“When people see the roads and bridges in their communities, when they see water systems being created … and they see the $65 billion in broadband expenditures, that is a big, big deal,” he said. “But if you do that and do that only, what would you have done for prescription drugs? Nothing, that’s in the other bill.
“So Build Back Better has got to get done because the highest polling thing yet is the prescription drugs,” Clyburn added, referring to the name of the social spending bill coined by the White House.
But most of those measures aren’t slated to go into law upon passage. Indeed, by the time voters see their impact, the election will have passed. Penalties on drugmakers that hike prices faster than inflation and a new $35-per-month cap on insulin won’t begin until 2023. A $2,000 cap for all out-of-pocket drug spending for seniors won’t be implemented until 2024, and the lower prices Medicare will negotiate with pharmaceutical companies for some of the most expensive drugs won’t be available until 2025 — with a full phase-in coming in 2028. Coverage of hearing aides under Medicare, another one of the provisions most popular with voters, will similarly not begin until 2024.
Some of these provisions aim to lower the cost of the drugs themselves, while others shift the burden onto insurance companies and the governments, and still others aim to simply slow the speed at which prices increase.
“It may all feel a little theoretical rather than tangible for voters, and that poses a challenge for Democrats in the midterm elections,” said Larry Levitt, the executive vice president of the Kaiser Family Foundation. “Any time when there’s a gap between a bill passing and it going into effect, that gives opposition forces time to mobilize. The Affordable Care Act, for example, had a long lag between its passage and when it took effect, and the opposition certainly mobilized during that time. It’s still standing, but Democrats took a big political hit.”
The lag in implementation could complicate the sales job for Biden and down-ballot Democrats as they try to sell the impact of the president’s sweeping package to aid families, boost child care and combat climate change. Currently, voters in multiple polls say they don’t know what’s in the president’s package. GOP lawmakers, meanwhile, have zeroed in on the prescription drug provisions, echoing industry arguments that they would hamper the invention of new medicines and drive U.S. pharmaceutical companies to move overseas.
The decision to push back some of the benefits in the Build Back Better legislation to the latter years was driven by the time needed to set up new programs and by the pressure to keep the cost of the bill under the threshold necessary to pass it without Republican votes.
“There are realities we’re up against, including scoring,” Ways and Means Chair Richard Neal (D-Mass.) lamented. “Arithmetic can be pretty stubborn.”
It echoes a similar dilemma the party confronted 12 years ago when it passed the Affordable Care Act. That law set up health care exchanges and accompanying subsidies to purchase insurance that were not available until well after the 2010 midterms. That was largely because it was difficult to craft those markets from scratch, but operatives subsequently concluded that Democrats were hurt by backlogging the law’s positive elements while front-loading its new taxes.
The party got crushed in those midterms. But the health care law subsequently became widely popular. And pledges to defend it against GOP repeal efforts and make health care less expensive helped the party win back the House in 2018 and the Senate and White House in 2020.
Democrats risk running into the same obstacles now, but they are aiming to learn lessons from their 2010 messaging issues around the ACA, and Biden’s team is making the sale of his agenda a top priority.
As Biden has ramped up travel to promote his economic agenda, the White House has increasingly distilled its message down to two sentences: “The Build Back Better framework lowers your bills for health care, child care, prescription drugs, and preschool. And families get a tax cut,” the president said recently. For months, Biden has repeatedly zeroed in on the provision allowing Medicare to negotiate lower prescription drug costs for seniors, aware that it remains one of the most popular elements of the legislative framework.
But White House officials also argue that there are many aspects of the bill that voters will experience right away and that Americans would rather see lower drug costs made into law no matter the implementation date than the alternative of nothing. Still, the slow rollout complicates the party’s message.
“I do think it’s difficult to tell them that when they don’t actually see prescription drug prices going down,” said Sarah Longwell, a Republican never-Trump strategist who frequently conducts focus groups of voters in swing states. Democrats will need to saturate voters in messages that they lowered prescription drug costs for it to resonate, Longwell said. “Donald Trump signed those [relief] checks, and everybody thought it was gauche — it was gauche — but Donald Trump made sure you knew he was the one who sent you those relief checks.”
Many vulnerable Democratic members up for reelection next year say they’re confident they can campaign on the bill’s health benefits that will be felt right away by voters — particularly the free health insurance for people in the dozen red and purple states that have refused to expand Medicaid. Those states, which could see more than 2 million uninsured people gain coverage next year, include states with high-profile Senate elections such as Georgia, Florida and Wisconsin.
Unable to create a new federal Medicaid program to cover people in non-expansion states as Democrats originally intended, they decided to offer them government-subsidized private insurance plans instead, both to appease industry-friendly centrists and to ensure people could begin to enroll right away. And though Democrats were not able to make permanent the enhanced Obamacare tax credits they temporarily enacted last year, they’re set to extend them for an additional two years, which the White House estimates will reduce the premiums of at least 9 million people.
“The difference between this and the ACA is that there will be a lot happening immediately in people’s lives — it helps show we are delivering on our promises in a real and tangible way,” said Rep. Carolyn Bordeaux (D-Ga.), who is working to hold onto a seat in the Atlanta suburbs she flipped in 2020. “The combination of the Affordable Care Act tax credits and the Medicaid expansion could allow us to bring the uninsured rate almost down to zero. Then we’ll say: ‘But there’s more!’”
Despite some health provisions’ delayed application date, White House officials are bullish that passage of Biden’s social spending plan will enable Democrats to say after years of unmet promises to lower prescription drug costs — including from Donald Trump throughout his presidency — that they got it done. A White House official also argued that the public understands that some provisions take time to implement, in part due to the nature of allowing pharmaceutical companies time to negotiate the price of drugs that they spent money and time on innovating.
John Anzalone, a top Biden pollster in 2020, argued that Democrats also have an effective line of attack heading in 2022: Zero Republicans supported the new health care benefits.
“We’re going to be communicating on the fact that we’re doing something about health care. We’re doing something about prescription drugs and paid leave and elder care and child care and the Republicans tried to block all of that,” said Anzalone. “I’ll take that debate every day of the week.”