WEDNESDAY, OCTOBER 27 , 2021. THE WASHINGTON POST EZ RE A
BY DAN DIAMOND,
RACHEL ROUBEIN,
AMY GOLDSTEIN
AND TONY ROMMDemocrats’ sweeping plans to
bolster Medicare and Medicaid
benefits have been scaled back
amid an assault from industry
groups and opposition from cen-
trists like Sen. Joe Manchin III
(D-W.Va.), with popular coverage
expansions likely to be narrowed
in hopes of reaching a deal this
week.
A proposal to expand Medicare
to cover dental, hearing and vi-
sion benefits is in danger of fall-
ing from the tax-and-spending
package rapidly taking shape in
Congress. A framework to expand
Medicaid to cover Americans in a
dozen mostly Southern states has
also been reworked.
Meanwhile, liberals’ plan to
give Medicare broad power to
negotiate prescription drug pric-
es has come under sustained at-
tack from pharmaceutical lobby-
ists and some Democrats, includ-
ing Sen. Kyrsten Sinema (Ariz.).
Scaling back that proposal, which
was expected to save more than
$700 billion over a decade, also
complicates Democrats’ efforts to
pay for coverage expansions.
Manchin told reporters on
Monday that he had concerns
about some of Democrats’ signa-
ture proposals, underscoring the
fragile state of negotiations.
“You’ve got to stabilize” Medi-
care’s long-term finances before
adding new benefits, the senator
said, adding that he thought the
Medicaid proposal was “unfair”
to states like his, which have
already helped pay for the expan-
sion of the program under the
Affordable Care Act.
The infighting over health care
also prompted Democratic lead-
ership this month to consider a
plan to delay some of the party’s
health agenda to next year, in-
cluding a plan to repeal a Trump-
era ban on prescription drug
rebates, hoping that election-year
deadlines would force lawmakers
to seal deals that are currently
proving elusive, said three people
with knowledge of the negotia-
tions, who spoke on the condition
of anonymity because of the sen-
sitivity of the negotiations.
But further delays could back-
fire with patients and at the polls.
Many Americans say that the cost
of health care remains their top
voting issue and that reforms that
lower prescription drug prices
are desperately needed. Backers
of other popular measures like
boosting home care and reducing
the cost of health plans sold
through ACA marketplaces are
also jockeying for their inclusion
in the package.
“The stakes for Democrats
here are high because there are a
number of important priorities
they’ve tried to address for years,”
said Larry Levitt, executive vice
president at the Kaiser Family
Foundation. “If they don’t pass
them now, it may be many years
before they have another oppor-
tunity.”
The last-minute negotiations
over the package’s health provi-
sions have pitted some of the
party’s most powerful wings
against one another. The Medi-
care benefits expansion, which
was originally forecast to cost
more than $350 billion and has
been championed by Sen. Bernie
Sanders (I-Vt.) and his allies who
favor single-payer health care, is
opposed by Manchin, who says
the measure is too costly. A com-
promise President Biden floated
to distribute vouchers to Medi-
care beneficiaries also has been
panned by an array of lawmakers,
ranging from Manchin to liberal
stalwart Rep. Debbie Dingell (D-
Mich.), even as other members
retrench to fight for their priori-
ties.
“I’m gonna do everything I can
to make sure that Medicaid ex-
pansion stays in this bill,” said
Sen. Raphael G. Warnock (D-Ga.),
whose state is among the dozen
that turned down the opportu-
nity to expand the program
through the ACA. “What’s unfair
is for the people in Georgia to be
paying for health care in other
states that they have no access to,
because they woke up in the
wrong state,” he added.
Democratic leaders are facing
a math problem: To pass their
social spending package, which
also would address priorities like
climate change and child care,
the par ty cannot lose a vote in the
Senate and can only spare three
votes in the House. Democrats
also are wary of losing their
tenuous control of Congress in
next year’s midterms.
The par ty is also facing a rapid-
ly approaching deadline: Biden’s
overseas trip on Thursday, with
the president hoping to trumpet a
congressional deal on climate
change at a U nited Nations con-
ference next week.
But key elements of the bill
remain in flux, with Senate Fi-
nance Committee Chairman Ron
Wyden (D -Ore.) conceding to re-
porters on Tuesday that “we’re
still working” on whether an ex-
pansion of Medicare benefits
woul d be included in the package
at all. Wyden added the fate of the
Medicare proposal was linked to
the embattled drug-price plan,
which he said would produce
“savings by stopping these Big
Pharma companies from ripping
people off.”
Democrats’ shrinking health
agenda has caught the attention
of Wall Street. A package that was
increasingly envisioned to con-
tain as much as $1 trillion in new
health-care spending is now like-
ly to include just a fraction of
that, investment firm Raymond
James told clients on Friday. The
firm predicted that total health-
care spending in the package
could be as low as $275 billion, in
addition to whatever Democrats
spent on home care, another pri-
ority at risk of being cut from the
bill.
Meanwhile, advocates contin-
ue to urge liberal Democrats to
pursue their original broad goals.
“Poll after poll after poll, every
single poll shows the most popu-
lar items are lowering prescrip-
tion drug prices and reinvesting
those funds into Medicare — den-
tal, vision and hearing,” said Bill
Sweeney, senior vice president for
government affairs for AARP, the
advocacy group for people 50 and
older. “We hope that Congress
will listen to their constituents
and listen to the need.”Vouchers compromise under
fire
Democrats’ plan to expand
Medicare benefits attracted new
scrutiny when Biden last week
said that the effort was a “reach,”
faulting Manchin’s opposition.
“I think it’s a g ood idea. And it’s
not that costly in relative terms,
especially if we allow Medicare to
negotiate drug prices,” Biden said
at a t elevised town hall on CNN.
“But here’s the thing ... Mr. Man-
chin is opposed to that.”
Manchin reiterated his con-
cerns on Monday, telling report-
ers he was worried about the cost
of Medicare expansion. House
Speaker Nancy Pelosi (D -Calif.)
on Sunday also said on CNN that
the dental benefits were “very
expensive” and noted the chal-
lenge of implementing them.
Sanders, along with congres-
sional allies, has publicly champi-
oned the Medicare benefits ex-
pansion “as one of the most
important provisions” in the bill
and has so far not indicated a
willingness to compromise. But
other Democrats and advocates
have increasingly rallied around
competing priorities like
strengthening the Medicaid so-
cial safety net.
Levitt said the push to expand
Medicare benefits has become “a
stand-in” for Medicare-for-all on
the le ft, describing it as “the last
shred of what progressives were
pushing for in trying to expand
Medicare to everyone.”
“It’s taken on a lot of symbolic
significance ... but it’s not ignited
the grass roots,” he added.
Meanwhile, health advocacy
organizations have condemned
the voucher option put forward
by Biden as “not a replacement
for real coverage” and pred icting
problems that “would minimize
any expected political payoff.”
“Vouchers instead of coverage
for dental care would not effec-
tively target those with the great-
est dental needs, would be ad-
ministr atively complex, and
would direct valuable resources
away from getting a more perma-
nent benefit off the ground,” the
Center for Medicare Advocacy,
Families USA and other groups
said in a joint statement Monday,
warning vouchers could also
spark fraud.Other measures in flux
Democrats’ original plan to
permanently extend Medicaid
cove rage to 2.2 million Ameri-
cans, many of them members of
minority groups in the 12 states
that refused the ACA’s Medicaid
expansion, seemed unlikely to
make it into the legislation, ac-
cording to two people familiar
with the negotiations.
But leaders are increasingly
coalescing around a strategy that
would let people in those states
get free plans in the online mar-
ketplaces set up by the law for
four years, or until 2025.
The plan still faces roadblocks,
including from lawmakers in
states like West Virginia that paid
part of the costs to expand Medic-
aid and say it is unfair to expect
them to foot the bill for holdouts.
Much of the politicking has cen-
tered on Manchin, who on Mon-
day expressed opposition to theeffort, drawing renewed atten-
tion from officials in states that
stand to benefit. House Majority
Whip James E. Clyburn (D-S.C.)
spoke with Manchin about thegoal to close the coverage gap, a
Clyburn aide confirmed, and
Warnock also said he was reach-
ing out to Manchin.
The dust-up reflects the diffi-culty for Congress to craft nation-
al policy on Medicaid, said Rod-
ney Whitlock, a vice president at
McDermott+Consulting and for-
merly a top Senate Republican
staffer overseeing Medicaid is-
sues. Whitlock added that law-
makers have sought to untangle
the disparities that resulted from
the Supreme Court’s 2012 ruling
making the ACA’s Medicaid ex-
pansion optional for states. “The
Medicaid side is a Gordian knot,”
he said.
Less controversial is a plan to
extend an upgrade that began in
the spring in the subsidies that
lower for most consumers the
cost of health plans sold through
the ACA, which are set to expire
next year. Democrats have agreed
on the measure, although leaders
earlier this month considered de-
laying the provision if talks on the
spending bill should collapse.
Democrats also plan to infuse
new funding into home care,
although an earlier vision of in-
vesting $400 billion would likelybe cut by at least one-third.
Separately, Democrats have
cont inued talks to empower
Medicare to negotiate drug prices
in a bid to lower seniors’ — and
taxpayers’ — costs. They’re seek-
ing to craft a compromise with
moderate lawmakers, including
Sinema, Rep. Scott Peters (D -Ca-
lif) and others, many of whom
represent districts with drug and
biotech companies, and who ar-
gue the drug negotiation measure
could stifle innovation.
But one of those wary Demo-
crats, Sen. Robert Menendez
(N.J.), said he recently had con-
versations with Wyden, a long-
time champion of Medicare nego-
tiation, about an alternative ap-
proach. “I think that what he
comes up with may be a way
forward on price negotiations,”
Menendez said Monday, declin-
ing to offer details.
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[email protected]Democrats scaling back Medicare, Medicaid proposals
JABIN BOTSFORD/THE WASHINGTON POST
Sen. Bernie Sanders (I-Vt.) has championed a M edicare benefits
expansion and signaled no room to compromise on its inclusion.Spending package’s price
tag, h ealth provisions are
key areas of dispute