Reconciliation, Infrastructure Deadline Gets Pushed To Month’s End Inside Health Policy
Congressional Democrats are now shooting to reach agreement on a scaled-back reconciliation package that could pass with the infrastructure bill by the end of the month when a short-term highway transportation bill expires -- giving lobbyists and lawmakers four more weeks to spar over how to fit their health care priorities into a partisan package that the White House made clear Friday must shrink from $3.5 trillion to around $2 trillion, and possibly lower, to get centrists onboard.
Lawmakers are faced with difficult decisions on whether to retain all their health care priorities -- new Medicare benefits, a fix to the Medicaid coverage cap, extension of enhanced Affordable Care Act tax credit, investment in home- and community-based health and permanent extension of the Children’s Health Insurance Program -- by scaling back how long they are funded, or instead scrapping some policies in favor of robustly funding others. Another continued question mark is what the final drug-pricing payfor will look like, and how much it will save.
President Joe Biden offered a relief valve to House Democrats Friday (Oct. 1), telling them at a caucus meeting there’s no urgency to pass the bipartisan infrastructure bill, after high-level discussions failed to produce a compromise to pass that bill and the reconciliation package at the same time. He also reportedly told lawmakers he wants both reconciliation and infrastructure voted on together, which is good news for progressives, but also reportedly set a new top-line reconciliation target of $1.9 trillion to $2.3 trillion. This is close to the $2 trillion that many on K street have speculated would be the final number, but Sen. Joe Manchin (D-WV), whose vote is needed, continues to call for a $1.5 trillion topline.
According to reports, the president told Democrats during the meeting that both bills will be enacted but he also said that it doesn’t matter exactly when. “It doesn’t matter (whether) it is in six minutes, six days or six weeks. We’re going to get it done,” he told reporters following the meeting. But Democrats then passed a one-month highway funding extension, so they view that as the new deadline for an infrastructure and reconciliation vote.
In a Saturday letter to her caucus, House Speaker Nancy Pelosi (D-CA) said the infrastructure deal must be passed well before the October deadline. And she explained Friday’s decision-making.
“Time was interrupted two weeks ago when the prospect of a changed budget made the climb to agreement steeper. But still the work continues. Since it all starts with the priorities and then seeing what it all adds up to, it is important to know that it all adds up to ZERO, because Build Back Better is paid for. Negotiations will continue now, with more time for decisions, legislative language, Senate parliamentarian review and public awareness."
Senate Majority Leader Chuck Schumer (D-NY) said over the weekend that the goal is to have both parts of the president’s agenda passed by the end of the month, but lawmakers first have to figure out how to deal with the debt ceiling, which is expected to be hit prior to Halloween. Republicans have told Democrats they should expect to raise the debt ceiling without help from the GOP, while the president said he couldn’t guarantee addressing the debt ceiling without Republicans. One lobbyist said the debt ceiling battle also provides helpful cover for Democrats as they fight over the reconciliation bill.
Senate Budget Chair Bernie Sanders (I-VT) told Meet the Press over the weekend that it doesn’t matter if it takes a few more weeks to pass both the infrastructure and reconciliation bills and what matters is getting them done. Prior to that, on Friday (Oct. 2) Sanders tweeted congratulations to House progressives for insisting on passage of the reconciliation and infrastructure packages together.
“The Reconciliation Bill is transformational. It's about taking on Pharma to lower prescription drug costs, the fossil fuel industry to combat climate change, the insurance companies to expand Medicare and demanding the rich pay their fair share. If we stand together, we win,” Sanders tweeted.
While Manchin’s $1.5 trillion top-line reconciliation number left lawmakers and lobbyists scrambling to protect their health care priorities late last week, Democrats appear to now be aiming to get him onboard a price tag around $2 trillion. One lobbyist said Congress needs to be careful not to ratchet back policies to a point they won’t help those for whom they are intended.
Democrats’ plans to add dental, hearing and vision benefits to Medicare continue to be a flashpoint, with Manchin raising reservations about adding benefits to Part B while the Part A Medicare trust fund is set to be insolvent in 2026. He is pushing to means test the social programs in the reconciliation bill.
House Majority Whip Jim Clyburn (D-SC) said last week that because Medicare isn’t a means-tested program, closing the so-called Medicaid gap should be a higher priority for Democrats than adding new benefits to Medicare. But others argued that covering hearing, vision and dental benefits would improve health equity.
On the pay-for side, it’s becoming increasingly clear that the bill Senate Finance Chair Ron Wyden (D-OR) is writing won’t extend Medicare negotiated drug prices to commercial insurers, will limit the instances in which Medicare negotiates, and will not aid negotiations with drug appraisals, lobbyists following the legislation said. Wyden is writing a watered-down version of House Democrats’ Medicare price negotiation bill that could pass the Senate, and the resulting savings will drive which Medicare, Medicaid and ACA reforms can be squeezed into the reconciliation package.
As health care lobbyists fixate on the heated Capitol Hill debate threatening to derail Democrats’ signature health care reforms, a lot of policy activity on health equity, mental health, transparency, and abortion has flown under the radar. Senate Finance Committee leaders are seeking input from stakeholders as they craft legislation aimed at cutting cut barriers to mental health services, academics are urging CMS to increase fines on hospitals not providing price transparency, HHS recently launched a three-pronged effort to protect patients and providers in Texas following enactment of the state’s anti-abortion law, and kidney stakeholders are touting a race-free approach to disease diagnosis. Find out more in Inside Health Policy’s federal roundup.
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