Locked Out of the Sausage Factory: Will Medicare Expansion Survive the Budget Reconciliation Debates?

The Build Back Better Bill started out as a great, sprawling piece of legislation comprising the most ambitious set of social programs since the Johnson Administration. It is an attempt to actually implement a major portion of President Joe Biden's campaign program. Such an attempt is itself a rarity in American politics where the usual practice is to relegate the presidential campaign program to the archives long before inauguration day. Even more rare is the fact that the Bill keeps the promise of the compromise reached between the winning Biden faction and the losing faction supporting Sen. Bernie Sanders at last year's Democratic Convention.

That such an expansive legislative package is even being considered is a tribute to a vigorous social democratic grouping within the House Democratic caucus with strong ties to external social movements. Energized by the popular support shown for the two Sanders presidential campaigns and the emergence of a growing "squad" of insurgent Representatives and tempered by the astute leadership of people like Representative Pramila Jayapal, who chairs the Congressional Progressive Caucus, for the first time since the 1970s this grouping has begun to operate in a strategic and disciplined fashion.

This is usually the point when progressive lawmakers fold because, for them, "something is always better than nothing" while the other side is perfectly willing to leave nothing but scorched earth.

But the fact that the Bill appears to be floundering is a reminder of the persistence of the forms of neoliberalism that exercised near hegemonic control over the policies and practices of the Democratic Party from the 1990s through the Obama administration (coupled, of course, with a generous amount of shameless corporate hucksterism that would make the likes of Billy Tauzin whistle in admiration). And overshadowing every calculation is the reality of a united Republican Party in thrall to the right-wing authoritarianism of Trumpism and following the scorched earth playbook perfected by Senate Minority Leader Mitch McConnell and his cronies. Under these circumstances, it would be folly to hope for even one Republican vote for any issue of substance.

The wild card in all of this has been the group of so-called "pragmatists" clustered around Biden. While still broadly supportive of the neoliberal approach, this group appears to have come to the conclusion that neoliberal "there-is-no-alternative" policymaking has created a vacuum that has nurtured the growth of right-wing authoritarianism. They are eager to enact some real improvements for working class Americans prior to the 2022 midterms. Until recently, they have sided with the Progressive Caucus in holding the line around a robust version of the Build Back Better Bill.

Over the past few days, however, President Biden has stepped in and let it be known that the time has come to cut a deal on a sharply reduced version. That's a bad sign as it makes the case for any deal that's better than what we have, which is, of course, any deal. We are now beginning to see some advocates for the Bill negotiating with themselves: reducing the package and adopting faulty designs like means-testing, limited benefits, and privatized administration without any indication that this will generate support from opponents of the Bill.

Build Back Better and Medicare for All

The original Medicare expansion proposals in the Build Back Better Bill lowered the age of Medicare eligibility to 60, capped out-of-pocket payments on traditional Medicare and added robust dental, vision, and hearing benefits to traditional Medicare. Most Medicare for All advocates supported these provisions because they would strengthen the social insurance model of healthcare as a public good, bring in new constituencies with an interest in moving forward to Medicare for All and undermine the power of the medical industrial complex while providing immediate benefits to millions of Americans. Importantly, they would also undercut the growth of private "Medicare Advantage" plans, which have been slowly privatizing Medicare.

Medicare for All advocates are also generally supportive of the proposals to expand Medicaid coverage to the 12 states that continue to refuse to accept federal funds to expand Medicaid coverage under the ACA to their own working poor residents. And the advocates tend to oppose the push by Pelosi and other neoliberal Democrats to increase subsidies for the purchase of private insurance plans under the provisions of the ACA.

If the Pharma lobby scuttles price reform, voters may rightly ask, what's the point of electing Democrats?

The lynchpin of all the programs related to Medicare and healthcare expansion has been the provisions empowering the feds to negotiate drug prices. The savings generated by those negotiations would fund most of the proposed expanded programs. Drug price negotiation would also provide a huge benefit in its own right by making drugs more affordable at least for Medicare participants and other beneficiaries of federal healthcare programs (under the obscure rules governing budget reconciliation legislation, it is unclear whether those savings could also be made to apply to private insurance plans) while reducing the power of Big Pharma.

It now appears that lowering the eligibility age and capping out-of-pocket costs are "off the table." Negotiators are focusing on the dental/hearing/vision improvements, which may be severely limited. Biden has floated the idea of providing Medicare recipients with an annual $800 medical debit card as a "transitional benefit." Meanwhile, Big Pharma has pulled out all the stops and the prospects for real drug negotiation authority are narrowing. It is quite possible that the Bill will end up with merely symbolic negotiating authority with minimal capacity to negotiate fair prices and achieve real savings.

The Democrats have run on prescription price reform since 2006 and it enjoys 80% public support. If the Pharma lobby scuttles price reform, voters may rightly ask, what's the point of electing Democrats? Such a defeat would remove a crucial piece of the social insurance structure central to long-term prospects for real healthcare reform on the Medicare for All model. And because legislative leaders have insisted that healthcare expansions be paid for separately, any reduction in anticipated savings from drug price negotiations increases the likelihood that the various other reforms will be pitted against each other.

Where Do We Go From Here?

End games are tough and we are no strangers to the art of compromise. But any compromise worth its salt must be based on real principles and a strategic sensibility. At this point, we must ask ourselves: Where will our movement be at the end of all of this? Will the Bill generate momentum to move us forward towards healthcare justice or will it demoralize and fragment our movement?

This means that we must do everything in our power to oppose changes to the Bill that would strengthen the stranglehold of private insurance and big pharma over healthcare policy, especially those that would accelerate the privatization of actually existing Medicare. Equally important, we must resist efforts to divide and conquer by, for example, pitting advocates for expanded benefits for Medicare recipients against advocates for expanded Medicaid coverage that would assist predominantly people of color in southern states.

Jayapal and the Progressive Caucus have accomplished much by holding together dozens of Representatives who have pledged not to vote for the Infrastructure Bill until a full Build Back Better Bill that they can support is on the floor.

But perhaps it's time to jettison the constraints imposed by the separation of the bi-partisan Infrastructure Bill from the Build Back Better Bill. Instead, combine the social insurance versions of a meaningful Medicare expansion, family leave, childcare, prescription drug price reform, and climate policy with the infrastructure elements in a reconciliation bill and put it on the floor for a vote. For good measure, include raising the debt ceiling limit as Senator Manchin proposes. This version would be a true compromise--everybody gets their top priorities and must accept the priorities of others.

Where will our movement be at the end of all of this?

The bipartisanship is a facade anyway as the GOP opposes everything else. An omnibus reconciliation bill would make the moderate Democrats choose between their corporate patrons and popular programs that have a chance of motivating voters in 2022.

This is usually the point when progressive lawmakers fold because, for them, "something is always better than nothing" while the other side is perfectly willing to leave nothing but scorched earth. But progressives would be much better served over the long term if they continue to assert the extraordinary unity and discipline that has taken them this far. If the Build Back Better Bill is gutted, they should vote down the Infrastructure Bill and hold out for a program that meets the needs of most voters.

One final note: A big reason that we are in this fix is because we have not yet built the kind of popular movement strong enough to back up the resolve of our Progressive Caucus stalwarts in the House. All too often, advocates and organizers get infatuated with the inside game when their real job is to build the kind of mass movement that can hold politicians accountable to real principles and real people. The lack of popular engagement in supporting all of the many provisions of the Bill that would make life better for working class Americans is stunning and certainly has been noticed by our corporate opponents.

They say that legislation is like sausage-making. The healthcare profiteers and their army of lobbyists all have their hands in the process together with all of the other monied interests with a stake in the Bill. Meanwhile the people whose lives will be most affected by the legislation have been locked out. And, as any trade unionist will tell you, the only way to break a lockout is to maintain unity, bring in new allies and shine the light of day on those who would deprive people of their livelihoods in order to keep the profits flowing.