National

Axios Vitals

Medications that prevent HIV — along with the necessary doctor's visits and lab tests — are supposed to be fully covered by most insurance plans under the Affordable Care Act.

Patients and advocacy groups tell Axios they're often not.

Why it matters: Studies show HIV pre-exposure prophylaxis, often called PrEP, is more than 90% effective in preventing the transmission of HIV.

But the brand-name version of the daily pill costs upward of $20,000 a year, and billing problems that shift costs to patients lead many who would benefit to opt out, advocates say.

 "You hear stories all the time," Jeffrey Crowley, director of the Infectious Diseases Initiative at the O’Neill Institute and a former director of the White House Office of National AIDS Policy, told Axios.

"They've been on PrEP and then all of a sudden, there's a new obstacle," he said. "They need to get prior authorization or they used to get their meds for 90 days and now they can only get them for 30 days. All of these hassle factors cause people to fall off."

Or as in the case of patients like Cambridge, Massachusetts resident Michael Brazile, they get fully covered PrEP treatments — along with a surprise bill for lab services required to obtain the drug.

A quick primer: The FDA in 2012 made Gilead's Truvada the first approved drug for HIV prevention in uninfected adults. There's now a generic version, plus another form of PrEP known as Descovy.

Since they are intended for those who are HIV-negative but at high risk of acquiring the virus, lab testing is a prerequisite, usually in person. 

In 2019, the U.S. Preventative Services Taskforce recommended PrEP as an effective method of preventing HIV, meaning health plans had to make it available at no cost to patients under the Affordable Care Act starting in January 2021. 

What's happening: Even so, patients are often hit with bills for the drug itself, for office visits, or lab work. 

Anthony Cantu, 31, who works in a health clinic in San Antonio where he counsels patients about PrEP, started the drug himself last summer. He got billed $374 for lab services connected with PrEP in October 2021 by Blue Cross Blue Shield of Texas. It was the first of several bills. 

After months of appeals and filing a complaint with the Texas Department of Insurance, his case was resolved. That is, until he recently got another bill for $187 for PrEP-related lab services. 

In a statement, the insurer said it "is committed to providing its members with equitable health care, including access to PrEP medication and clinical support related to PrEP," but did not specifically address concerns about instances where it wasn't covered

As Axios reported earlier this year,  Peter Sacco, 28, of Washington, D.C., was billed for copays for clinic visits and lab work associated with monitoring his health for a generic Truvada prescription and had difficulties appealing.

By the numbers: There isn't good data about how often this happens, Carl Schmid, executive director at HIV + Hepatitis Policy Institute, told Axios. 

But "I'm helping six people right now and we have to go to insurance commissioners every time?" Schmid said. "There really is a problem. With the ACA it's supposed to be seamless and that's not what's happening."

More federal enforcement and penalties for non-compliance are needed to make a meaningful change rather than state-by-state complaints, Schmid said. 

The other side: Insurers say the problem often is physicians aren't properly coding their visits as preventative, but when that happens it can be fixed on the backend, said AHIP Spokeswoman Kristine Grow.

Some plans are engaged in education campaigns with providers to appropriately submit claims, Grow said. And "health insurance providers are engaging with patients and their providers who have questions or concerns when they receive an unexpected bill and are working swiftly to address them," she said. 

Yes, but: "I am sympathetic to that. But once [insurers] know about that, it should get fixed. And it keeps happening," Katie Keith, a health law expert at Georgetown University who has written about this issue, told Axios.

"I'm much more deeply troubled by, even when you're telling your plan or your providers to tell your plan that this should be covered, that people are having to jump through such incredible hoops," she said. 

What to watch: An injectable form of PrEP was approved by the FDA, one of the multiple longer-lasting forms of the drug coming to market aimed at boosting compliance, Crowley said. It's unclear what will happen with coverage. 

HIV PrEP is supposed to be covered, but often isn't

HIV prevention still comes with unexpected costs

Illustration of a red AIDS awareness ribbon shaped like a "no" sign 

Affordable Care Act

The U.S. faces a range of health care flashpoints — unaffordable drugs, opioids, vaping — as we debate whether to adopt universal care. For now, the Affordable Care Act is the law of the land, but Republicans want to issue it a final death blow.

Health

The formal end of the pandemic could swell the ranks of uninsured children by 6 million or more as temporary reforms to Medicaid are lifted.

Why it matters: Gaps in coverage could limit access to needed care and widen health disparities, by hitting lower-income families and children of color the hardest, experts say.

The big picture: A requirement that states keep Medicaid beneficiaries enrolled during the public health emergency in order to get more federal funding is credited with preventing a spike in uninsured adults and kids during the crisis.

Children are the biggest eligibility group in Medicaid, especially in the 12 states that haven’t expanded their Medicaid programs under the Affordable Care Act.

The lifting of the public health emergency, which was just extended to July 15, will lead states to determine whether their Medicaid enrollees are still eligible for coverage — a complicated process that could result in millions of Americans being removed from the program.

What they’re saying: The end of the continuous coverage guarantee puts as many as 6.7 million children at very high risk of losing coverage, per Georgetown University’s Center for Children and Families.

That would more than double the number of uninsured kids, which stood at 4.4 million in 2019.

"It is a stark, though we believe conservative, estimate," said Joan Alker, the center's executive director. "There are a lot of children on Medicaid."

Between the lines: Not all of the Medicaid enrollees who are removed from the program would become uninsured. But parents and their children could be headed down different paths if their household income has risen even slightly. 

Adults who've returned to work may be able to get insurance through their employer. Others could get coverage through the ACA marketplace, though it's unclear whether that would come the COVID-inspired extra financial assistance that's now being offered. 

Most kids would be headed for the Children's Health Insurance Program, Alker said — a prospect that can entail added red tape and the payment of premiums or an annual enrollment fee, depending on the state.

What we're watching: Changes in children's coverage could be most pronounced in Texas, Florida and Georgia — the biggest non-Medicaid expansion states, which have higher rates of uninsured children than the national average.

Congress could still require continuous Medicaid coverage, the way the House did when it passed the sweeping social policy package that stalled in the Senate over cost concerns.

CMS' Office of the Actuary projects a smaller decline in Medicaid enrollment than some health policy experts are predicting — and the Biden administration continues to move people deemed ineligible for Medicaid onto ACA plans, Raymond James analyst Chris Meekins noted in a recent report on the unwinding of the public health emergency. 

Pandemic's end could surge the number of uninsured kids

Illustration of an umbrella with holes in it. 

Digital content

Health care costs

Percent change in the number of uninsured people if premium tax credits expire, 2023

Data: Urban Institute Health Insurance Policy Simulation Model 2022; Cartogram: Jacque Schrag/Axios

A disproportionate share of young adults, low-income, Black Americans and residents of Southern states will lose health coverage if Congress doesn't extend enhanced Affordable Care Act subsidies, according to a new analysis by the Robert Wood Johnson Foundation. 

Why it matters: The analysis estimates that 3.1 million Americans would become uninsured when the subsidies expire beginning next year, and millions more would face much higher premiums than they currently pay. But those effects wouldn't be felt evenly across the country.

The big picture: Democrats' coronavirus relief package last year made ACA subsidies more generous and expanded who was eligible for them, but only temporarily. 

Millions more people have entered the ACA marketplaces as a result. But Democrats' efforts to extend the subsidies have stalled in the Senate, along with the rest of President Biden's domestic agenda. 

Details: The uninsured population would increase most significantly among people with incomes of 138-400% of federal poverty absent congressional action, according to the analysis. 

When looking at race and ethnicity, Black Americans would see the largest change, followed by white Americans. Young adults ages 19-34 would be the most affected age group.

States that haven't expanded Medicaid, like Florida, Georgia and South Carolina, would see some of the highest increases in their uninsured populations.

Yes, but: Extending the larger subsidies would cost the federal government more than $25 billion in 2023 alone, and $305 billion over 10 years.

Between the lines: Being uninsured obviously has implications for people who then struggle to pay for health care when they need it. 

But it also creates financial problems for hospitals, which are required to treat patients having emergencies regardless of their ability to pay.  

What we're watching: Insurers calculate premiums months before open enrollment begins in November. 

That means that if the tax credits aren't extended in the first half of this year, insurers may not have time to adjust their premiums accordingly — meaning premiums would likely be inflated, the authors of the analysis argue.

That, in turn, could discourage marketplace enrollment and increase federal costs.

Go deeper: End of the pandemic could usher in spike of uninsured

Affordable Care Act subsidy cliff hits Southern states hardest

More than 3 million people will lose their insurance if enhanced ACA subsidies expire, per an analysis.

President Biden, joined by former President Obama, on Tuesday will announce regulatory changes to Affordable Care Act rules that could make health insurance more affordable for millions of Americans. 

Yes, but: The announcement comes amid significant doubt about whether Congress will be able to prevent millions of current ACA enrollees from seeing large premium hikes next year — or from losing their insurance altogether.

Driving the news: The administration is closing what's known as the "family glitch," which stems from part of the health law that deals with eligibility for premium subsidies and ultimately prices some families out of health insurance. 

Under current regulations, people who are eligible for "affordable" employer health insurance aren't eligible for premium assistance on the ACA marketplaces. 

The Obama administration defined affordability as the premium for a single beneficiary — the employee — being below a certain percentage of family income. That doesn't take into account the higher cost of adding dependents to family coverage.

The Biden administration is changing the definition and tying the eligibility threshold to the price of family coverage, which it says will lead to hundreds of thousands more Americans gaining coverage and more than a million spending less on premiums.

Biden will also sign an executive order today directing agencies to continue finding ways to make coverage more affordable. 

The other side: The policy is one of the largest regulatory changes to the ACA to date. But the biggest legislative change so far — the subsidy enhancement Congress passed last year — is set to expire at the end of this year, which would reverse progress made on coverage and premium costs.

HHS estimated last month that 3 million people will lose coverage if the policy expires, nearly 9 million would receive lower subsidies and 1.5 million would lose their subsidies entirely but remain insured.

What we're watching: Congressional Democrats still have time to revive the sweeping social policy legislation containing the bulk of Biden's domestic agenda, including an extension of the enhanced subsidies. 

But even if the bill comes back to life, it's an open question what it will contain. The consequences of dropping the ACA piece make it a likely bet for inclusion.

Biden's Affordable Care Act lifeline

The administration is fixing the family glitch, but the ACA's enhanced subsidies are still at risk.

The confrontation over gender-affirming care for transgender youth hit a boil this week as Texas Gov. Greg Abbott doubled down on his call for state officials to investigate "transition care" for minors as "child abuse."

Driving the news: Even as Abbott's team called the issue a political "winner," major medical groups including the American Academy of Pediatrics condemned the stance, saying it trampled on the doctor-patient relationship and injected politics into medical care.

Why it matters: Research has demonstrated transgender kids are more prone to anxiety, depression, and suicide than their peers, adding a high degree of urgency to the issue, experts say.

State of play: Legislation to block gender-affirming care for minors was introduced in at least 21 states in the last year alone, according to the UCLA Williams Institute. 

In Idaho, legislation was introduced in a state House committee last month to ban gender-affirming surgery on minors.

In Arkansas last year, lawmakers banned administering puberty blockers or hormones to transgender youth. The law is being challenged in court and has not taken effect.

Tennessee also banned "gender-confirming" care for minors last year.

The big picture: HHS Secretary Xavier Becerra released a statement Wednesday calling the Texas government's actions "unconscionable," saying "at HHS, we listen to medical experts and doctors, and they agree with us, that access to affirming care for transgender youth is essential and can be life-saving," he said.

Medical associations, such as the American Medical Association, have also urged governors to oppose such measures, saying trans and non-binary gender identities are "normal variations of human identity and expression."

Between the lines: The field of transgender healthcare is rapidly evolving. Doctors are divided, for instance, over whether teens should receive counseling before receiving care, such as hormones, the New York Times reported.

In the gender-affirming care model, the AAP says "pediatric providers offer developmentally appropriate care that is oriented toward understanding and appreciating the youth's gender experience."

"There are a lot of conversations" over time with the child, family and other clinicians, such as mental health professionals, to carefully assess the best way to proceed, Kathryn Melland Lowe, a pediatrician and a member of AAP's executive committee on LGBT health and wellness, told Axios.  

For instance, if a child is distressed over body appearance and has begun puberty, a doctor may prescribe "puberty blockers" to pause sexual development in order to offer more time to consider the options.

If the patient, family and medical care team decide to move forward, the patient may be taken off the puberty blockers and prescribed hormones for sexual development that matches their identified gender, Lowe said. While surgery generally isn't recommended for kids, their doctor may find it appropriate based on the individual patient, she said.

Yes, but: As with any treatment, there are potential risks involved. For instance, there are some side effects that accompany the use of hormones and well as concerns for longer-term impacts such as infertility.

But, but, but: Those risks must be weighed against the risks of foregoing therapy, which can cause a great deal of mental distress and harm, Lowe said. 

A study published in JAMA Network Open last week found rates of depression and suicidal thoughts dropped significantly among transgender or nonbinary teens within a year of receiving puberty blockers or gender-affirming hormones.

"I've seen a number of kids go on gender-affirming medications and truly just come to life and thrive and they can move on with their life. They aren't just stuck in their inner turmoil. Their inner gender now matches their physical body," Lowe said. "And that is supported in the research." 

Editor's note: This story originally published on March 3. 

Culture war around care for transgender kids heats up

The culture war over transgender health care for kids is heating up again as Texas Governor Greg Abbott doubled down this week on a rule directing state officials to investigate 'transition care' for minors as "child abuse."

Illustration of a child in silhouette holding a transgender pride flag over their shoulders like a cape

Transgender

Democrats who hoped they'd have transformational new health legislation in place by next year could instead be facing one of the largest increases in the U.S. uninsured rate in recent history.

Why it matters: Temporary pandemic-era reforms to Medicaid and the Affordable Care Act marketplaces caused enrollment in each to swell, but these policy changes are due to end soon, and millions of people could lose their health coverage.

The big picture: The massive drop in the insured rate that was feared early on in the pandemic never materialized, thanks to Medicaid and enhanced ACA subsidies.

Congress in 2020 included measures in pandemic relief legislation that increased the share of federal Medicaid spending if states offered continuous coverage to enrollees, suspending the program's usual churn.

A year later, Democrats increased the value of Affordable Care Act subsidies and expanded who was eligible for premium assistance.

Both programs then served as safety nets for people who lost their employer-sponsored coverage during the pandemic or would have otherwise been unable to afford insurance. But the extra allowances are due to sunset with the end of the public health emergency or at the end of the year.

What they're saying: "If continuous coverage in Medicaid ends and the extra ACA premium assistance isn’t extended, we could see one of the biggest jumps in the number of people uninsured ever," said Kaiser Family Foundation's Larry Levitt. 

State of play: The Medicaid changes are tied to the formal Public Health Emergency, which is currently scheduled to end April 15. The prevailing assumption is that it'll likely receive one more extension and then expire sometime this summer.

States will then determine whether their Medicaid enrollees are still eligible for coverage — a huge undertaking that could result in millions of Americans being removed from the program.

“Pretty clearly, this is going to be one of the biggest inflection points for health coverage that we've seen in a very long time — in a decade at least, and it's probably going to mean the largest reduction in Medicaid coverage in memory," said Matt Salo, executive director of the National Association of Medicaid Directors.

Salo estimated that some 10–15% of the Medicaid population -- potentially more than 12 million people — will fall off the program rolls.

Where it stands: Although extending the enhanced ACA subsidies is a key part of Democrats' health care agenda, it's unclear whether their stalled domestic policy legislation can be revived. 

Under current law, the enhanced subsidies expire at the end of the calendar year.

The stalled legislation also would ease the expiring Public Health Emergency's impact on Medicaid.

Between the lines: Even if millions of Medicaid enrollees are removed from the program, that doesn't mean they'll all become uninsured. 

Many who've returned to work can likely get insurance through their employer. Others could get coverage through the ACA marketplace. But that becomes less likely without the extra financial assistance that's currently being offered.

"While the majority of the people who would be leaving Medicaid would likely be eligible for employer coverage, a substantial minority would likely turn to the marketplace. And marketplace coverage will look a lot more attractive if the expanded subsidies continue," said Matt Fiedler of the USC-Brookings Schaeffer Initiative for Health Policy. 

By the numbers: ACA marketplace enrollment hit a record high this year, but it could come crashing down next year.

Around 1.7 million people nationally could drop their insurance, according to a recent Covered California analysis, and millions more would see significantly higher premiums.

As of September, around 14 million more people were insured through Medicaid than at the start of the pandemic.

What we're watching: States will have a huge role in ensuring eligible people remain enrolled in Medicaid and those who aren't eligible are connected to other forms of coverage, including ACA plans.

"It's going to involve really reaching out to the community more so than states have had to do in the past," Salo said. "There's very clearly going to have to be a lot more handoffs [and] a lot of human touches."

End of the pandemic could usher in spike of uninsured

Temporary Medicaid and Affordable Care Act reforms are set to end.

Health insurance

Coronavirus

Democrats are touting record Affordable Care Act enrollment, but a lot of those gains will be wiped away next year unless Congress takes action. 

Why it matters: Millions of Americans have taken advantage of the enhanced ACA subsidies Congress passed into law last year, with many enrolling in health insurance for the first time. But under the status quo, that more generous coverage is going to expire at the end of 2022 — and people will be notified right before the midterm elections.

The big picture: When Democrats' coronavirus response bill last year expanded the amount of ACA premium subsidy assistance available to millions of low-income Americans, it also made more middle-income Americans eligible for premium help. 

That led to a 21% spike in enrollment year over year, totaling 14.5 million. If you include other special ACA plans in New York and Minnesota, total enrollment is closer to 15.5 million people, according to marketplace tracker Charles Gaba.

State of play: An extension of the enhanced subsidies was included in Democrats' Build Back Better legislative package. But that's stalled in the Senate, and it's unclear which pieces — if any — will make it into law.

Unlike the other health care components of the package, the subsidy extension prohibits the loss of a benefit and, subsequently, higher costs for Americans. The other pieces were designed to provide new benefits or lower costs.

That makes inaction on the subsidies sting worse for enrollees — and a big political risk for Democrats.

Between the lines: This isn't exactly the taste Democrats want in voters' mouths as they head to the polls.

"Democrats would be facing all kinds of negative news about their signature domestic achievement of the last decade," said KFF's Larry Levitt. "President Biden has successfully reinvigorated the ACA, as he promised to do. But, that success will be sustained only if the extra premium help continues."

The bottom line: As Democrats try to salvage their reconciliation package, preserving the larger ACA subsidies is likely to be a top priority.

The subsidy extension "has a two-way motivation to pass," said Democratic strategist Chris Jennings. 

"First, to avoid a significant increase in premiums and decrease in coverage," he said. "And second, to secure an affordability legacy and policy sustainability of the law for the Biden administration and the Democratic Congress."

ACA enrollment soars, and faces a perilous fall

Congress must act, or else enhanced ACA subsidies will go away.

Illustration of the US Capitol building with a caduceus on top. 

President Biden has made the COVID-19 crisis and a post-Trump return to national unity and traditional democratic ideals his top priorities. From vaccinations to stimulus to schools, Biden is seeking bipartisan compromise while showing a willingness to use executive authority and bare Democratic majorities in the U.S. House and Senate to implement his policies. Republican leaders are navigating deep party divisions over if and how to move beyond former President Trump.

Politics & Policy

Patients who take pre-exposure prophylaxis (PrEP), a medication that prevents HIV, should not be paying anything out of pocket for the drug — or for any blood work or doctor visits associated with getting PrEP.

The big picture: The federal government specifically reminded health insurers last year to make sure those types of ancillary services for PrEP were free at the point of care, but some patients are getting hit with bills anyway.

Zoom in: Peter Sacco, 28, of Washington, D.C., has a prescription for generic Truvada, a PrEP medication.

Sacco buys health insurance from CareFirst, a Blue Cross Blue Shield plan, on D.C.'s Affordable Care Act marketplace.

Sacco pays nothing out of pocket for his PrEP prescription, but last year he was charged copays for clinic visits and lab work associated with monitoring his health for the prescription.

The bill: $130 — two $60 copays for doctor visits in May and November of 2021 and a combined copay worth $10 for lab work for both visits.

Context: The Affordable Care Act requires health insurers to cover all preventive services that receive an "A" or "B" grade from the U.S. Preventive Services Task Force for free.

PrEP has an "A" grade, and federal officials told insurers last year there should be no copays for "baseline and monitoring services" for PrEP as part of USPSTF's recommendation.

After learning about this, Sacco appealed CareFirst's copays electronically and via mail. Both appeals were denied, and the insurer never addressed his concerns about how the copays ran afoul of the ACA.

What they're saying: "Insurers should've been lowering barriers even without this guidance from the federal government," said Katie Keith, a health law expert at Georgetown University who has written about this issue. "I'm worried people aren't being protected."

"It frustrates me that I've gone through the work of learning about [no cost-sharing for PrEP-related services], and there's a lot of people who don't know about it and are just paying these copays," Sacco said. "The cost burden for me is not as bad, but it could be more for others."

The other side: Maria Tildon, a marketing and lobbying executive at CareFirst, would not comment on Sacco's case. But Tildon said the broader problem stemmed from doctors not coding PrEP visits as "preventive," even though insurers ultimately have the responsibility to ensure there is no cost-sharing.

"We're in the throes of developing and distributing a pretty aggressive communications campaign to our provider partners to make sure that as they offer this treatment, they know how to submit the claim," Tildon said.

Samuel Le Church, a primary care physician and certified medical coder in Georgia, said it is "probably accurate" that many doctors prescribing PrEP aren't coding the other services as preventive, but "to be fair, there are so many things that come up with insurers ... and there's only so much bandwidth physicians have."

The resolution: After Axios asked CareFirst about Sacco's case, and as Sacco filed an appeal with the D.C. Office of Health Care Ombudsman, CareFirst told Sacco that all copays he paid will be refunded.

Tildon added CareFirst is conducting a retrospective review to see if other members who take PrEP have paid for related services and are owed refunds: "We want our members to be billed appropriately."

This is part of Axios' series, Billed and Confused. Have you been hit with an unexpected medical bill? Maybe the overall medical billing experience left you feeling puzzled or upset? Email bob@axios.com, so we can dig into what's happening. Note: this story was originally published on Jan. 20. 

Many surprise medical bills are now illegal (Jan. 1, 2022)

Out-of-network costs spin out of control (Nov. 16, 2021)

When you're charged a copay you shouldn't owe

CareFirst may not have been in compliance with the ACA.

A man wearing glasses and a coat stands in front of a house.

Peter Sacco fought with his health plan to clear a copay he should have never been charged. Photo: Peter Sacco

Billed and Confused

After a record economic expansion, the coronavirus pandemic sent the U.S. economy into a recession as unemployment soared to staggering heights. The country now faces urgent questions about how much stimulus is needed for reeling consumers and businesses, and what a recovery might look like.

Economy & Business

After campaigning on health care one election cycle after another, Democrats have put forward a social policy framework that does nothing to lower prescription drug prices, expands Medicare benefits to only include hearing coverage, and temporarily builds on the Affordable Care Act.

Why it matters: The framework may be the best the party can do with razor-thin vote margins in Congress. But some health care advocates say it's unacceptable — and voters may not be thrilled either. 

The big picture: Democrats can certainly claim some health care victories.

The framework would extend the enhanced ACA subsidies that the party enacted earlier this year, although only through 2025. This has been plenty of moderate Democrats' primary health care goal. 

The framework also makes ACA subsidies available to people in the Medicaid coverage gap in states that have chosen not to expand, another major priority for many Democrats. This would also last through 2025. 

The other side: Progressives have a much tougher pill to swallow. And when it comes to drug prices, nearly the entire party has campaigned on lowering them. 

Progressives, championed by Sen. Bernie Sanders, have been pushing for Medicare to cover dental and vision benefits, as well as hearing. And that's a far cry from what they actually want, which is Medicare to be offered to more or all Americans. 

Lowering drug costs and expanding Medicare benefits are also very popular with voters — particularly seniors, who vote in large numbers. 

What they're saying: “We are outraged that the initial framework does not lower prescription drug prices," said AARP in a statement. "Americans are fed up with promises that have not been kept."

“The president and Democratic leaders are on the record fiercely supporting drug price negotiations and Medicare dental benefits. These are wildly popular benefits that almost all families across this nation want. Unfortunately, this small number of intransigent Democrats, who are schilling for lobbyists and drug companies, are standing in the way," Families USA wrote in a statement. 

What we're watching: What's out today is just a framework, and some key Democrats are vowing to keep fighting. 

Energy and Commerce Chairman Frank Pallone and Senate Finance Chairman Ron Wyden both told reporters that drug prices are still being discussed. 

And plenty of other Democrats, especially those in vulnerable seats, may be very sensitive to the prospect of failing to follow through on the party's commitment. 

Democrats' prescription drug collapse

They've campaigned on lowering drug prices for years, but are now passing on their opportunity.

Illustration of a prescription drug bottle with a shrug emoji typed on the label

Drug prices

Some Democrats say it's possible that pieces of their social policy agenda end up being enacted or extended for only a year or two, including major Affordable Care Act and Medicaid provisions.

Why it matters: Limited terms may be the only way Democrats can strike a deal within their budget. But the risk is that Republicans will be able to undo these temporary programs if they're able to regain control of Congress through next year's midterms.

There also aren't many policy areas that Republicans are less excited about than the ACA and Medicaid expansion.

What they're saying: Extending programs for only a year or two is a "possibility," Senate Majority Whip Dick Durbin (D-Ill.) told Axios. 

Extending enhanced ACA subsidies and closing the Medicaid coverage gap were measures that "we wanted ... to be permanent," said Sen. Ben Cardin D-Md.). "Clearly there's a lot of pressure to get as much in as we can, [which] means shorter periods."

 "I think all of the programs are being considered for shorter periods. There are some that are of greater importance to get as long as possible," Cardin added. He said it's also possible that an extension of the child tax credit would also last only a year. 

The big picture: Political, budgetary and practical factors are all at play as Democrats try to figure out what's in and what's out of their reconciliation bill.

But one giant consideration when it comes to the health care provisions — particularly the ACA and Medicaid ones — is that Republicans may not feel compelled to extend these programs should they gain power.

"I expect Republicans would be glad to take back the mantle of the child tax credit but Democrats should not fool themselves into thinking Republicans will feel any real pressure to extend these health care policies," said Brendan Buck, a longtime aide to former Republican House Speaker Paul Ryan. 

The other side: Republicans may encounter political pressures similar to the ones they did in 2017, when they struggled — and ultimately failed — to repeal and replace the ACA.

Declining to extend Democrat-enacted coverage policies in the next couple of years would be somewhat similar, in that the result would be millions of low-income people would lose their health coverage or see its cost skyrocket.

Democrats' risky health care play

Temporary Affordable Care Act and Medicaid extensions would be politically risky.

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Affordable Care Act

The big picture

The ACA didn't solve birth control access

The Supreme Court could be Trump's ACA nightmare

The ACA is doing fine without a mandate penalty

The political risk of overturning the ACA

Trump's all-or-nothing ACA gamble

All Affordable Care Act stories