Can Democrats Reconcile Their Health Policy Differences?

October 7, 2021

Image by Jessica Rodriguez Rivas licensed under CC BY-SA 4.0

Democratic lawmakers face tough compromises as they struggle to secure votes for their blockbuster spending bill and its sweeping health care provisions.

Scroll down to listen to the full episode, read the transcript, or find more resources.

If you want more deep dives into health policy research, check out our Research Corner and subscribe to our weekly newsletter.

News clip: What we are gonna talk about first is the mess on Capitol Hill. 

Dan Gorenstein: Democrats still have high hopes of passing some historic health reforms.

New federal powers to negotiate drug prices; dental, vision and hearing benefits for seniors; insurance coverage for millions more low-income Americans.

But deadlines… 

News clip: House Speaker Nancy Pelosi…

DG: …have come…

News clip: unable to bridge the gap between moderates and progressives in her party.

DG: and gone. 

News clip: Is the centerpiece of the president’s ambitious legislative agenda now on life support?

DG:  Democrats are stuck, unable to pass their $3.5 trillion spending bill with all its sweeping provisions.

News clip: Major pieces of President Biden’s domestic agenda are at risk this weekend.

President Biden: Whoa, whoa, whoa, whoa, whoa…doesn’t matter whether it’s in 6 minutes, 6 days or 6 weeks. We’re gonna get it done.

DG: Now lawmakers enter a new round of negotiations. 

Today, we head to the Hill, where Democrats face tough compromises and pressure to pare down the package’s price tag. 

From the studio at the Leonard Davis Institute at the University of Pennsylvania, I’m Dan Gorenstein, and this is Tradeoffs.


Alice Miranda Ollstein: I’m Alice Miranda Ollstein. I’m a health care reporter for Politico.

DG: Alice has been reporting from Capitol Hill for more than a decade. 

She’s spent a lot of hours there lately as Democrats look to avoid a Republican filibuster and pass their massive social spending package through a process called reconciliation.

DG: So Alice, what’s the most telling quote that you’ve heard about these negotiations so far from a Hill source? One that really sort of like captures the essence of what’s hard here. 

AMO: So, I’ve been talking a lot to Representative Peter Welch from Vermont. He’s very keyed in on all of these health care negotiations, and he said to me… 

Peter Welch: We’re trying to do something 10 times more complicated than the ACA in one-tenth of the time.

AMO: We’re trying to do something 10 times as complicated as the Affordable Care Act in one-tenth of the time.

DG: Why that quote, why does that quote, resonate so much with you?

AMO: Well, we all have seen how hard the Affordable Care Act was to pass and implement and defend. And for someone who was involved in that to say that this is 10 times more complicated really puts it into perspective. What they’re trying to do is so sweeping and they have no margin for error because they need it to pass the Senate where Democrats can’t lose a single vote and they need it to pass the House, where they can only lose a couple votes. And so any small handful of dissenters can completely derail everything, which we’re already seeing happen on a number of levels.

DG: Yeah, no, and that’s exactly the conversation that we’re going to get into with you. And it’s really exciting that you’re here again. Thanks for joining us. As you know, Senators Manchin and Sinema, moderate Democrats, have said that they will not vote for reconciliation unless it comes in closer to $1.5 to $2 trillion. That’s way shy of the bill’s original $3.5 trillion price tag. Specific policies aside, Alice, what potential avenues are Democrats actually considering to get closer to this lower price point?

AMO: So there’s a big debate going on right now about whether it’s better for Democrats to do fewer programs in a fuller, more permanent way, or to try to do a slimmed down version of everything on their agenda.

But some of the things they’re considering to bring down the cost are for instance, you know, phasing in a program very slowly over several years. They’re also talking about only authorizing some programs for a few years and then having them expire. There’s talk of basically limiting programs to only give benefits to people below a certain income. So, you know, these are ways to chip away at the cost, but if they’re forced to cut it enough there’s no amount of snipping here and trimming there that’ll get you that’ll make the math work. 

DG: And Alice, it seems like there’s this real fault line between Medicare or Medicaid. And the question is: Should you prioritize insuring the 2 million or so low-income Americans, including many people of color, who are living in the dozen states that have yet to expand Medicaid under the Affordable Care Act? Or should you prioritize giving dental, vision and hearing benefits to tens of millions of seniors on Medicare? Where does this debate stand?

AMO: So It’s gotten pretty heated up on the Hill. You have just so many different factors playing into this. So you have lawmakers pointing to the racial demographics of the different populations that would be served and saying that it’s incumbent for achieving racial justice that Democrats prioritize the Medicaid population. At the same time, there is, you know, also a bit of resentment on Capitol Hill. You have people who are from the states that did expand Medicaid voluntarily saying, wait a minute, we did the right things, we’ve been spending money on this all along. Why should these other states, you know, be rewarded for holding out and denying their populations health care? 

Senator Warnock: If you believe that health care is a human right, you don’t believe it’s a human right in just 38 states. Can you imagine social security in 38 states? Medicare in 38 states? It’s unimaginable. 

AMO: On the Medicare benefits side, you know, giving more benefits to seniors is a political winner and it’s also filling a deep need. You know, millions of seniors don’t have access to those services. Dental care is very expensive in the private markets. And this is something that could benefit a lot of people,

Senator Sanders: And I can tell you in Vermont and all over this country you’ve got senior citizens whose teeth are rotting in their mouth, older people who can’t talk to their grandchildren and people who can’t read a newspaper because they can’t afford glasses.

AMO: You know, Democrats keep saying, we don’t want to pit these programs and these populations against one another, but when you have limited resources, that’s inevitably going to happen.

DG: With moderate Democrats on Capitol Hill demanding a cheaper bill, that’s exactly what is happening…pitting programs and people against each other. 

When we come back, we’ll talk drug prices, home health care and the Democrats’ odds of reconciling their policy differences.


DG: Welcome back. 

We’re talking today with Politico’s Alice Miranda Ollstein, who’s been reporting from the Hill on Democrats’ negotiations over the health care provisions of their blockbuster spending bill.

The House has yet to vote on the package, which began with a $3.5 trillion price tag, and Democrats are struggling to reach consensus over its size and scope.

So Alice, another huge potential reform on the table: giving the federal government the power to negotiate directly with drugmakers over the prices that Medicare pays for some prescription drugs. Democrats were really banking on this piece to generate savings, something like $500 billion over the next decade, and that money would go to fund other priorities. 

It sounds like there are members in both chambers who oppose this. At its root, what are they actually worried about here? 

AMO: Basically, these are folks who are echoing the arguments from the pharmaceutical industry itself saying that if they were forced to negotiate prices with the government, they would make less in profit and thus would have less to invest in coming up with new drugs, new cures and bringing them to market. And they point to the Congressional Budget Office, which analyzed this question and said that yes, a few fewer drugs would come to market over several years as a result of this. 

On the other side, progressives argue that the drugs that are coming to market don’t do a lot of good if people can’t afford to take them. 

DG: Right, that CBO report said the US would see about 30 fewer new drugs over the next decade, and it’s not clear if those drugs would be more like new cures or more like copycats. 

So, Alice, what role, if any, do you think campaign contributions from big pharma play and/or just the fact that some members feel like part of their job is to represent these companies that are in their districts?

AMO: That’s absolutely a factor right now. I think that it is often overly simplistic to draw a straight line between, you know, so-and-so got X amount of dollars from X industry and then immediately voted like this. But many of them, you know, not only are they the recipients of these political donations, but also they represent districts where the pharmaceutical industry represents a lot of jobs. So there’s absolutely a connection there. I will say there has been a lot of spending on the other side, on the part of advocacy groups to run ads, to pressure them, to change their minds. So this is all a very active battle playing out right now.

DG: Another health provision that’s already shrunk a lot is money for home and community-based services for seniors and people with disabilities. President Biden originally wanted $400 billion for those services. But the most recent version of the House bill I think has it at less than half, like around $190 billion. Do you expect that piece to keep shrinking, maybe even disappear? Where’s the debate on this particular provision right now, Alice?

AMO: This is an important provision to a lot of people on Capitol Hill. I went to a rally for it recently with home care workers and all of the top brass came. Pelosi was there, Schumer was there….but it’s not going to get anywhere close to the $400 billion that President Biden wanted. So right now, what folks on the Hill are pushing for is to say, okay, we need it to be at least $200 or 250 billion because that would at least allow us to clear the waitlist for care. There are more than 800,000 people currently on a waitlist to have home care under Medicaid. Obviously, they want to do a lot more. They want to raise wages for those workers, et cetera. But they are now saying at the bare minimum, this is what we need.

DG: What’s the mood on Capitol Hill? If the two poles are a sense of momentum and opportunity and the other is doom and gloom, where’s that needle?

AMO: Oh, it has been swinging around, let me tell you. Some days, Democrats seem, you know, honestly, a bit panicked, saying, “If we can’t get this done, if we can’t deliver real meaningful health care improvements that we can campaign on next year, we are dead in the water.” And then another day they’ll say, you know, “Negotiations are going well, we’re going to get this done. These deadlines are arbitrary. If it takes a little bit longer, that’s fine.” So I guess ask again at the end of the month when they’re at their new arbitrary deadline and see how they feel then.

DG: [Laughs] Hilarious. Final question, influenced by a senior producer, Leslie Walker, who always is thinking about snacks…do you have a particular beverage or snack that is fueling you in these long hours on Capitol Hill? 

AMO: I mean coffee all day, every day, of course. Big coffee addict. Yes. I’ve been enjoying cold brew all summer. Although now that we are getting into the colder temperatures, I might, you know, be ready for my annual switch to hot coffee. Not sure we’re there yet.  

DG: Maybe, maybe a little pumpkin spice sort of flavor?

AMO: Oh no, I’m a purist. Just black coffee for me. 

DG: Very good. Alice Miranda Ollstein, thank you so much for taking the time to talk to us on Tradeoffs. Really, really.appreciate your time.

AMO: Thank you so much, really enjoyed it. 

DG: I’m Dan Gorenstein and this is Tradeoffs.

Want more Tradeoffs? Sign up for our weekly newsletter!

Episode Resources

Additional Reporting on Reconciliation and Democrats’ Health Care Priorities:

Agonizing choices as Dems debate shrinking health care pie (Ricardo Alonso-Zaldivar, Associated Press, 9/29/2021)

Top Democrats want to expand health care access. But they need to find a way to do it. (Paul Kane, Washington Post, 9/25/2021)

Democrats’ Stumble on Drug Prices Shows Power of Industry (Margot Sanger-Katz, New York Times, 9/15/2021)

Unpacking The Coverage Provisions In The House’s Build Back Better Act (Katie Keith, Health Affairs, 9/12/2021)

Biden’s $400 Billion Bet on Caring for Older and Disabled Americans at Home (Ryan Levi, Tradeoffs, 4/8/2021)

Research on Potential Reconciliation Health Care Provisions:

Options for containing the cost of a new Medicare dental, hearing, and vision benefit (Matthew Fiedler, Brookings, 9/10/2021)

The Coverage and Cost Effects of Key Health Insurance Reforms Being Considered by Congress (Jessica S. Banthin, Michael Simpson and Andrew Green; Commonwealth Fund; 9/9/2021)

Filling the Coverage Gap: Policy Options and Considerations (Robin Rudowitz, Rachel Garfield and Larry Levitt; Kaiser Family Foundation; 4/22/2021)

Budgetary Effects of H.R. 3, the Elijah E. Cummings Lower Drug Costs Now Act (Congressional Budget Office, 12/10/2019)

Policy Options for Improving Dental Coverage for People on Medicare (Meredith Freed, Lisa Potetz, Gretchen Jacobson and Tricia Neuman; Kaiser Family Foundation; 9/18/2019)

Episode Credits


Alice Miranda Ollstein, health care reporter, POLITICO

The Tradeoffs theme song was composed by Ty Citerman, with additional music this episode by Blue Dot Sessions. Peter Welch audio provided by Alice Miranda Ollstein.

This episode was produced by Leslie Walker and mixed by Andrew Parrella.

Additional thanks to:

The Tradeoffs Advisory Board and our stellar staff!