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A bittersweet health care win for Democrats

Democrats are widely expected to lose control of one or both chambers in November, and MEPs are aware that today’s vote on the Inflation Reduction Act may be their last chance for some time to make sweeping reforms to the US health system.

In 2020, the party campaigned for universal health insurance coverage, either through “Medicare for All,” a public option, or a mix of private and government programs. In 2021, Democrats pushed through, and in some cases passed, bills to enact sweeping drug price reforms, permanently expanding Obamacare subsidies and expanding Medicaid in the 12 retaining states that have refused to do so, and hundreds of billions into home health care for the elderly and people with disabilities and add dental, vision and hearing benefits to Medicare.

But in 2022, to win over a handful of more conservative Democrats in the House and Senate, they had to drastically scale back their ambitions, drop everything but drug pricing and ACA subsidies, and shrink both so that only a few drugs will be subject to negotiations in a few years, and the subsidies will end in 2025.

These policy sacrifices can have political consequences.

Democrats plan to campaign for their health policy victories over the next three months, but almost everything in the bill that voters would have immediately felt has been omitted. Negotiations on the price of drugs mandated by the bill will not begin until 2026 and will initially cover just 10 of the most expensive drugs that have been on the market for nearly a decade. And while the Medicare cash-spending limit 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 win over Big Pharma and ask the public to trust them for the positive changes to come.”

The extension of the Affordable Care Act’s enhanced tax credits bill will take effect immediately, preventing the monthly health insurance premiums of millions of people from rising by the end of the year. Legislation Democrats passed in 2021 made the subsidies more generous and entitled more middle-income people to them. But voters won’t see new benefits or cheaper insurance, and Democrats will have to hope their message — that it could have been worse — resonates with an audience that regularly tells pollsters that health care costs are too high.

“While Democrats have avoided a major political headache, it’s not like insurance premiums will drop,” Levitt noted. “Lawmakers will have to convince people that it would have been terrible if they had not acted and that the status quo itself is a victory.”

Even more difficult for members, especially progressives who dreamed of universal coverage, they may not be able to make another major effort for health reform for years to come — 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 reform — and Democrats have had to fight in the intervening years to regain control of Congress and the White House and defend the law against repeated withdrawal attempts.

Rep. 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 they pass this week for years to come.

“They may not get a bite of the apple for a long time to come. But once you’ve created a policy lever, it’s always easier to extend it than to create a new one,” said Benedic Ippolito, a senior fellow at the American Enterprise Institute. “This could be a recurring reward for Democrats. They could increase the number of drugs that have been negotiated here or there, say from 20 to 22 drugs, or postpone it for a year here or there until negotiations begin.”

However, the bill’s long implementation path carries other risks. Not only will Republicans likely 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 that will take a hit will already planning legal challenges and lobbying to mitigate its impact, and a future congress or president could try to roll back or weaken the law before it goes into full effect.

Still, Democrats and their allies argue that the drug industry’s threats highlight the bill’s huge victory and predict that they can build on it in the future. Even the bill’s more restrictive provisions, they emphasize, will give them something to take to voters in November to argue that they can and will do more if they manage to maintain and expand their majorities.

“We need to make it clear that without a small minority of the Democratic caucus, it would have been feasible to get a much wider scope of drug price negotiations without such a long delay, and to use those savings to support the extend the benefits of Medicare. and lower the benefit age. Those things depended on just a few seats difference,” said Steve Knievel of Public Citizen, one of the leading progressive groups putting Democrats on the bill. “It would have been politically better to do something bigger and bolder. But now they can credibly say that they’ve put in place a system that will ultimately make a big difference and that they’ve busted one of the most powerful lobbies in Washington and won.”

While the limited drug price reforms could expand in the future, it’s a tougher lift to reinvigorate the other items that have been ripped off the bill — and leaving them behind could have political ramifications, too.

Some of the most vulnerable members of Democrats in the House and Senate have… had a fight for months that a federal expansion of Medicaid in the 12 states that have refused to use the Obamacare provision would give them a significant boost in their reelection bids. Now lawmakers from Georgia, Wisconsin, Florida and North Carolina — states that need Democrats to hold the House and Senate — will face voters without taking home that advantage.

The Democrats have also abandoned their efforts to pump hundreds of billions of dollars into home care for the elderly and people with disabilities, meaning the current long waiting lists and staff shortages will likely continue. And while many of the drug pricing benefits of the new legislation are aimed at seniors, the party’s promised Medicare expansion to cover dental, vision and hearing benefits did not materialize.

Senate Budget Chairman Bernie Sanders (I-Vt.), who originally drafted a much broader and more expensive bill that would have included all those provisions and more, took the floor over the weekend to force amendments to add some of those line items back. add. Democrats joined Republicans in beating them — fearing any last-minute changes could threaten the passage of the underlying law.

“This bill does nothing to address the dysfunction of our current health care system,” Sanders lamented just before he voted in favor of the legislation. “Millions of seniors will continue to have rotten teeth and lack the teeth, hearing aid or glasses they deserve.”

Still, Faiz Shakir, Sanders’ chief political adviser, told POLITICO those amendments were intended less as an outrageous exercise and more as an argument to voters as to why they should give Democrats more power in November.

“That was the purpose of Bernie’s amendment fight: to say that we shouldn’t just accept and bag a moderate, centrist deal,” he explained. “We should go into this election and highlight what we still want to do by saying, ‘Here are steps 2, 3 and 4. This is what we will do if you give us two more seats, and we have credibility because we step 2 have already completed. 1.’ That is the real choice for voters: do you want more action on health care or do you want us to stop here?”

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