Last winter, when the Build Back Better Act (BBBA) was declared “dead” after Senator Joe Manchin of West Virginia revealed that he would not support it, health care reform advocates were disappointed. Hopes that important legislation would finally be passed to bring down the price of prescription drugs, bolster funding for home health care and expand subsidies to more Americans to afford health insurance were dashed. Therefore, when we heard that Senator Manchin and Senate Majority Leader Chuck Schumer unveiled an enormous bill called the Inflation Reduction Act (IRA) to combat climate change and reform health care, hope was rekindled. It seems as though Senator Manchin, the same centrist who shot down the BBBA, has come around to supporting progressive legislation after many months of negotiations with bipartisan leadership. The IRA, which has now been passed, includes several provisions that will positively impact the health care system for patients and providers alike. For one, it will allow Medicare to negotiate prices for a small subset of drugs, starting with 10 Part D drugs in 2026 and up to 20 Part B and D drugs in 2029. These negotiations are expected to save Medicare $288 billion over the next 10 years. Furthermore, the act will cap out-of-pocket costs to $2,000 per year for Medicare beneficiaries and will require drug companies to offer rebates to Medicare if their drug prices increase at a rate faster than that of inflation. Finally, the IRA will expand access to health plans sold on ACA marketplaces by extending the time that subsidies exist to more Americans. Specifically, it would extend premium tax credit subsidies by three years. While this all does sound hopeful, it is no wonder why those who advocated for more progressive legislation would be disappointed. The IRA is only a shadow of the now-dead BBBA, President Biden’s original $2 trillion plan to address a host of social issues, including health care. It fails to address certain pieces of legislation that progressives have been advocating for years, such as lowering in-patient hospital costs. The IRA’s prescription drug negotiation provisions are also incredibly restrictive, only allowing drugs to be considered if they meet a host of criteria. The Kaiser Family Foundation found that only exactly 20 non-insulin drugs would be open to negotiation per the current criteria, but even some of these drugs would not be eligible in 2026 due to increasing competition from generics. Some progressive health reform advocates have long felt that incremental reform has inadequately chipped away at a broken system that needs a complete overhaul, such as a single-payer system. However, Congress is divided, with any ambitious legislation requiring a super-majority in the Senate (the IRA is reconciliation legislation, so it only requires a simple majority vote), and the national political climate has never been so polarized. It has been a while since Congress has passed any major social spending, so the IRA is reason to be hopeful, as it shows that the American people still understand the importance of health care reform and its connection to inflation and the long-term well-being of the U.S. And in some way, this understanding is reflected in Congress beyond the IRA. The Senate is set to vote on the South Asian Heart Health Awareness and Research Act, which has already been passed in the House. Although it may seem that health care reform has taken a backseat, it is clear that the fight is still very much on. Additionally, the reality of the IRA is such that it will eventually help Americans financially, even if it is just a few hundred dollars back into the pockets of a few million Medicare beneficiaries. This incremental effect is exactly what is needed to shift the public’s support for more progressive approaches to health reform. We saw this play out after the Affordable Care Act was passed in 2010 under Obama. While approval of the legislation has been largely split by partisanship ever since then, its favorability increased in 2017 when Republicans threatened to remove it. This shows that once the health care provisions of the IRA are in place, the Act is likely to be popular among a wide range of beneficiaries — progressives and conservatives, low and middle-income Americans — because it actually may help struggling Americans, shielding it from future efforts to repeal it by those who oppose it for political reasons. In effect, these incremental policies have a beneficial impact for Americans and lay the groundwork for progressive policies in health care reform that become harder to overturn as time passes. On the one hand, we can sit idly and bemoan the apparently limited scope of the IRA’s health care provisions. Or on the other hand, we can acknowledge that it is the direct product of decades of advocacy for health care reform. The Overton window is a concept in politics that describes the range of policies deemed acceptable to the mainstream population at any given time. The window tends to shift either leftwards or rightwards due to influences of “unthinkable” opinions. While overhaul of our health care system such as single-payer may still be in the category of the “unthinkable,” the passage of the IRA in the Senate is living proof that the shouts and screams of progressives are being heard, and that the window is slowly shifting in favor of major health care reform. Source
