President Joe Biden reiterated a call to “finish the job” on insulin prices, address the mental health crisis and “end cancer as we know it” in his address to Congress on Tuesday — initiatives that could have bipartisan support from lawmakers.

But enacting the president’s requests is easier said than done in an extremely polarized Congress, where razor-thin margins exist in both the Republican House and Democratic Senate.

Insulin

While Democrats succeeded in capping Medicare copays for insulin at the lower of either $35 or 25 percent of the list price in the health and climate law last year, the broader commercial cap was dropped amid parliamentary disputes over the rules of budget reconciliation.

Biden urged Congress to cap costs at $35 a month for “everybody,” an idea that has some bipartisan support but has faced obstacles to passage, with lawmakers trying to hammer out intricate policy impacting a convoluted drug pricing system. 

“There are millions of other Americans who are not on Medicare, including 200,000 young people with Type 1 diabetes who need insulin to stay alive,” Biden said to applause from Democrats and a few Republicans, including Sens. Mitt Romney of Utah and Lisa Murkowski of Alaska.  

Sens. Jeanne Shaheen, D-N.H., and Susan Collins, R-Maine, have been working on a more complicated bill attempting to address the warped incentives of the drug supply chain, which both senators said Tuesday they hope to introduce in the near future.

“I suspect we’ll be introducing a version in the coming weeks,” Collins said. “We’ve got to revamp it, but we will be doing so.”

The bill would cap commercial copays and implement incentives for lowering list prices often paid by the uninsured, although it remains to be seen how many companies would take up the idea. 

Research shows that average insulin net prices have remained relatively flat for decades, while the lion’s share of list price profits are absorbed by the likes of pharmacy benefit managers and pharmacies through rebates from drugmakers. But targeting rebates is likely to trigger a rise in insurance premiums, which makes the political outlook uncertain at best. 

Oregon Democratic Sen. Ron Wyden, who chairs the Finance Committee, reiterated support for the idea this week.

“We’re going to push very hard to get protections on insulin in the private sector,” he said.

He also vowed that this Congress would take on pharmacy benefit managers, which some blame for higher list prices for drugs, including insulin. 

Mental health and substance use

Biden also called on Congress to pass legislation to address growing mental health and substance use concerns — highlighting the need to expand the behavioral health workforce, address the needs of children and ramp up drug interdiction.

He alluded to two bipartisan efforts last year to expand access to behavioral health treatment: a gun safety and mental health law and a provision in the 2023 omnibus spending law that removed barriers to prescribing medication-assisted treatment for opioid use disorders.

The omnibus included some measures included in a broad bipartisan Finance Committee mental health package, but some provisions, like requiring Medicare Advantage to maintain an updated provider directory, were not included. 

“The president’s people have been talking to us nonstop about mental health,” said Wyden, who is hopeful about additional mental health action. “I think the president’s ideas are going to give us much to build on.”

He and ranking member Michael D. Crapo, R-Idaho, did not signal specific bills or a focus for building a new package. But Wyden told reporters last month he wants to address the shortage of mental health professionals, ensure insurance companies have accurate provider directories and make sure they are following laws that require parity between behavioral health and physical health services.

“We’re still working on putting everything together. We’re continuing with the very same endeavors that we were working on at the end of the last Congress,” said Crapo.

Concerns about mental health increased during the pandemic, with more people reporting symptoms of anxiety or depression. But those symptoms haven’t entirely dissipated with the easing of COVID-19; in early January, more than a third of Americans reported symptoms of anxiety or depression, according to the Centers for Disease Control and Prevention.

Youth mental health is also a growing concern for advocates, and Biden criticized the impact of social media companies on mental health in a plea to “pass bipartisan legislation to stop Big Tech.” 

The Senate marked up a bipartisan children’s tech safety bill from Sens. Richard Blumenthal, D-Conn., and Marsha Blackburn, R-Tenn., last year. Proponents say the bill could limit promotion of self-harm or disordered eating and reduce online drug sales. Despite intense lobbying, it was not included in the omnibus.

Biden also called for a “major surge to stop fentanyl production and the sale and trafficking” and “strong penalties to crack down on fentanyl trafficking.” The lion’s share of drug overdose deaths are still attributed to fentanyl, a powerful synthetic opioid. 

But he stopped short of a key ask of Energy and Commerce Chair Cathy McMorris Rodgers, R-Wash., and other Republicans to permanently schedule fentanyl-related substances, referring to chemically similar drugs, through legislation. The omnibus temporarily scheduled fentanyl analogs until 2024.

The Drug Enforcement Administration testified at a hearing last week that permanent scheduling was the agency’s top priority.

2024 messaging

The president also highlighted three asks that are unlikely to become law but are important priorities for Democrats.

A 2021 law extended premium tax credits until 2025 for low-income individuals who earned too much to qualify for Medicaid.

Biden called to make the “savings permanent, expand coverage on Medicaid,” an increasingly difficult task with a split Congress. States that have not yet expanded Medicaid coverage have been reluctant to take this step, citing financial concerns, even when offered an additional financial incentive to expand under the 2021 law.

He also asked Congress to pass legislation to codify abortion rights and to prohibit sex-based discrimination related to sexual orientation, gender identity or sex. 

But some abortion rights groups said simply codifying protections under Roe v. Wade would not be enough to prevent further harm.

Last Congress, House Democrats passed legislation to codify both protections, but neither bill has been able to pass the 60-vote threshold in the Senate. Under GOP control of the House, it’s unlikely either bill would come up for a vote again.

Cancer

Biden made “ending cancer as we know it” one of his top goals as president, and he used his podium Tuesday night to gin up some enthusiasm for the work still to come in that effort. His “moonshot” campaign aims to cut cancer deaths by 50 percent over 25 years.

Speaking in grandiose terms, Biden talked of how American medical research could make cancer a curable disease, much like previous administrations’ efforts to cure HIV/AIDS.

Biden will need Congress’ help to keep the Cancer Moonshot moving. The 21st Century Cures Act’s $1.8 billion authorization for the Cancer Moonshot program expires this September. The White House also told reporters on Tuesday that it will soon call on Congress to reauthorize the National Cancer Act of 1971, but Biden didn’t bring it up in his speech. The White House did not say why.

“For the lives we can save and for the lives we have lost, let this be a truly American moment that rallies the country and the world together and proves that we can do big things,” Biden said of the Cancer Moonshot.