Budgetary Implications of the IRA
This study begins by documenting the budgetary implications of the IRA from 2023–2031. These are summarized in the table below. It is important to note that the budgetary estimates are based on the original Congressional Budget Office (CBO) cost estimate of the IRA as enacted, and more recent estimates from CBO and the Joint Committee on Taxation that reflect policy developments after enactment.[1] Most significant, the estimates presented here reflect more recent estimates of the energy and environmental tax credits, as well as minor changes to the Internal Revenue Service funding-related revenue collection.
From the perspective of Medicare, the IRA contains two key provisions. First is the Medicare Inflation Rebate – that is, the provision holding that 100 percent of any increase in the price of a drug above the general rate of inflation must be returned to the federal government as a rebate on that drug. This “inflation tax” in isolation is anticipated to generate $6.9 billion in revenue over the budget window (along with $56 billion in direct budget savings included in the $260 billion figure below).
The second and larger provision is from the drug price “negotiation” in which the Health and Human Services (HHS) secretary sets the maximum fair price (MFP) on selected drugs each year. The statute dictates that the MFP must be a maximum of between 40 and 70 percent of the average manufacturer’s price (depending on how long the drug has been on the market), but that the secretary can negotiate the price lower. If the secretary concludes that the firm did not negotiate in good faith, she can levy a tax of 95 percent on the domestic sales (including non-federal sales) of the drug. (Notice that the 95 percent rate on the tax-inclusive price translates to a 1900 percent rate on the price received by the firm.) The negotiation regime takes effect in 2025 and this, along with savings attributed to other Medicare changes like the inflation rebate, amounts to the $260 billion in savings. (The minor bump in 2024 spending stems from capping the out-of-pocket costs of seniors at $2,000.)