WASHINGTON (AP) — Democrats are debating how to divide up what could be a smaller serving of health care spending in President Joe Biden's domestic policy bill, pitting the needs of older adults who can't afford their dentures against the plight of uninsured low-income people in the South.
"There's always a battle of where you place your priorities," Rep. Jim Clyburn, the No. 3 House Democratic leader, said Wednesday. "We don't means-test Medicare, which means that pretty wealthy people will be getting both dental care (and) vision care while poor people will be denied. ... I don't know that that's a real good choice."
Clyburn explained that more than 100,000 of his fellow South Carolinians remain uninsured because Republicans in charge of state government have refused to expand Medicaid to low-income working adults under the Affordable Care Act.
Health care is foundational to Biden's $3.5 trillion domestic policy bill, which touches everything from taxes to climate change, child care to community college.
When budget screws get applied, entire proposals can disappear from legislative wish lists, or they can get authorized for a shortened time period, a fiscal tactic akin to wading in the water as opposed to swimming.
For now, nothing has been dropped from Democrats' health care agenda, which includes new dental, vision and hearing coverage under Medicare, richer subsidies that reduce premiums for "Obamacare" plans, a federal work-around to expand Medicaid in a dozen states still refusing, improved post-partum Medicaid coverage for low-income women, and a permanent extension of the popular Children's Health Insurance Program.
The health care upgrades amount to a major renovation of federal programs covering more than 145 million Americans and part of the Democratic political legacy.
"The health care elements are the tip of the spear, the most important, the most popular, and the most politically salient, and we simply have to get that done," said Brad Woodhouse, executive director of Protect Our Care. The advocacy group, which is urging Democrats to go big, sponsored a teleconference with lawmakers Wednesday.
The plan has been to pay for health care improvements with savings reaped by authorizing Medicare to negotiate prices for the costliest prescription drugs. But there's a dilemma. Just as with the overall price tag for the legislation, Democrats have disagreements over Medicare negotiations. A Senate bill still in the works may not go as far as the measure pending in the House.
And there's another element to factor in: Biden is pushing for a major expansion of home-based long-term care services under Medicaid, an alternative to institutional placement in nursing homes.
Tensions are simmering between Senate Budget Chairman Bernie Sanders and some House Democrats. The Vermont independent is pushing hard to keep expanded Medicare benefits for dental, vision and hearing care at the front of the line, but Democratic veterans in the House who labored to pass and preserve the Obama-era health law see improving it as unfinished business that is their calling to complete.
Under the umbrella of the Obama law, closing the so-called Medicaid coverage gap has become a rallying cry for Black and Latino lawmakers, as well as for advocates for the poor. Some 2 million people in states refusing the health law's Medicaid expansion make too much to qualify for Medicaid and too little to be eligible for HealthCare.gov plans. Three out of 5 are Black or Hispanic. Texas and Florida, states Democrats would like to flip, could see the biggest gains in coverage if the federal government steps in.
The intraparty political dynamics differ from the House to the Senate. While many House Democrats represent districts that would benefit from closing the Medicaid coverage gap, only three Democratic senators come from states that have not already expanded their programs. They are Sens. Tammy Baldwin of Wisconsin and Georgians Raphael Warnock and Jon Ossoff. They represent a sliver of the Democratic caucus in the Senate, but also the edge that gives Democrats control of the evenly divided chamber. Warnock, who faces reelection next year, has made closing the Medicaid gap his signature issue.
Advocates are worried that lawmakers will pare back the Medicaid fix to save money and apply it only for a brief period of several years, leaving it to a future Congress to make the change permanent.
"If the policy isn't permanent, it's important that it extend long enough to get the federal Medicaid program up and running," said Judy Solomon of the Center on Budget and Policy Priorities, a nonprofit that advocates on behalf of low-income people. Medicaid is one of the most complex government programs and splicing in a new federal component for a limited number of states could be a time-consuming process.
For now, Democrats are hoping they don't have to slice and dice their health care ambitions to fit new budget constraints.
"Obviously negotiations are ongoing," said Rep. Lauren Underwood, D-Ill. "I'm sure that these critical health care topics have come up in discussion. I think that what we know for sure is that you can't 'build back better' without protecting folks' health care and lowering out-of-pocket costs, period."