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Good morning, Early Birds. We hope you had a good Thanksgiving. Get ready for a hectic December. Send your best tips to <a href="mailto:earlytips@washpost.com">earlytips@washpost.com</a> and your tastiest Thanksgiving leftovers to 1301 K Street NW. (Just kidding, don't send us your leftovers.)

Big pharma isn't the only powerful player in the prescription drug pricing fight

Who will win? Few industries have lobbied harder to shape Democrats’ massive health care, child care and climate bill than the pharmaceutical industry, which has spent months working to <a href="https://www.washingtonpost.com/politics/2021/10/25/inside-phrma-fight-kill-democrats-drug-pricing-plan/">kill the party’s plan</a> to lower prescription drug prices.

But there's also a well-funded counteroffensive being waged by powerful collection of patient groups, health insurers, hospitals, other health-care interests and AARP. And they've arguably won the first round.

The influential seniors' lobby alone has spent more than $16 million so far this year on TV, radio and digital advertising urging lawmakers to include drug pricing reforms in the bill, according to AARP.

AARP has shelled out $8.5 million on lobbying on drug pricing and other issues in the first nine months of this year, according to disclosure filings — a little more than a third of the $22.4 million that Pharmaceutical Research and Manufacturers of America, the industry’s flagship trade group, has spent.

But, crucially, AARP has been able to rely on its tens of millions of members for lobbying help. When the White House earlier issued a framework for the bill excluding drug pricing, AARP members made more than 9,000 calls to congressional offices in one week.&nbsp;

As lawmakers <a href="https://www.washingtonpost.com/us-policy/2021/11/28/congress-shutdown-debt-ceiling-reconciliation/">return to Washington</a> today to take up Democrats' roughly $2 trillion package — while also working to stave off a government shutdown by Friday and finding a way to raise the debt limit in the coming weeks — the group has leaned into the imagery of taking on one of the most powerful players in Washington.

“PhRMA has the money. We have the voters,” David Certner, an AARP lobbyist, <a href="https://twitter.com/DavidCertner/status/1455636187067133957?s=20">tweeted</a> last month.

“We’re a good-sized advocacy organization, so I don’t always use the analogy,” Nancy LeaMond, AARP’s top lobbyist, said in an interview last week. “But it’s certainly true that in this case, PhRMA is Goliath and we may be David.”

PhRMA has countered that it's easy for insurers and other parts of the health care system to support reforms that don’t target them in the same way (and in some ways could help them).

The Campaign for Sustainable Rx Pricing, for instance, a coalition that's backing the bill's drug-pricing reforms, has spent more than $1 million on ads and hundreds of thousands of dollars more on lobbying. Its members include health insurance companies and the Pharmaceutical Care Management Association, which represents pharmacy benefit managers (PBMs) — companies that manage drug benefits on behalf of insurers and others.

“Democrats and Republicans recognize the central role insurance companies and middlemen play in determining what patients pay at the pharmacy, yet through a campaign of misinformation these powerful industries have managed to block any real accountability in this bill,” Brian Newell, a PhRMA spokesman, told The Early in a statement.

The argument that middlemen and insurers are being spared has gotten as least some sympathy from Democrats.

“I think if we want to tackle prescription drug pricing we’ve got to go after PBMs, we’ve got to go after insurers, we’ve got to go after providers,” Sen. Tim Kaine (D-Va.) said last month. “Because it’s often not just the manufacturer that is responsible for the sticker shock that people are experiencing when they go to the pharmacy counter.”

Asked whether Kaine planned to push for changes to the drug-pricing measures in the bill, a spokeswoman said the senator believes changes to the system "should include reforms affecting all parties who contribute to artificially high prices” and that the bill’s details “are still being negotiated.”

The Campaign for Sustainable Rx Pricing, meanwhile, says PhRMA is pointing at others “to deflect accountability.”

“The fact is, brand name drug companies are solely responsible for setting and hiking list prices on their products and Congress must remain focused on solutions that hold Big Pharma accountable to lower drug prices for the American people,” executive director Lauren Aronson said in a statement.

Democrats <a href="https://www.washingtonpost.com/health/2021/11/01/reconciliaton-medicare-prescription-price-negotiation/">clashed for months</a> over drug pricing before <a href="https://www.washingtonpost.com/us-policy/2021/11/02/democrats-spending-manchin-election/">reaching a compromise</a> that could pass the House. As the bill heads to the Senate, AARP and other groups are fighting to ensure it isn’t scaled back or stripped out.

“We sort of view it like a Jenga tower,” said David Mitchell, the founder of Patients for Affordable Drugs. “We're concerned that if we pull out something, the thing will collapse. … And so our position is don't change anything, pass what the House passed intact, for fear that we upset this delicate balance.”

Mitchell and his allies have some reason for optimism.

The three Democratic senators viewed as most skeptical of allowing Medicare to negotiate drug prices — Sens. Kyrsten Sinema (Ariz.), Robert Menendez (N.J.) and Tom Carper (Del.) — have all said they back the current compromise language. (AARP nevertheless held a town hall with Carper last week to make sure the issue remained on his mind.)

Instead, the bigger threat might be the Senate parliamentarian, who could rule some of the House language is barred under reconciliation rules. Or the entire effort to pass the bill could collapse, taking drug pricing down with it.

“At this point, honestly, I think my concerns are less about the drug-pricing provisions … and more about getting the whole package across the finish line,” said Bari Talente, a lobbyist for the National Multiple Sclerosis Society, which is advocating on the issue.

First Peek from Post: Democratic concerns about the party's midterm strategy mount as they struggle to sell agenda to voters

Demetrius Freeman

Brag Back Better: “Beyond a struggle to sell the nuts-and-bolts of legislation, there are [deep] fears among Democrats that the party lacks a cohesive and convincing argument to win over voters in next year’s elections,” <a href="https://www.washingtonpost.com/politics/democrats-midterms-fears/2021/11/28/b3d2280a-4d4d-11ec-94ad-bd85017d58dc_story.html">our colleagues Tyler Pager, Sean Sullivan, Michael Scherer and Marianna Sotomayor report.&nbsp;</a>

“Democrats are eager to tout the bills they have passed in President Biden’s first year, but a strategy tying together the disparate pieces of legislation — ranging from lowering the cost of child care and eldercare to combating climate change to building roads and bridges — is still lacking.”

“When discussing their pitch to voters, Democrats from the president to rank-and-file lawmakers often spout off a laundry list of policies they have passed, many of which are individually popular. The problem is that most voters have not given Democrats credit for implementing the measures.”

“Concerns about the party’s midterm strategy dominated a private briefing for Senate Democrats earlier this month with some of the party’s top strategists and pollsters … Strategists urged Democrats to focus their pitch on the economy, particularly as it relates to Biden’s Build Back Better plan. They also argued that the Biden agenda, as it was developing through legislation, would be a strong issue to run on in the midterms.”

“But one presenter advised the lawmakers to stay away from talking about the social safety net, concerned that the phrasing would turn people off, and instead focus on job creation and improving wages.”

Meanwhile, former president Donald Trump has opted to place loyalists in key positions across the country, including as paid precinct judges, elected county clerks and state attorneys general, <a href="https://www.washingtonpost.com/politics/trump-allies-election-oversight/2021/11/28/3933b3ce-4227-11ec-9ea7-3eb2406a2e24_story.html">our colleagues Amy Gardner, Tom Hamburger and Josh Dawsey report.</a>

“The effort goes far beyond the former president’s public broadsides against well-known Republican state officials who certified Biden’s victory, such as Georgia Secretary of State Brad Raffensperger and Arizona Gov. Doug Ducey.”

“If they succeed, Trump and his allies could pull down some of the guardrails that prevented him from overturning Biden’s win by creating openings to challenge the results next time,” election officials and watchdog groups told our colleagues.

All eyes on the Great Lake State: “Few states have seen more fervor for replacing election officials than Michigan, where the push extends from candidates for statewide office down to the most local level of election administration — county boards of canvassers, whose members served as bulwarks against Trump’s efforts in 2020.”

“One leader of the effort to challenge the 2020 vote in the state, West Michigan lawyer Matthew DePerno, is seeking the GOP nomination for attorney general. DePerno, who waged a failed legal battle over an election-night vote-counting error in Antrim County, has built his campaign around a vow to expose fraud.”

Trump has endorsed DePerno and Michigan secretary of state candidate Kristina Karamo as “part of a wave of Republican contenders across the country who have embraced the former president’s false assertions about the 2020 election — including 10 running for secretary of state and eight running for attorney general.”

What we’re reading:&nbsp;

ICYMI (SCOTUS week prep): <a href="https://www.washingtonpost.com/politics/interactive/2021/supreme-court-abortion-stances/?itid=hp-top-table-main&itid=lk_inline_manual_63">What the Supreme Court justices have said about abortion and Roe v. Wade</a>. By The Post’s Robert Barnes and Shelly Tan.

<a href="https://www.cnn.com/2021/11/28/world/omicron-coronavirus-variant-vaccine-inequity-intl-cmd/index.html">Vaccine inequity and hesitancy made the Omicron variant more likely, scientists say</a>. By CNN’s Ivana Kottasová.

<a href="https://www.thedailybeast.com/inside-a-divided-politico-playbook-drama-woke-police-fears-and-union-fights?ref=home">Inside a divided Politico: Playbook drama, ‘woke police’ fears, and union fights</a>. By the Daily Beast’s Zachary Petrizzo and Lachlan Cartwright.

<a href="https://www.nytimes.com/2021/11/28/us/politics/mark-esper-memoir-lawsuit.html">Esper claims defense dept. is improperly blocking parts of his memoir</a>. By the New York Times’s Maggie Haberman.&nbsp;

Houston, we have a dropout:&nbsp;

Thanks for reading. You can also follow us on Twitter: <a href="https://twitter.com/theodoricmeyer">@theodoricmeyer</a> and <a href="https://twitter.com/jaxalemany">@jaxalemany</a>.

Deadline Club Award for Newspaper or Digital Local News Reporting, 2014

McGill University

Columbia University

Theodoric Meyer is a national political reporter for The Washington Post and a co-author of the Early 202 newsletter.

Theodoric Meyer

Harvard University, BA IN Government

Jacqueline Alemany is a Congressional Investigations reporter for The Washington Post. Previously, she was the author of The Early 202, The Post's flagship early morning newsletter featuring news critical to the nation’s many power centers. Alemany is also an on-air contributor to NBC News and MSNBC.

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Big pharma isn't the only powerful player in the prescription drug pricing fight