenges and lobbying blitzes to mitigate its impact, and a future Congress or president may try to roll back or weaken the law before it takes full effect.
Still, Democrats and their allies argue that the threats from the pharmaceutical industry make it clear what an important victory the bill is and predict they can build on it in the future. Even the narrower provisions of the bill, they point out, give them something to bring to voters in November to argue that they can and will do more if they manage to maintain and expand their majorities.
“We must make it clear that without a small minority in the Democratic caucus, it would have been possible to achieve a much broader scope of drug price negotiations without such a long delay and use those savings to expand Medicare benefits. and lowering the eligibility age. These things were based on a difference of just a few seats,” Steve Knievel said with Public Citizen, one of the main progressive groups pressing Democrats on the bill. “It would have been politically better to do something bigger and bolder. But now they can credibly say that they put in place a system that will ultimately make a big difference and that they took on one of the most powerful lobbies in Washington and won.
While the limited drug pricing reforms could expand in the future, reviving the other elements removed from the bill carries greater weight – and leaving them behind may also have political ramifications.
Some of the most vulnerable members of Democrats in the House and Senate have argued for months that a federal expansion of Medicaid to the dozen states that have refused to take advantage of the Obamacare provision would give them a significant boost in their re-election bids. Now lawmakers in Georgia, Wisconsin, Florida and North Carolina — state Democrats will have to hold the House and Senate — will face voters without reporting that advantage.
Democrats have also abandoned efforts to pour hundreds of billions of dollars into the home health care system for the elderly and disabled, meaning the current long waiting lists and labor shortages are likely to continue. And while many of the new legislation’s drug price benefits are aimed at seniors, the party’s promised expansion of Medicare to cover dental, vision and hearing benefits has not materialized.
Senate Budget Chair Bernie Sanders (I-Vt.), who originally drafted a much broader and more expensive bill that would have included all of these provisions and more, spoke out over the weekend to force amendment votes on the added some of these items. Democrats joined Republicans in defeating them — fearing any last-minute changes could threaten passage of the underlying bill.
“This bill does nothing to address the dysfunction of our current health care system,” Sanders lamented just before voting in favor of the legislation. “Millions of older people will continue to have rotten teeth and won’t get the dentures, hearing aids or glasses they deserve.”
Yet Faiz Shakir, Sanders’ chief political adviser, told POLITICO the amendments were less about shaming and more about explaining to voters why they should give Democrats more power in November.
“That was the whole point of fighting Bernie’s amendment: to say we shouldn’t just accept a moderate centrist deal and wrap it up,” he explained. “We should go into this election focusing on what we still want to do, saying, ‘Here are steps 2, 3 and 4. Here’s what we’ll do if you give us two more seats, and we have credibility because we have already completed step 1.’ This is the real choice for voters: do you want more action on health care or do you want us to stop here?”
