WHAT MANCHIN'S 'NO' DOES ON HEALTH — West Virginia Sen. Joe Manchin 's declaration Sunday that he can't support the current Build Back Better bill set off a firestorm of criticism from fellow lawmakers to the White House. It also leaves a pile of health care reforms and funding measures without a certain fate. "I cannot vote to continue with this piece of legislation," Manchin said on "Fox News Sunday" as he discussed the president's more than $2 trillion social spending package. "I can't get there." The timeline was already delayed — senators left town Sunday morning without voting on the bill — but now measures affecting health, childcare, climate, education and more are entirely in question. And Democrats are fuming. How it hits health care: — Medicare expansion. The House BBB version would expand Medicare benefits to include hearing, phasing in coverage over the next decade after vision and dental coverage got dropped in earlier tussling. Manchin objected to adding new benefits, warning the entitlement program is headed toward insolvency in its present form, Adriel writes. He eventually agreed to the pared-down hearing plan but then said that even just those benefits may be a problem, citing concerns about the program's cash flow. — Medicaid expansion. The current bill would set up a system to cover a swathe of low-income people not covered in states that opted out of expansion under Obamacare, without cost to those states. But the West Virginia senator argued this expansion would reward "holdout" states at the expense of those that expanded their programs and picked up costs — like West Virginia. — Prescription drug price negotiations. The House proposal to let Medicare directly negotiate certain drug prices and fine drugmakers who hiked prices past inflation was always divisive. But the measure also promises big savings to cover other ambitions, including expanded coverage, and other drug pricing proposals — like capping patients' out-of-pocket costs — remain popular across the aisle. "Panic and disbelief." The senator dispatched an aide to tell the White House and congressional leaders his stance Sunday morning, less than a half-hour before his Fox appearance, POLITICO Playbook's Ryan Lizza reports. "We tried to head him off," a senior White House official told Playbook, but Manchin "refused to take a call from White House staff." White House Press Secretary Jen Psaki issued a pointed statement within hours, noting Manchin had brought a compromise bill, similar in size and scope, to President Joe Biden. "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. What's next: Manchin said, "This is a no on this legislation," offering a shard of hope to Democrats hoping to salvage sweeping proposals and push a jump-started bill in 2022. But with Manchin's reticence on Medicare and Medicaid proposals, Democrats could lose their chance for massive reforms before the midterms. WHAT'S 'FULLY VACCINATED' IN THE OMICRON ERA? — With two competing strains and a burst of new cases, officials are rethinking what it means to be fully vaccinated — and how to steel the public for the possibility they'll need fourth shots (or even more). It's not just semantics. Changing the criteria and messaging could influence how quickly workplaces and public events reopen and how much a crisis-weary, and in some cases confused, population responds to pleas to get booster shots. There's "no doubt in anyone's mind" that the original regimen plus a booster is ideal, especially with Omicron looming, said one health official familiar with the discussions. But "[Biden officials are] not going to change that anytime soon, because there's too many legal aspects hanging on this issue of what is fully vaccinated." The winter was already going to be bad. Biden officials anticipated a bad winter well before Omicron as breakthrough cases with the Delta variant rose and booster rates moved sluggishly along — while new vaccination rates virtually stalled. That's already shifted the conversation about the benefits of vaccination from protecting you against most Covid-19 infections (spurring relaxed mask measures) to the message Biden pushed Thursday night: Vaccination protects you against severe disease and death. "With boosters, they're hoping to get us through this winter surge" even as a broader discussion plays out about what a complete vaccine regimen looks like, said a person familiar with the discussions within the Biden administration. "I don't think this is a long-term solution at all," the person added. "You cannot be getting boosters every four to six months." THE SURPRISE BILL SPENDING RUSH — A year after Congress passed a fix for surprise medical bills — and less than two weeks before the law takes effect — health insurers, hospitals and doctors are still spending millions to tailor the fine print in their favor. The incoming law is supposed to protect 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, POLITICO's Megan Wilson reports. And each group is aggressively campaigning to see their interpretation of the law play out. Battle lines: 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. Trade groups representing providers say the law lists several other factors that should be equally weighted when calculating service costs, such as the doctor's experience and the procedure's complexity. "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. A senior health department official, who asked to be anonymous to talk about the issue, told POLITICO the agency isn't surprised by the level of advocacy given the stakes. "These rules are fixing this broken" system, the official said, "and there's a lot of money on the table." | 
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