The Washington PostDemocracy Dies in Darkness

Democrats fret about delivering on health care promises ahead of midterms

A truck sponsored by the Service Employees International Union, carrying messages from home care workers urging Congress to pass President Biden's Build Back Better agenda, passed by the Health and Human Services Department on Jan. 4 in Washington. (Paul Morigi/Getty Images)
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In 2020, Democrats pledged a slew of health-care changes if voters would just give them Congress and the White House. Voters did just that — and now Democrats are feeling pressured to deliver on their promises as midterm elections approach.

The party campaigned on an ambitious agenda of beefing up Obamacare, increasing health care access to America’s most vulnerable patients, and, most significantly, lowering the high cost of prescription drugs in the United States. A year later, there’s increasing concern within the party about what falling short on their long-standing goals could mean for this year’s midterms.

“It has been a concern for us,” said Congressional Progressive Caucus Chair Pramila Jayapal (D-Wash.). ”You can see it with the number of Democrats in vulnerable districts across the country who want to be able to go back and tell people that we’ve lowered their costs for child care, for pre-K, for elder care, for drug pricing, for health care.”

President Biden’s roughly $2 trillion social spending bill includes an array of Democrats’ health-care policy ambitions, yet the package’s prospects remain in peril after Sen. Joe Manchin III (D-W.Va.) said he couldn’t vote for it. The legislation represents Democrats’ best opportunity to further expand health care and make changes to the complex system in more than a decade. And they don’t expect to get any help from Republicans, whose main effort on health care has been trying — and failing — to repeal the 2010 Affordable Care Act.

While that landmark law was a big step forward in expanding health coverage, improving the U.S. health-care system remains a confounding and difficult project.

Advocates say the health care portions included in the House-passed sweeping economic package are some of its more popular provisions, and they are hopeful they’d remain in any further iterations of the bill. This includes efforts like boosting in-home care for seniors and the disabled, extending Medicaid to 2.2 million poor adults and granting Medicare the power to negotiate prescription drug prices.

“I feel ultimately that Democrats will manage to get something over the finish line that is substantial on health care,” said Eliot Fishman, a senior director of health policy at Families USA, a left-leaning consumer health lobby. “[That’s] because it’s something which the public wants, because they know about the potential consequences for the midterms, and because it’s something which there’s not a lot of disagreement on among Democrats.”

There’s still time to go before campaign season gets into full swing, and Democrats view passing health measures as energizing to their base. The party’s stance on further expanding health care helped it win back the House in 2018 after voter outrage over Republicans’ failed efforts to repeal and replace Obamacare. The issue — along with curbing the coronavirus pandemic and combating racial injustice — also buoyed the party to win the White House in 2020 and control of the Senate a few months later.

“I prefer to think of it not as a negative, ‘Oh, we’re doomed if we don’t get these things done,’ but as a real groundswell if we can get these things passed,” said Rep. Susan Wild (D-Pa.), one of the House’s vulnerable members. “People want to know that the people they elect can get things done that are going to make a difference in the lives of ordinary citizens.”

Congressional leaders and the White House insist they haven’t given up on their economic package, known as the Build Back Better Act. Yet things aren’t looking good for the legislation; Manchin said he is no longer in talks with the White House after tensions flared before the holidays and his $1.8 trillion counteroffer may no longer be on the table, The Post reported last weekend.

Still, some Democrats and lobbyists contend they see a potential path forward. The party will be rethinking the contours of the package, plotting what may be scaled back or nixed.

“It’s important for us to get it done,” said Sen. Gary Peters (D-Mich.), chairman of the Democratic Senatorial Campaign Committee.

But if Democrats fail?

“It would not only be a lost opportunity from a policy perspective, but it would be a significant detriment to Democrats’ ability to score some important political points for policies that the public cares about,” said Chris Jennings, a longtime Democratic health policy consultant who worked in the White House during the Clinton and Obama years.

The party’s Senate campaign arm maintains that Democrats have a strong health care record to run on. Democrats passed Biden’s coronavirus pandemic stimulus package on a party line vote last spring, which bolstered financial help for many who get coverage on the individual marketplaces and included enticements for states to expand Medicaid.

Democrats have “a clear contrast to make against Republican candidates, who already have opposed popular proposals that have lowered the cost of health care for millions of Americans,” said Jazmin Vargas, a DSCC spokesperson.

On the other side, Republicans are gearing up to push back against that agenda.

“Democrats are not sitting there saying they want to make sure people get health care. They're sitting there saying they want government-run health care,” said Sen. Rick Scott (R-Fla.), the chair of the National Republican Senatorial Committee.

More than 60 million Americans get health coverage through Medicare, which is run by the federal government, and Democrats’ social spending bill would add hearing services to the program.

The economy and the coronavirus pandemic are likely to be top issues for voters this year, as coronavirus cases surge to record levels and the administration grapples with how to keep society functioning while curbing a deadly virus.

Yet, Americans historically rank health care among their top priorities. Several drug pricing measures included in Build Back Better are high on that list, such as letting Medicare negotiate the prices of prescription drugs and limiting how much money seniors pay out-of-pocket each year for medicines.

“We’ve campaigned for a long time on taking it to the drug companies and passing the bulk negotiation of prices. It’s something that voters understand,” Sen. Chris Murphy (D-Conn.) said. “I think it’s problematic if we can’t get that done.”

Some lawmakers say they’re making contingency plans in case the party doesn’t pass its sweeping economic package to overhaul federal health-care, education, climate, immigration and tax laws.

In private conversations during the holidays, some House Frontliners — a group of the chamber’s most vulnerable Democrats — discussed introducing standalone bills, including on health care, according to Wild.

Others, such as Jayapal, are reviewing what the Biden administration can do through executive action, particularly around drug pricing. The Biden administration has already worked to unwind some Trump-era health actions hated by Democrats and to build on former president Barack Obama’s over-a-decade-old health law, including rolling back Medicaid work requirements and boosting funding for groups helping people enroll in ACA plans.

But there’s a limit to what can be changed through regulation or beefing up existing law.

After months of fierce intra-party debates, the House passed the economic package in November with only one Democratic defection and without any Republican votes.

“House Democrats worked tirelessly to pass the President’s popular Build Back Better agenda because they’re laser focused on fighting for families by lowering prescription drug costs and expanding Medicaid so millions of Americans can access the health care they need,” Nebeyatt Betre, a spokesperson for the Democratic Congressional Campaign Committee, said in a statement.

But it’s lagged in the Senate since, and congressional Democrats are cognizant that they may not have the power to enact their health agenda come next year.

“There’s pressure to act not only to have policies to campaign on in the midterms, but [it] might be the last time in quite a while that Democrats control Congress and can control the agenda,” said Larry Levitt, an executive vice president of the Kaiser Family Foundation.

If Democrats do manage to pass their social spending bill, they’ll face another daunting challenge: Communicating to voters what the legislation will do. That’s because many of the provisions aren’t slated to begin right away, such as adding hearing benefits to Medicare.

“The problem is that, once we pass the laws, we’re dependent on agencies to implement a lot of the aspects of those laws,” Wild said, “and sometimes that is a very frustrating piece of the process.”