Medicare and Medicaid extensions must be congressional priorities


Of the many problems Democrats are trying to solve with the Build Back Better Act, none are as likely to give them post-traumatic stress flashbacks as health care. As the size of the bill shrinks under centrist demands for cost reductions, the number of new policies that can be implemented also drops, forcing a choice on which constituencies to favor.

The problem

The United States spends more on health care per capita than any other country in the developed world. Attempts to address this issue are met with headwinds from the healthcare industry and its lobbyists, as well as the United Republican opposition. Conservative governors have also spent years refusing to expand Medicaid as permitted by the Affordable Care Act, depriving millions of Americans of cheaper coverage. And although Medicare Part D funds more than a third of all prescription drug sales in the United States, the federal government is legally prevented from negotiating with drug companies for lower prices.

The promise

For years, Democrats have promised to end price hikes and negotiate lower costs for older Americans on Medicare. In August, President Joe Biden said “the prices have tested too many families and stripped them of their dignity” and urged Congress to act. Meanwhile, his U.S. Plan for Families calls for extending the reduced subsidies for Obamacare participants included in this year’s Covid stimulus bill.


There are four main healthcare-related policies at stake as Democrats negotiate the details of the multibillion-dollar budget reconciliation bill. Here’s how it looks in the bill that the House Energy and Commerce Committee passed last month.

Extension of Obamacare grants

Temporary tax credits for insurance premiums passed this year, which caused an increase in Obamacare enrollments, would be extended over the next 10 years. “Households representing up to 150% of the federal poverty level would benefit from fully covered insurance on health law trade,” says Roll Call. “The legislation would definitively eliminate the ceiling on subsidies granted to households earning more than 400% of the poverty line. Premiums would also be limited to 8.5% of a household’s income, making insurance more affordable for people at all income levels.

Bridging the Medicaid Gap

The Build Back Better Act would offer a two-step plan to close the coverage gap that leaves 2 million people earning too much money to enroll in Medicaid but not enough to qualify for Obamacare grants. Here’s how Judith Solomon from the Center on Budget and Policy Priorities explains it:

For the first three years, people would be eligible for premium tax credits that would pay for coverage for plans offered in ACA markets, which would be enhanced to better meet the needs of low-income people. Providing market coverage would give the Secretary of Health and Human Services (HHS) time to establish a federal Medicaid program that aligns with Medicaid rules that apply to state expansions and is available for people in states that have not expanded from 2025.

Reduce prescription drug costs

The ban on negotiating with drug manufacturers for lower prices would be lifted, establishing a “fair price negotiation program” that would set a maximum fair price for Medicare beneficiaries. Federal spending reduced through savings would then be used as a means to pay for other parts of the plan. The bill would also tax businesses that do not comply with the new rules and cap the maximum annual payments that a Medicare Part D member would have to pay for drugs at $ 2,000.

Adding vision, hearing and dental care to Medicare

While many Americans with insurance from their employers can opt for such coverage, Medicare seniors do not have this option. The bill that passed energy and trade would solve this at a cost of $ 350 billion over 10 years. Enrollers would be covered for “routine eye exams, glasses and contact lenses” on October 1, 2022, and for “hearing aids for people with severe or profound hearing loss” one year later . Coverage for dental care and dentures would begin in 2028.


There are two major cracks in the Democratic caucus over these policies. The first is whether to abandon one of the most expensive but most transformative parts of the bill: expanding medicare to cover vision, hearing and dental care.

Progressive Congressional Caucus Chair Pramila Jayapal, D-Wash. Argues it would be a mistake not to follow a policy that bolsters favor for the elderly, a popular demographic on election day. The change is not as broad as “Medicare for All,” but it has become a major rallying point for progressives who insist there is no evidence the expansion would bankrupt Medicare, as some more conservative members of the caucus have warned.

Let’s be clear: America’s health care system sucks.

But the Democratic House leadership would rather focus on Obamacare grants and close the Medicaid gap. These policies, they say, would lock in a feature that has benefited middle-class voters and, despite objections from GOP governors, provide access to health care to voters in potential states such as Florida, North Carolina. , Wisconsin and Georgia. (Progressives also oppose the American Dental Association, which has spoken out against the proposed new dental benefit for the elderly.)

Meanwhile, a small contingent of moderate House Democrats have come close to derailing prescription drug reforms in committee and no longer appear ready to accept them in a final bill. No great surprise that the Democrats in question – and Sen. Kyrsten Sinema, D-Arizona, who is also wary of the change – clawed back significant campaign funds from the pharmaceutical industry. If there are no federal savings on cheaper drug prices, it would make it harder to pay the overall bill. It would also mean removing one of the most popular parts of the Democrats’ political platform, a truly confusing political choice.


Let’s be clear: America’s health care system sucks. The changes that are on the table will not completely solve this problem, as long as the healthcare industry continues to increase costs for patients in search of profit. But the options on the table represent a real chance to make things easier for millions of Americans.

For southerners whose states have blocked them for years and seniors who suffer from massive toothache because they cannot afford dental care, this bill would make all the difference. Democrats will be excoriated in attack ads for overspending, regardless of the size of the final bill. There is no good reason not to provide as much help as possible.


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