“The coronavirus pandemic has fully exposed the flaws in the US health care system and deepened many of its disparities. Yet there is a serious possibility, now that Sen. Joe Manchin (D-WV) has rendered the current version of the Build Back Better Act dead, that the current Congress will not pass any long-term provisions to cover more people, make health care more affordable, or better prepare the nation for the next pandemic.
Though they have not attracted as much attention as other parts of the legislation, Democrats had written a wide-ranging health care section in Build Back Better. They were planning to patch up holes in the Affordable Care Act, extending assistance to middle-class families as well as people in poverty; to reduce drug costs for millions of Americans; and to make investments in the country’s health care infrastructure, with the goal of better preparing the US for the inevitable next pandemic.”
“The law, which takes effect Jan. 1, protects patients from receiving expensive bills for unexpected out-of-network care but doctors, hospitals and insurers are still at odds over which factors an independent arbitrator should rely on to decide who picks up the tab.
The outcome could swing billions of dollars in payments, significantly influence how doctors and hospitals negotiate prices with insurers and possibly affect premiums for millions of Americans.
“This is probably one of the most significant overhauls in the health system since the [Affordable Care Act] ACA,” said a spokesperson for the Coalition Against Surprise Medical Billing, which represents insurers, employer and union groups, and works with patient groups. “We certainly don’t see any end in sight in terms of the battle in making sure that these regs are implemented.”
The coalition supports the Biden administration’s interim final rule that instructs arbitrators to rely primarily on a single factor — the median in-network rate in a geographic area — when settling disputes between providers and payers. It has sponsored multiple six-figure digital ad-buys, including one that runs through Christmas, urging regulators to stay the course.”
“Hospitals and doctors allege the Biden administration’s decision to emphasize the median in-network rate, a figure the insurance companies calculate, gives large insurers a huge advantage when negotiating how much a service should cost.
Insurers would have an incentive to keep the in-network rates lower to avoid paying more to out-of-network doctors. And they say payers would know doctors and hospitals have little recourse if they choose to remain outside an insurer’s network.
“Being out of network is really the physicians’ only control over how their contracts look,” said Randall Clark, the president of the American Society of Anesthesiologists. “If the insurance companies can treat us the same whether we’re in network or out of network, there is no impetus on the part of the insurance companies to negotiate fair contracts.”
Trade groups representing providers say the law lists several other factors that should be equally weighted when calculating how much a service costs, such as the doctor’s experience and the complexity of the procedure. While these metrics can still be introduced during the dispute resolution process, the Biden administration’s rules don’t give them as much weight as the median in-network rate metric, which providers say puts them at a disadvantage before the process even begins.”
“First, the legislation doesn’t address why child care is so expensive in the first place. More people seeking it will only collide with ill-advised government restrictions on the supply of such care—restrictions like the excessive occupational licensing and credential rules that prevent plenty of qualified people from offering their services. A bill that truly aims to reduce the cost of child care would remove these restrictions and allow parents to choose any capable provider.
BBB doesn’t lift any restrictions and adds more. As University of Chicago economist Casey Mulligan explains, “the bill requires that child-care workers be paid a ‘living wage’ and that their earnings be ‘equivalent to wages for elementary educators with similar credentials and experience.'” As a result, child care will become even more expensive for all families that don’t qualify for “free” child care.”
“As part of Biden’s plan to rein in carbon emissions, the bill contains a provision which would provide a $7,500 tax rebate to any consumer who purchases an electric vehicle (EV), including both all-electric and plug-in hybrids. However, that amount increases by $4,500 if the car was manufactured in a unionized U.S. factory, as well as by an additional $500 if the vehicle contains a U.S.-made battery.
Ostensibly, this provision is part of Biden’s “Buy American” policy of incentivizing or mandating purchases to be made domestically. In practice, the order has simply carried over the protectionism of the Trump trade policy and increased costs to taxpayers. The EV credit proposal, though, is much more egregious, in that it not only incentivizes a particular type of product, but incentivizes particular brands, as well.
If enacted as written, the bonus $4,500 in EV credits could only apply to cars made by Ford, General Motors, and Stellantis (formerly Fiat Chrysler). In other words, a driver who wants to purchase a hybrid Toyota Camry, which U.S. News & World Report ranks as having “Great” reliability, does not qualify for the extra money, even though the car is manufactured in Kentucky. But if that same shopper elects to purchase a Chevrolet Bolt, which recently halted production because the batteries were catching fire, they would receive the extra rebate. As a matter of fact, out of more than 50 EVs currently on the market, the only vehicles which currently qualify for the extra money are two variations of the Bolt.
This is what is most pernicious about this policy: Rather than simply a blanket advantage for American companies (which would be bad enough), it is a clear giveaway to the United Auto Workers (UAW).”
“The West Virginia moderate said he can’t back the $1.7 trillion package. But Manchin has supported many of the bill’s individual policies, giving hope for Democratic leaders now plotting to get the centrist senator on board with a far slimmer proposal or spinning off other bills that include some of the package’s well-liked items.”
“Extension of the beefed-up Child Tax Credit that Democrats pushed through in March, which many of them considered a landmark legislative achievement since taking control of the White House and Congress.
The huge expansion of the program, which benefits an estimated 61 million children, will expire at the end of the year unless Democrats find some way to keep it alive or revive it after it lapses. The IRS cut its final round of monthly checks for 2021 last week, sending about $16 billion to more than 36 million families.
The demise of the expansion would mean the end of payments for millions of children whose families would no longer qualify. The maximum credit would fall to $2,000 from $3,600, it would revert to a yearly benefit instead of a monthly payment and a work requirement for parents would be reinstated.”
“Manchin wanted fewer upper-income households to qualify for the benefit and said the work requirement should be brought back. He also considered the one-year extension a budget gimmick because it was likely to be extended again later.
Many Democrats wanted to make the expansion permanent. But bowing to Manchin’s objection to the price of the overall spending package, they settled on a one-year extension in the House bill.”
“Biden left negotiations with Manchin this week thinking the two men could cut a deal next year on his sweeping agenda. Then the West Virginia Democrat bluntly said he is a “no” on the $1.7 trillion in an interview on “Fox News Sunday.”
“If I can’t go home and explain to the people of West Virginia, I can’t vote for it. And I cannot vote to continue with this piece of legislation. I just can’t. I’ve tried everything humanly possible. I can’t get there,” Manchin said. “This is a no on this piece of legislation. I have tried everything I know to do.”
Those comments prompted an immediate war with the White House, who took personal aim at Manchin for what officials saw as a breach of trust. White House press secretary Jen Psaki released an unusually blunt statement saying that Manchin’s comments “are at odds with his discussions this week with the President, with White House staff, and with his own public utterances.”
In announcing his opposition, Manchin raised the same concerns about the bill that he’s had all along: inflation, rising debt and a mismatch between the package’s 10-year funding and its shorter-term programs. But until Sunday, Manchin had never taken a hard line on the legislation. In the past week, he’s spoken directly to Biden several times, with the president and other Democrats furiously lobbying him to support the bill.
With an evenly split Senate, Senate Majority Leader Chuck Schumer needs every Democrat to go along with the legislation, which only requires a simple majority vote. That dynamic gives Manchin enormous leverage over Biden’s agenda, allowing him to single-handedly sink a priority that Democrats have spent much of the year working on.
Manchin’s rollout on Fox News infuriated Democrats Sunday morning. Psaki said that the senator had brought Biden an outline of a bill similar in size and scope that “could lead to a compromise acceptable to all.”
“If his comments on FOX and written statement indicate an end to that effort, they represent a sudden and inexplicable reversal in his position, and a breach of his commitments to the president and the senator’s colleagues in the House and Senate,” Psaki said. “Just as Senator Manchin reversed his position on Build Back Better this morning, we will continue to press him to see if he will reverse his position yet again, to honor his prior commitments and be true to his word.”
And while the centrist senator’s staff informed White House and Democratic aides about his forthcoming blow to Biden’s agenda, some Democrats were steamed that Manchin himself hadn’t called Biden or Schumer.”
“now may be an opportunity to revisit a concept of the bill that included fewer programs but was paid for over more years — an option that moderate House Democrats and party leaders such as Speaker Nancy Pelosi had pushed for previously. Centrist New Democrat Coalition Chair Rep. Suzan DelBene (D-Wash.) said in a statement Sunday that including fewer programs in the legislation but for longer durations “could open a potential path forward for this legislation.””
“The West Wing saw Manchin’s Sunday comments as a shocking about-face — White House officials believed he had been sending signals that a deal could eventually be struck.”
“Manchin’s position is a validation of progressive fears — they believed passing that infrastructure bill was a mistake without an explicit guarantee from all 50 Democratic senators to support the rest of Biden’s agenda. Progressive House Democrats fumed at Sunday’s developments, though the nearly 100-member caucus had not regrouped to find a path forward.
“I wish we would have kept both bills together. That was the plan throughout several months of negotiation,” Bowman said. “I was frustrated then and obviously frustrated now that we decided to decouple those bills, because, as Manchin has shown in the past, we cannot just take his word for something.””
“”The Build Back Better Act relies on a number of arbitrary sunsets and expirations to lower the official cost of the bill,” explains the Committee for a Responsible Federal Budget (CRFB), a nonprofit that advocates for balanced budgets. The group’s newly updated analysis of the Build Back Better plan finds that the package will cost an estimated $4.8 trillion over 10 years if all provisions are made permanent—double the price tag applied by the CBO last month.”
“several key parts of the bill are designed to game the CBO’s method for scoring the cost of legislation by setting arbitrary expiration dates even though lawmakers obviously intend for those policies to be permanent fixtures. Probably the best example is the expanded child tax credit, which would expire after just a single year. Other parts of the bill, including the universal pre-K funding and new subsidies for child care, would expire after six years. Expanded subsidies through the Affordable Care Act would last until 2025.
With all those gimmicks in place, the CBO assessment of the bill projects that it will cost about $1.8 trillion and add about $367 billion to the deficit over the next decade.
If all the Build Back Better plan’s proposals were made permanent, however, the final price tag would be $4.8 trillion, and the bill would add about $2.8 trillion to the deficit, according to the CRFB.
“To be sure, lawmakers may choose not to extend some or all of these provisions,” the CRFB analysis states. “However, if they do, they would need to more than double current offsets in order for the bill and the extensions to be paid for. The alternative would be a substantial increase in the debt.””
“For the past six months, families with kids have received monthly payments from the federal government as part of the expanded child tax credit — a policy that has slashed child poverty in the US.
If Congress doesn’t act, however, this measure is set to expire for future payments near the end of the month. The last monthly payment was scheduled to go out on December 15, after which these installments will end.”
“The Center on Budget and Policy Priorities, a think tank focusing on social programs, estimates 9.9 million children could fall back into poverty or deeper into poverty if the credit is not extended. It estimates, too, that poverty rates for Black, Latino, and American Indian or Alaska Native (AIAN) children, in particular, will be hardest hit. If BBB doesn’t pass, poverty rates would be 22 percent for Black children compared to 13 percent if it did, 21 percent for Latino children compared to 12 percent, and 18 percent for AIAN children compared to 10 percent.”
“The bill, led by Sens. Kirsten Gillibrand (D-N.Y.), Dick Durbin (D-Ill.) and Graham and Reps. Cheri Bustos (D-Ill.), Morgan Griffith (R-Va.) and Pramila Jayapal (D-Wash.), addresses companies’ common use of private arbitration to settle allegations of misconduct on the job. The process faced widespread criticism from victims as well as advocates, particularly after former Fox News host Gretchen Carlson’s 2016 sexual harassment lawsuit against the network and its then-CEO, the late Roger Ailes.
With Trump out of office and prominent misconduct cases largely faded from public view, however, the bill has acquired unique momentum. On a Senate Judiciary Committee that’s known for its partisan divide, especially in recent years, the forced arbitration bill counts support from GOP hardliners like Missouri Sen. Josh Hawley and progressives like Hawaii Democratic Sen. Mazie Hirono. The panel’s approval of the Gillibrand-Graham bill by voice vote is a positive sign for its prospects on the Senate floor.”
“Opponents of forced arbitration argue that the process is skewed in favor of employers, keeping misconduct allegations and resulting investigation findings confidential and requiring employees to settle their case outside a court of law.
Business groups like the U.S. Chamber of Commerce counter that arbitration can be less expensive and swifter than taking a case to court. The Chamber backed an alternative proposal recently floated by Sen. Joni Ernst (R-Iowa) that would eliminate mandatory arbitration completely for on-the-job sexual assault claims. Under Ernst’s bill, companies could still arbitrate sexual harassment claims if they meet a list of criteria, including allowing victims to talk about their cases publicly if they choose to.
Ernst said Tuesday that she is working with Gillibrand on making changes to the original bipartisan legislation since “this is the one that’s moving” and that the duo — who worked together on bipartisan military sexual assault reform — is getting “much closer.””
“It’s not clear yet to what extent business groups will lobby against the Gillibrand-Graham legislation. The U.S. Chamber of Commerce hasn’t publicly taken a position on the bill and referred POLITICO to its letter supporting Ernst’s alternative.
“Listen, if I’m a business person I’d want to limit legal exposure, and arbitration in business matters is OK,” Graham said. “But this is not a business matter. This is misconduct directed toward individual workers.””