After months of back and forth, congressional Democrats now say their effort to push drug-pricing reform into the social spending bill may be weakened in order to win support from centrist lawmakers.

In August, President Joe Biden called on Congress to include reform in the sweeping 10-year spending package, which had originally been priced at $3.5 trillion. Those comments represented the most forceful stance the Biden administration had taken thus far around drug pricing. The original proposal would have allowed Medicare to negotiate drug prices and capped out-of-pocket Medicare prescription expenses — a change that could potentially save the government hundreds of billions of dollars while lowering costs for millions of Americans.

But even though pricing reform is popular among the public — a recent Kaiser Family Foundation poll found that 83% of Americans supported allowing the federal government to negotiate drug prices – moderate Democrats remain unswayed. Similarly, Senate centrists have trimmed down the original package into something that might cost closer to $2 trillion.

“It’s been eviscerated,” Rep. Lloyd Doggett (D-Texas) told Politico.

But other lawmakers and experts believe the situation is still very much in flux, and that some form of pricing negotiations will ultimately find their way into the bill.

“The original Democratic proposal came too close to outright regulation and was ripe to be scaled back,” noted Terry Haines, founder of healthcare consultancy Pangaea Policy. “I expect the new idea to focus on providing the ability for the federal government to negotiate — not dictate — prices, and also to focus on the most popular drugs.”

Given that pricing reform has long been a Democratic priority and a top public concern, not to mention that it raises money that’s needed to pay for the bill itself, it’s unlikely that it will be dropped entirely.

Discussions over the limited version of the pricing proposal comes after months of intensive lobbying from the pharma industry, which included a seven-figure ad campaign from PhRMA. The group has meted out some $22.4 million in lobbying expenses against drug pricing and related issues so far in 2021.

New data from Kaiser Health News’ Pharma Cash to Congress, which tracks campaign contributions from the pharma industry, reveals that pharma companies and industry groups donated more to moderate Democrats this year than in years prior, when they largely focused on funnelling funds to Republicans. These strategic donations were sent to Rep. Scott Peters (D-California), Sen. Robert Menendez (D-New Jersey) and Sen. Kyrsten Sinema (D-Arizona), whose votes are essential to the passing of the social spending package.

Industry groups like PhRMA have consistently argued that allowing the government to negotiate drug prices would hamper access and innovation, especially in light of the life-saving development of COVID-19 vaccines in the last year.

“As voters learn about the extreme policies being discussed in Washington, they are sending a clear message to policymakers: Don’t sacrifice access and innovation,” PhRMA president and CEO Stephen Ubl said in a statement. “Americans don’t want Congress to fundamentally upend Medicare and interfere in decisions best left to patients and their doctors.”

On the other end of the spectrum, pricing reform advocates are urging Democratic lawmakers to stay as close to the original proposal as possible. In a letter directed to House Speaker Nancy Pelosi and Senate Majority Leader Chuck Schumer, AARP and Patients for Affordable Drugs said the social spending bill represented a “historic moment” to “get the job done.”

“This is not a moment to equivocate, delay or dilute the foundational elements of effective reform,” the groups wrote. “This is the moment to enact legislation that will help millions of Americans who are forgoing drugs they have been prescribed but cannot afford, rationing, and choosing between paying rent or paying for prescriptions they need.”

Haines believes an eventual agreement will land somewhere in the middle. “This gets Democrats the power they really wanted, and also is a small positive for pharma since it’s not regulation,” he explained.