Why Build Back Better Is a Health Care Bill Now

WASHINGTON — President Biden and Democrats in Congress had hoped to pass a broad domestic policy package that would expand the social safety net, raise taxes on corporations and the wealthiest Americans, and tighten regulation of climate-changing pollutants. But the decision by Senator Joe Manchin of West Virginia to withdraw his support from other aspects of an already-shrunken package this week leaves nothing but health care on the table.

But even if what was once a sidecar of sorts to the so-called Build Back Better Act is now the only vehicle left on the road, it would still have a substantial impact on the lives of many Americans. And unlike other provisions that faced a mixed political reception, the central health care proposal that remains is enormously popular with the public — including Republicans.

That piece is prescription drug price reform, which Democrats have been promising for years and many Americans tell pollsters they want. The bill would take several whacks at the price of drugs — directly regulating prices for a group of expensive medications purchased by Medicare and punishing drug companies that raise prices too fast on existing medicines for all Americans.

The legislation under discussion would also expand Medicare’s prescription drug benefit, increasing financial help for poorer seniors and eliminating the program’s current unlimited cost sharing, which leaves some beneficiaries facing more than $10,000 a year in medication costs. No one on Medicare would be asked to pay more than $2,000 a year for prescription drugs under the legislation, a significant benefit to patients who take expensive medications for serious diseases like cancer and multiple sclerosis.

The prescription drug provisions are unusual in that they offer Americans tangible benefits — lower drug prices, more financial protections — while actually saving the federal government money. That’s because the bill essentially puts the savings on the back of the pharmaceutical industry, which will have to accept lower prices for some of its big sellers.

Defenders of the industry in Congress, and the drug companies themselves, argue that the change could thwart innovation and cost jobs. Such arguments have staved off drug price reforms in the past. But previous rounds of negotiation suggest that this package is likely to have enough votes to pass the Senate.

Mr. Manchin has also signaled his support for another health provision that has received less attention in recent reports of the emerging deal. He said he was open to an expansion of premium subsidies that lower the price of insurance for Americans who buy their own coverage, rather than get it through the government or a job.

Those subsidies were already expanded as part of Congress’s pandemic relief bill last year, but the expansion will expire in December unless new legislation continues them.

The subsidies are important to many Democratic lawmakers because they are seen as fulfilling the promise of the Affordable Care Act. The extra money lowers premiums for nearly every American who buys a health plan through the Obamacare marketplaces, making certain plans free for lower-income Americans and offering financial support for higher-income people who previously received no help paying for insurance.

In a statement on Friday supporting the measures in which he called on the Senate to pass the legislation before its August recess, Mr. Biden said Democrats had “come together” and “beaten back the pharmaceutical industry.”

“This will not only lower the cost of prescription drugs and health care for families,” he added, “it will reduce the deficit and help fight inflation.”

But for Democrats who had hoped for social spending on programs other than health care, the price of extending the Obamacare subsidies may disappoint. A slightly outdated estimate suggests they will cost the federal government nearly as much to extend as the drug-pricing provisions would save — $220 billion over a decade, compared with about $288 billion in savings.

Mr. Manchin has said he might be open to considering climate and tax provisions in the fall. If he is also hoping for deficit reduction, there may be less money to spend than some lawmakers expected.

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