Sen. Joe Manchin's (D-W.Va.) bombshell announcement that he won't support President Joe Biden's $1.7 trillion social spending agenda puts key healthcare provisions at risk. But there may be a path forward in the new year. Democrats need Manchin's support to pass legislation that passed the House last month. It contains numerous healthcare policies, including expanding Affordable Care Act health insurance subsidies and items important to providers.
"We're now quite concerned," said Ceci Connolly, president and CEO of Alliance of Community Health Plans, which supports the coverage expansions. "It seemed as if Build Back Better was going through all of the normal, reasonable deliberations and negotiations in Washington. But now the suggestion that it is potentially blown up is very troubling from a healthcare perspective."
The legislative package is wide-ranging and addresses disparate issues including climate change, paid family leave, health coverage and taxes.
Democratic leaders sought to appease the party's progressive and moderate camps as they assembled the legislation. Lawmakers in the latter group, particularly Manchin and Sen. Kyrsten Sinema (D-Ariz.), have proved the hardest to satisfy. Republicans unanimously oppose the domestic policy bill, making each Democratic vote precious, especially in the evenly divided Senate.
If the Build‧Back‧Better‧Act doesn't pass, Democrats will have to find another way to advance their healthcare objectives, which include extending enhanced ACA subsidies for middle- and higher-income earners before they expire at the end of 2022. The Build‧Back‧Better‧Act also would make subsidies more generous for lower-income people. The bill further would offer health insurance subsidies to 2.2 million low-income adults who live in the 12 states that haven't expanded Medicaid under the ACA.
The Democratic bill also carries several healthcare policies that aren't controversial in themselves, including healthcare workforce provisions such as funding for Medicare Graduate Medical Education, expanded access to home- and community-based services, funding for capital projects at community health centers, and spending for public health preparedness. The legislation also would add hearing aid coverage to Medicare, allow Medicare to negotiate some drug prices and permanently authorize the Children's Health Insurance Program.
Manchin centers his objections on the bill's cost and has expressed opposition to extending a tax credit for low-income families with children. The senator also accused fellow Democrats of using "budget gimmicks" to make the bill's total cost appear smaller by temporarily funding programs even though Democrats intend to renew those in the future. Manchin previously agreed to the legislative framework he now says he opposes, according to the White House.
There may be alternative legislative vehicles Democrats can use to move its healthcare provisions next year, including bills to fund the government and to reauthorize prescription drug user fees.
"They're just too compelling and too popular, and there's too much agreement on them in the Democratic caucus, that they're going to be part of anything that gets through," said Eliot Fishman, senior director of health policy at Families USA.
According to a Washington Post report Monday, Manchin told the White House he would accept a $1.8 trillion package that extends the ACA subsidies but excludes an extension of the child tax credit.
Senate Majority Leader Chuck Schumer (D-N.Y.) indicated Monday that the Senate will consider the package early in the new year, despite Manchin's current position. Congress is on recess for the rest of the year.
"We simply cannot give up," Schumer wrote in a letter to Senate Democrats Monday. "We are going to vote on a revised version of the House-passed Build Back Better Act—and we will keep voting on it until we get something done."