Medicare expansion collides with health care for the poor as budget bill shrinks

WASHINGTON – Democrats face tough moral and political decisions on how to pursue their century-old dream of universal health care, now that their ambitious $ 3.5 trillion social security bill will almost certainly have to be cut.

As they attempt to reduce the cost of the bill, party members disagree on whether to extend coverage to more poor adults in states whose leaders have refused to do so or to provide new Medicare benefits to seniors at all income levels.

Southern Democrats, in particular, are urging their leaders to prioritize insurance coverage for 4.4 million working poor across the 12 states, mostly in the South, with Republican or divided leaders who have refused to expand Medicaid under the Affordable Care Act. But the Progressives, led by Senator Bernie Sanders, the Vermont Independent and former presidential candidate, are determined to provide older Americans with dental, hearing and vision coverage.

Many provisions of the delicately crafted bill are interconnected, and the division over how to cut prescription drug costs and raise taxes will likely prevent the party from acting boldly on both fronts.

“I believe health care is a human right, and if you believe it is a human right, you don’t believe it is a human right for 38 states,” said Senator Raphael Warnock, Democrat of Georgia , whose push for Medicaid expansion in his was at the heart of his special election victory last year, and who looks forward to bringing such an achievement to voters when he runs for reelection next year. “People are literally dying for lack of access to health care. “

Health care has long been a winning issue for Democrats. He delivered the House to them in 2018 and helped them get elected to the Senate in 2020, thanks in large part to second-round victories in Georgia for Mr Warnock and Senator Jon Ossoff.

But in crude political terms, most of the states that have refused to expand Medicaid – like Alabama, Mississippi, South Carolina, South Dakota, Tennessee, and Wyoming – are beyond the reach of Democrats. Older Americans, on the other hand, are consistent voters, more and more up for grabs. These voters would like Medicare to start paying for dental, vision and hearing care.

Some Democrats, furthermore, argue that Congress should not reward states that have refused to expand Medicaid by creating a separate, fully federally funded insurance program for their working poor. Under the Affordable Care Act, states that extend Medicaid pay 10 percent of the cost. The topic was raised at a recent political lunch for Senate Democrats.

“Some members have raised the question of whether we are giving a Medicaid benefit to states that have not expanded, those that have will feel like, ‘Wait a sec,'” said Senator Tim Kaine, Democrat of Virginie, although he said it was not his point of view.

Democratic leaders envisioned four major health care components of the bill: It would close the so-called Medicaid coverage gap, reaching poor adults who earn too much to qualify for traditional Medicaid, but not enough to qualify. a private insurance subsidized under the 2010 health law. It would provide Medicare beneficiaries with dental, vision and hearing care for the first time. It would extend recently passed grants that help middle-income people buy insurance under the Affordable Care Act.

All of this would be paid for by a provision allowing Medicare to negotiate prices with drug makers and tie drug prices to those paid by other developed countries.

Republicans are largely absent from the conversation; they oppose the budget measure in its entirety, and therefore do not weigh on whether to expand Medicare or Medicaid. But they have long opposed Medicare to negotiate drug prices, which they say stifles innovation in the pharmaceutical industry.

This part of the bill is now in jeopardy. Last week, three Democrats sided with the Republicans on the House Energy and Commerce Committee to remove it from the law. The House Ways and Means Committee approved it, with a dissent, but if the prescription drug measure cannot survive a full House vote, it will mean a loss of around $ 500 billion in dollars. savings Democrats hoped to spend to expand both Medicare and Medicaid. The total cost would be around $ 600 billion over 10 years.

Caught between these competing imperatives are lawmakers like Representative Lloyd Doggett, a senior Democratic official on the Ways and Means Committee whose home state of Texas did not extend Medicaid. In a fight for scarce resources, he said, older people who already have good coverage for most of their health needs through medicare must give way to the working poor. that have no coverage at all.

“I give priority to those who have been completely left out,” he said. “They are desperate.”

As House and Senate committees work to draft their versions of the bill, Democrats of all philosophical backgrounds are struggling to decide where their own priorities lie.

Representative Charlie Crist, a Democrat from Florida who was once his state’s Republican governor, noted that 800,000 of its residents lacked health insurance because state officials refused to expand Medicaid. But Florida also has a large senior population that wants expanded Medicare coverage.

“I think you stand up for both; this is my position, ”he said. “It’s extremely important. We are the richest country in the world and one of the few industrialized countries that does not provide health care for all, and we must do it.

Massachusetts Democrat Senator Elizabeth Warren said “the drug companies have the best lobbyists in town,” but the party should not abandon the crackdown on rising prescription costs to free up money for them. two priorities.

“I’m saying the choice is between billionaires and people who don’t have health care,” she said.

Pragmatists realize that certain concessions will have to be made. Mr Kaine said it was possible Democrats would expand both Medicare and Medicaid in a more modest way, perhaps by phasing in the benefits.

The four House Democrats who have voiced their opposition to the drug measures – Kurt Schrader of Oregon, Scott Peters of California, Kathleen Rice of New York and Stephanie Murphy of Florida – are enough to bring the entire bill down in the tightly divided House. And more defections are likely from representatives with pharmaceutical interests in their districts, who have not had a chance to speak out.

Democrats in favor of expanding Medicare have largely remained silent, given the sensitivity of the issue. But they see a political boon in the expansion approved by House committees last week. Seniors would see immediate vision care coverage. In 2023, the audience would be added. Dental coverage, which should be created from scratch, would not begin until 2028.

Medicare supporters say Congress has given states that haven’t extended Medicaid enough time and incentives to do so, and it’s time to focus on other priorities. This year’s $ 1.9 trillion pandemic bailout bill included huge new grants for those states if they agreed to expand Medicaid. None have.

States pay up to half the traditional costs of Medicaid, but under the Affordable Care Act, the federal government pays 90 percent of the costs for population expansion.

The two Georgian Senators and Senator Tammy Baldwin of Wisconsin, who also did not expand Medicaid, initially envisioned a Medicaid-like program run from Washington that would offer recalcitrant states even more federal funding if they eventually join Medicaid, relieving them of virtually any tax budget. responsibility.

Two House committees – Ways and Means and Energy and Trade – passed a measure last week that would, for now, extend existing premium subsidies under the Affordable Care Act to those who are now too poor. to qualify, covering 94% of their total health care costs, rising to 99% in 2023. By 2024, the Department of Health and Social Services will have implemented a Medicaid-type program on the model of the Senate’s proposal for these 4.4 million people.

To some liberal Democrats, the plan seems unfair to the 38 states that extended Medicaid under the original terms of the health care law – at a greater cost to those states.

Mr Warnock has a ready-made answer to that: “I remind my colleagues that Georgia gave us the majority.

“We would not have the privilege of debating these priorities and a package that we are proposing if the Georgian people had not stood up and sent Jon Ossoff and me to the United States Senate,” said he added. “So we owe it to them to give them the coverage they deserve.”

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