Exactly what American health care will look like if Democrats can pass their $3.5 trillion spending plan is unclear, but the senator negotiating its health-related provisions hopes what emerges will be dramatic: the first complete health care system for older Americans and significantly reduced costs for everyone else.
“We are setting very, very ambitious goals,” Sen. Ron Wyden (D-Ore.) told KHN. “And that’s appropriate because the fact is a lot of challenges have gotten short shrift — and I’m not just talking about the last four years, I’m talking about 10 years.”
But the budget plan is highly controversial within the Democratic caucus and on a tight time frame. Senate Majority Leader Chuck Schumer set a Wednesday deadline for Democrats to agree on the broad outlines. Wyden insists that lawmakers from different wings of his party can come together to support a framework to move forward.
“He told us to be ready on Wednesday, and we will be,” said Wyden, who chairs the powerful Finance Committee and is also a member of the Budget Committee.
While health policy questions have generally taken a back seat in the recent debate over possible infrastructure and climate provisions in the package, health care will account for a large proportion of the cost.
Provisions would include steps to reduce prescription drug costs, to extend the generous federal subsidies for people buying insurance on the Affordable Care Act’s marketplaces, to provide coverage for low-income residents in states that did not expand their Medicaid programs and to massively increase health care options for older Americans.
Medicare could wind up with new programs to provide people with dental, vision and hearing care for the first time. The plan could realize President Joe Biden’s proposal to spend $400 billion so seniors would get home-based and community health care to live at home longer instead of moving to nursing homes.
Drug spending would be lowered partly by allowing Medicare to negotiate prices with pharmaceutical companies, thus saving the federal government and consumers money.
In raw dollars, the health care components of the plan Democrats announced last week could easily exceed the initial $940 billion cost estimates of the Affordable Care Act.
“I think it’s huge,” said Paul Ginsburg, a professor of health policy at the University of Southern California and senior fellow at the Brookings Institution.
“Many of these components of the plan on their own would be considered major policy accomplishments, maybe the highlight of a congressional session,” Ginsburg said. “This just multiplies it all, puts a number of these programs together, many of which on their own would be major, major accomplishments.”
Yet there remain major question marks, as well. For instance, some of the proposals tread into territory that has never been tried before, and policy experts aren’t sure how they will work. Ginsburg pointed to the dental, hearing and vision proposals for Medicare, noting there has been relatively little careful analysis related to including those benefits in Medicare.
“Nobody’s talked about that. We don’t know how to do it,” Ginsburg said. “It’s very different from medical insurance issues.”
The plan is moving through what’s known as the budget reconciliation process. First Congress approves budget instructions for bills that affect spending, revenue or debt. Under congressional rules, those bills can then advance on an expedited basis and pass in the Senate with a simple majority, with no threat of a filibuster.
Still, there is no room for error. With just 50 Democrats, Schumer will need every one of them — and Vice President Kamala Harris’ tie-breaking vote — if Republicans remain united against the package. In the House, Democrats also have a tiny majority and could likely lose only a handful of members as they try to pass the budget framework.
Wyden and others are trying to help lawmakers reach consensus on a plan. Moderate Democrats have raised concerns about how these initiatives would be paid for, and not all are keen on the drug price measures, including allowing Medicare to negotiate. Progressives, on the other hand, have called for higher spending to cover even more robust initiatives.
Wyden said he is shuttling between the Senate and the House and moderates and progressives, and he intends to stay glued to the Capitol to meet Schumer’s deadline.
He cautioned, though, that people should not expect to see every detail in whichever package is released this week. It will be an outline that tells committees to get to work on specifics. More details will come later.
“They will not be bills that people think of as legislation — Section 406-B and paragraph three and the like. This is a general framework. We’re kind of flushing this out,” Wyden said.
And even though he calls the overall effort ambitious, Wyden prefers to work out the details quietly, and make sure they are acceptable to his colleagues and the Senate parliamentarian, who determines if provisions of the bill qualify for the reconciliation process. “We’re putting in the time to do this right,” Wyden said, pointing to previous bills he has gotten passed. “That’s kind of my style — underpromise and lower the decibel level and focus on getting it done.”
That leaves ample wiggle room in terms of what would emerge, probably in the fall if Democrats can pass the budget reconciliation this summer. Lawmakers’ tinkering and negotiations over how much each item will cost, how long to fund it and how comprehensive a specific program will be could leave certain elements looking skimpy.
Wyden said Democrats may need to settle for very basic versions of these new programs. But the key, he added, is to get the programs started, and show people what is possible.
“The way we’re talking about it — and this is going to be the subject of many, many discussions — is we want to get the architecture of these changes, bold changes,” Wyden said.
Exactly how grand each change turns out to be in the short run may not be the most important thing, Wyden suggested.
“There’s going to be a discussion — this number of years, that number of years and the like,” he said. “But what’s really important, and we’ve talked about it — the Budget Committee’s talked about it — if we get the architecture right, we can start serving people and build on it.”
Wyden often talks about how he got into politics after spending nearly seven years running the Gray Panthers advocacy organization in Oregon and teaching gerontology. What he’s believed for a long time is that Medicare simply is not enough to meet people’s needs.
“I would say Medicare is a half a loaf,” Wyden said.
He wouldn’t quite promise a full baguette when the reconciliation process is done.
“This is going to make a significantly bigger set of health care options for seniors. I’m not going to start dividing loaves,” Wyden said.