One-point-five trillion dollars is a lot of money. But by reportedly saying that’s the most he is willing to have the federal government spend on a package of social, climate and infrastructure programs, Sen. Joe Manchin of West Virginia is forcing his fellow Democrats to make choices they avoid in their $3.5 trillion plan. Some of the most difficult for them involve health care.
House Speaker Nancy Pelosi’s priority is strengthening the Affordable Care Act, also known as Obamacare. Subsidies for it were expanded earlier this year, but only on a temporary basis. She wants to make them permanent. Sen. Bernie Sanders, the socialist Democrat from Vermont and chairman of the Senate Budget Committee, is more eager to expand Medicare. When Senate Democrats introduced their budget resolution last month, Sanders touted its Medicare provisions and didn’t mention Pelosi’s health-care priorities. He has criticized the House Democrats’ budget bill for offering inadequate dental benefits under Medicare.
It’s a split that highlights two different ways of thinking about the progressive project. The question for Democrats is which matters more: advancing the goal of a government-directed health-care system or giving more help to Americans with low incomes? Or, to put it another way: socialism or redistribution?
The Medicare expansion that the left wing of the Democratic Party favors would offer more federal benefits for everyone: rich, poor and in-between. Americans aged 60 to 64 would for the first time be eligible for Medicare. As a group they have a higher net worth than the national average. They are also the age group of working adults most likely to have private health insurance.
Dental insurance was uncommon when Medicare began in the 1960s, and the traditional program still does not offer it. Adding dental benefits has some appeal as a way of updating it. But 43% of seniors have chosen a private Medicare Advantage plan, and 89% of them include dental benefits. Full implementation of a new dental benefit in the traditional program would cost $60 billion a year. Chris Pope, a health-policy scholar at the conservative Manhattan Institute, points out that it’s low-income working-age adults who have the worst access to dental care — and Medicaid, the program that covers them and their children, spends only $14 billion a year on such care.
If your objective is to provide help to those who need it most, expanding Medicare is an odd way to go about it; boosting dental benefits under Medicaid would be one of many superior alternatives. Sanders’ plan makes more sense as a way of furthering the goal of Medicare for All, something near and dear to the hearts of Sanders-style Democrats. Putting people between 60 and 64 in Medicare would extend its reach, give it more power over health markets and enlarge its political constituency. Adding dental benefits would make the traditional program more attractive than Medicare Advantage, which Sanders wants to abolish (too capitalistic). Extending Medicare might be more attractive to voters if it includes universal dental coverage, something that not even Canada, with its single-payer health system, provides.
Showering money on people who don’t need it is a feature of these proposals rather than an unfortunate side-effect. The point is to build a new system that includes everyone and that, eventually, no one will be able to escape. It’s a line of thinking that dovetails nicely with a critique of Obamacare that has always had currency within the political left: It was too complicated, too market-oriented, and too politically damaging, and expanding popular entitlement programs would have been a wiser course. Rep. Pramila Jayapal, the Washington State Democrat who chairs the House Progressive Caucus, advocates Medicare expansion in these terms: “We need to recognize that while the ACA did many good things, just providing subsidies to private insurance is not the way to move forward.”
There is something to that critique. One study has found that ACA enrollees reap fewer than 50 cents of every dollar the government spends on subsidizing them. Spending more money on the program without reforming it, as the Democrats propose to do and Pelosi has at the top of her health-care agenda, may accomplish less for the public good than they think. These proposals are, however, at least better targeted toward people who need public assistance than the Medicare-expansion ideas are.
So far, debate over these different approaches has been muffled. Asked whether expanding Medicare would mean the ACA got “short shrift,” Pelosi recently replied: “I think both will be present. That’s not a problem.” But to govern is to choose — and Manchin seems to be insisting on it.