Democrats’ Dilemma: How to Capture Healthcare Expansion in Their Big Spending Bill



By Tami Luhby, Jessica Dean and Ali Zaslav, CNN

To the President Joe Biden and Congressional Democrats who $ 3.5 trillion budget reconciliation invoice was a chance to fulfill her long-standing dreams Expansion of health insurance.

The proposed package includes the addition of Medicare Dental, visual and hearing benefits, Medicaid in the 12 states that refused to adopt, expand, and make permanent the provision of the Affordable Care Act generous bonuses for Obamacare policy. To pay for that, the Democrats would enable Medicare to negotiate drug prices – another long-term goal.

But the political priorities have turned into that tough buzz saw of politicsthat threatens the party’s ability to insure more Americans and improve health equity. Democrats are divided over the scope of the law, and moderate members say they will not accept such massive measures. The party needs the votes of all of its 50 senators to pass the law.

West Virginia Senator Joe Manchin has announced it will support a $ 1.5 trillion package, though the Democrat admitted earlier this month that he would not rule out anything as high as $ 1.9 trillion to $ 2.2 trillion.

The party is now involved shrink the packagewhich will likely mean dumping some of some members’ most coveted provisions overboard or reducing their generosity to fit as much as possible. One or more of the health measures are also at risk.

“It is very difficult to weigh the tradeoffs in these various additions,” said Tricia Neuman, executive director of the Kaiser Family Foundation’s Medicare Policy Program. “There are competing needs. There is a strong electorate for each of these proposals. “

In a letter to colleagues last week, House spokeswoman Nancy Pelosi suggested that Democrats should “do less things well,” but later hinted that she hopes lawmakers won’t have to drop anything and instead set the timeframe of the Provisions would shorten.

Progressive tend to stick to as many measures as possible and limit their costs in other ways.

“We keep these conversations inside the caucus, you know. Part of the challenge is that we still don’t know what the final number will be, “Georgia Democratic Senator Raphael Warnock told CNN.

A federal Medicaid expansion program

Warnock, who is due for re-election next year, is one of the Senate’s biggest supporters for the expansion of Medicaid. About 14.5% of Georgia residents were uninsured in 2020 – the third highest in the country, according to a Kaiser analysis of the census data.

“We have a chance, unlike any other chance we’ve had before, to fill the gap and save lives,” wrote Warnock in a USA today op-ed The beginning of October. “Now is the time to take it.”

The reconciliation package would extend coverage to a total of more than 2 million low-income adults in Georgia and the 11 other states that Medicaid did not expand. It would give them premium grants first to buy coverage under the Affordable Care Act, then move them to a new federal Medicaid expansion program in 2025, which is paid in full by the federal government. How much that would cost is not yet known.

However, this move is not doing so well with lawmakers in states that have already decided to expand Medicaid – and are paying 10% of the cost.

“As I was told, federal agencies will pay for Medicaid. Well what about Montana? We’ve already expanded it, ”said Democratic Senator Jon Tester from Montana, a GOP-controlled state. “Does that mean that the state’s share is still paid by the state because if it does it will be hard to sell.”

Expanding Medicaid to include low-income adults would allow Democrats to cater for this important demographic ahead of the 2022 midterm elections in hopes of maintaining control of Congress. And it would help fulfill the party’s promise to improve racial justice.

“This is the last population, and probably the most vulnerable of all populations, to be left on their own for health care,” said Leslie Dach, founder of Protect Our Care, which is working to increase coverage. “We have seen the effects of that in this pandemic.”

More benefits for seniors under Medicare

Expanding Medicare benefits would serve a similar purpose to win votes from the Seniors, another important constituency. The Law of Reconciliation would provide visual services starting next October and hearing services the following October. Dental insurance, which would cost far more, wouldn’t start until 2028.

While the Congressional Budget Office has not yet considered this latest proposal, it noted that a House bill in 2019 to add these benefits would increase spending by approximately $ 358 billion over a 10-year period.

Almost half of Medicare beneficiaries, or 24 million Americans, were out of dental care in 2019, according to Emperor. Many also lack visual and hearing advantages.

Those who signed up for Medicare Advantage plans were more likely to have all three services, but the scope of those benefits varied.

Vermont Senator Bernie Sanders, an independent MP who works with the Democrats, is the Senate’s strongest advocate for adding these benefits to Medicare. He has claimed that this is a red line for him and other progressives.

“Should we not hear older people who have no teeth in their mouth and cannot afford glasses, say we should not expand Medicare?” Sanders said when asked what might be cut on the bill. “We can afford that.”

However, Manchin has raised concerns about expanding a federal program that is already on shaky financial grounds. In order to reduce costs, he decided to limit these additional benefits based on income. It would be the first time Medicare coverage was limited by income.

Increased allowances under the Affordable Care Act

As part of their $ 1.9 trillion coronavirus aid package earlier this year, Democrats were finally able to fix a major flaw in the Affordable Care Act – its lack of affordability for many Americans, especially the middle class.

The US bailout has temporarily increased the law’s premium subsidies. Anchoring this permanently in the reconciliation package is a high priority for many in the party leadership.

This year and next, policyholders pay no more than 8.5% of their income for coverage, up from nearly 10%, while lower-income policyholders receive grants that completely eliminate their premiums.

Those earning more than 400% of the federal poverty line – about $ 51,000 for an individual and $ 104,800 for a family of four in 2021 – are also eligible for help for the first time.

These changes have helped convince an additional 2.8 million Americans to sign up for policies during the special enrollment period that Biden introduced earlier this year.

Permanently increasing subsidies and closing the Medicaid coverage gap by widening eligibility for assistance would reduce the number of uninsured Americans by nearly a quarter or 7 million people in 2022, according to a recent report from the Urban Institute. The increased costs would add up to $ 442 billion over 10 years.

But the phasing out of the increased subsidies could have the opposite effect.

Democrats “have to grapple with the reality that through the ARPA they have expanded access and affordability in the short term. That would be something that will be undone if not renewed, “said Cynthia Cox, director of the Kaisers program at the ACA, of the deployment of the American rescue plan.

Allow Medicare to negotiate drug prices

One way the Democrats hoped to pay their massive spending bill was by Allow Medicare to negotiate prices with prescription drug manufacturersthat could be used to offset $ 700 billion in costs.

The House version would require the Secretary of Health and Social Services to negotiate maximum fair prices for at least 50 and up to 250 expensive drugs without competition, including insulin. The award would be available to Medicare beneficiaries and individuals enrolled in group health plans.

A large majority of Americans across the political spectrum are in favor of allowing Medicare negotiations even after hearing the argument that drug companies must charge high prices to fund the research, a recent release published Kaiser tracking survey found.

Although negotiating Medicare has long been a party priority, moderate Democrats in the House and Senate have refused to support them. The powerful pharmaceutical industry has also cracked down on the effort.

Pelosi hinted on Thursday that progressives may have to ditch the proposal in order to reach an agreement on the massive social safety net package.

But she told KQED in San Francisco, “We’re still fighting this fight. I’m not even sure we’ll include it in this bill. We’ll get some of that, but it won’t be the complete package that many of us have been fighting for for a long time. “

The CNN Wire
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CNN’s Manu Raju contributed to this report.

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