Democrats jostle over health care priorities for scaled-back package

Jockeying is intensifying over a range of competing health care priorities as Democrats shrink their social spending package in an attempt to shore up enough support to advance the legislation.

Sen. Bernie Sanders (I-Vt.) is pushing for expanding Medicare to include dental, vision and hearing benefits, saying the provisions are “not negotiable.”

But House Majority Whip James Clyburn (D-S.C.) says that expanding Medicaid for low-income people living in the 12 GOP-led states that have so far declined the expansion should take precedence, noting that Medicare includes coverage for “millionaires and billionaires.”

Sen. Joe Manchin (D-W.Va.), a key centrist vote, has also expressed concern with expanding Medicare benefits, saying he wants to shore up the finances of the current Medicare program before expanding it. 

Speaker Nancy Pelosi (D-Calif.), meanwhile, has prioritized a third health care move: extending enhanced financial assistance to help people afford premiums under the Affordable Care Act (ACA), a key part of her legacy.

With the overall size of President Biden’s Build Back Better package shrinking, Democrats are searching for ways to fit in all of the health care priorities, leading to tensions in the party over the differing initiatives.

Democrats are discussing making the Medicare, Medicaid and ACA provisions all temporary as a way to save money and avoid completely eliminating any one of them. But even with this approach, lawmakers have indicated there are still contentious debates that need to be worked out.

Rep. Ami Bera (D-Calif.) said he suggested in a meeting with Biden and other moderate lawmakers on Tuesday that the Medicare dental benefits be left out of the package as a way to focus on other health care priorities. Bera acknowledged to reporters that Sanders disagreed and is still pushing for dental coverage.

“Everything’s a trade-off right now,” Bera said. “Vision and hearing obviously are a lot easier.”

Dental benefits pose implementation challenges and would take several years to set up. 

One option, discussed in a meeting with progressive lawmakers and Biden on Tuesday, is to give seniors vouchers that they could use for dental care as a way to more quickly give people a tangible benefit. 

On Medicaid, Democrats are looking to provide coverage to more than 2 million low-income people currently left out of the program because 12 Republican-led states have declined to expand Medicaid under the ACA.

The House package unveiled in September would have created a new federal program to provide coverage in those 12 states.

But Democrats are now discussing a temporary plan that would instead subsidize private coverage in the ACA marketplaces. That could be easier to set up and avoid pushback from industry groups that worry a new federal program is a stepping stone to a larger-scale, government-run “public option.”

Backers of the Medicaid expansion push argue that if it must be made temporary, it should last as long as possible.

Sen. Jon Ossoff (D-Ga.), whose home state has so far refused the expansion, told The Hill on Wednesday he is pushing for the Medicaid expansion to last at least through 2027. 

Clyburn, a key figure in the House Democratic Caucus, has also been making the case for prioritizing Medicaid as a way to help low-income people. 

“While I fully support expanding Medicare, if forced to choose between the two, I would prioritize health care coverage to low-income Americans who have no coverage at all over additional health coverage for millionaires and billionaires, who already have basic Medicare,” Clyburn wrote in a recent op-ed. “If both can’t be funded permanently, at the very least, the two should be treated equally.”

For the third bucket — enhanced financial assistance to help people afford premiums under the ACA — moderate lawmakers and Biden on Tuesday discussed a three-year extension, according to a source familiar with the meeting. 

Shortening the duration of any of the priorities in a bid to include them all poses risks, though, given that it sets up cliffs when the provisions will expire. Republicans very well could control at least one chamber of Congress or the White House when that happens, throwing future extensions of programs into doubt.

Democrats are banking on the proposition that benefits are politically hard to take away once they are in place, as was seen with efforts at repealing ObamaCare in 2017.

“It’s always hard to take benefits away from people, but these are programs that would be created entirely with Democratic votes and there’s no guarantee a future Congress, which could be under Republican control, will extend them,” said Larry Levitt, a health policy expert at the Kaiser Family Foundation. 

“This Build Back Better package is looking to check a lot of boxes, that gives it broad support, but it makes the trade-offs when dollars are limited that much harder,” he added. 

Returning from a meeting with Biden on Tuesday, Rep. Pramila Jayapal (D-Wash.), chair of the Congressional Progressive Caucus, said Medicare dental, vision and hearing benefits are all “very much on the table still.”

“We have to figure out what that exactly looks like, and it’s not all agreed to until it’s all agreed to by everybody,” she said.