Two Causes, Two Iconic Leaders & One Very Difficult Decision for Democrats
Seniors need dental care, poor people in a dozen states need health insurance -- and there may not be money for both
The pressure to downsize "Build Back Better" legislation is forcing Democratic leaders to make some tough choices about which initiatives to fund fully and which to fund partly — and which not to fund at all.
Today at HuffPost, I wrote about a particularly difficult dilemma pitting two health care initiatives against one another in a competition for funds.
One proposal would fill in the "Medicaid gap" -- that is, it would provide insurance to the more than 2 million low-income Americans who were supposed to get Medicaid through the Affordable Care Act, but haven't because GOP state leaders have refused to participate in the ACA's expansion.
The other initiative would bolster Medicare by adding key benefits, including dental coverage. Nearly half of seniors have no dental insurance today, which is why many develop problems that are painful, require drastic action and sometimes lead to other medical conditions.
Most Democrats would like to fund both, as would most of their allies. But that was going to be difficult even with a $3.5 trillion/10 year bill, let alone one that is closer to Joe Manchin's preferred top-line of $1.5 trillion. What's more, Democratic leaders decided long ago to treat the two health care initiatives (plus another one to shore up the Affordable Care Act) as one, self-contained unit that should pay for itself with savings from elsewhere in the health care budget. That too will limit available funds.
Health care advocates and experts have been warning of the coming squeeze for months. Now it's here.
The most outspoken advocate for the Medicaid gap initiative is Jim Clyburn, the veteran South Carolina Democrat and House Majority Whip. He has emphasized the importance of targeting limited resources at the people who need it most -- and addressing racial inequities that, in health care, have been made worse by the same GOP state officials with histories of suppressing Black votes and, more generally, backing policies that foster racial inequity.
The most outspoken advocate for Medicare dental is Sen. Bernie Sanders, the former presidential candidate and most influential progressive in Washington. For him, it's not just about the need for dental care among the elderly, especially those with less money. It's also about the importance of tending to America's one true government health insurance program, which he hopes can serve someday as a platform for covering all Americans.
Versions of this same debate are playing out over other funding choices Democrats face as they try to fit everything into a smaller legislative package. Child care or housing assistance? Paid leave or community college? Try to fund them all, even if that means scaling back what the plans do? Or pick out a handful and try to fund them fully? Target dollars where they'd make the biggest difference? Or focus on universal programs that touch the most people?
Political considerations are part of the calculations Democrats must make. They want to create programs that will be popular enough to withstand the inevitable future efforts at defunding or repeal. They want to build faith in the public sector. They want to show the public they can deliver on their promises. They want to do what they can while they still control Congress and the White House, because that opportunity might not come again for a long time.
Some people think the choices Democrats should make are clear-cut. I don't -- and, with this article, I didn't try to provide them. I simply tried to lay out the tradeoffs, which will exist no matter what Biden and his allies end up doing.
Thank you for reading!