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Lofty SOTU rhetoric to collide with gridlock

Illustration of President Biden exiting the frame of two overlapping speech bubbles

Photo illustration: Sarah Grillo/Axios. Photo: Drew Angerer/Getty Images

President Biden is going to lay out some lofty health care goals in the State of the Union tonight, but the contrast with Congress' struggles to pass much of anything on the issue this year will be jarring.

Why it matters: Biden's messaging tonight is tailored for his campaign and future congresses, not the frustrating grind of the current session.

  • He'll propose expanding the IRA's drug price negotiations to 50 drugs per year from 20, as well as extending a $2,000 out-of-pocket cap to people with private insurance, among other changes.

Reality check: In the current Congress, lawmakers are still struggling to put together FY24 appropriations, and to potentially revive talks on policy priorities like PBM reforms or health price transparency.

  • Reauthorizing the pandemic preparedness and PEPFAR programs or addressing drug shortages or behavioral health reforms seem like even longer shots.
  • Although the Senate seems to be on track to pass the first minibus containing six of the less-controversial appropriations bills, lawmakers are still working out the second tranche, which includes the Labor-HHS bill.
  • Among the details are how to work around controversial House Republican riders that would block federal funding to Planned Parenthood and for Medicare and Medicaid to pay for gender-affirming care. The expectation is that they will be dropped.

Senate appropriators seemed optimistic Thursday about reaching a second deal by the March 22 deadline.

  • "We're making really good progress," Sen. Tammy Baldwin, chair of the Senate Appropriations Labor-HHS subcommittee, told Axios. "I think there's a tiny number of unresolved issues."
  • Top Democratic appropriator Sen. Patty Murray also said Thursday that progress was being made.
  • But even if the two chambers are able to agree and get the second set of bills passed, they're going to have to quickly start the process all over again for the FY2025 bills.
  • In a typical year, appropriators would already be doing that. And they'd be getting more of a fix on which items in the FY2025 budget Biden rolls out on Monday actually have a chance.

What they're saying: There still are rumblings about the possibility of folding hospital price transparency and PBM changes into the second funding package.

  • But there are no signs of a breakthrough, justifying skepticism over a deal coming together.
  • And there's still a divide over whether to apply PBM changes to the commercial market. "Let me just say this: Clearly [Senate] HELP pushed it out, we passed it, I'm trying to get it done," Sen. Bill Cassidy told Axios Thursday when asked if there was still a divide.
  • Rep. Brett Guthrie also wasn't sure whether an agreement could be reached by March 22. "We passed it. The Senate hasn't passed it. We're negotiating with the Senate who hasn't passed a bill. So that's been frustrating," he told Axios on Wednesday.
  • Still, Senate Finance Chair Ron Wyden told us, "Last time I looked, the lame duck was a long way away, so why not pull out all the stops to do it now?" And House Energy and Commerce Chair Cathy McMorris Rodgers said, "It's never over till it's over."

What's next: As for Biden's bigger-ticket items, much will depend on the election. Expanding IRA drug price negotiations can really happen only with a Democratic trifecta and unified control of government.

  • Aware of the realities, Rodgers, who's retiring this fall, issued a statement prebutting Biden's proposals Thursday.
  • "President Biden praises his Moonshot Initiative to cure cancer, yet he is responsible for laws and regulations that will delay achieving this goal," she said, calling for him to work with the GOP on "undoing the worst parts of the Inflation Reduction Act."
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