There has been an obvious, deep-seated tension among a few like-minded Democrats that became public in recent weeks. It’s about two health care initiatives in President Joe Biden’s “Build Back Better” legislation ― and the likelihood that there won’t be enough money to fully fund both.

One refers to a proposal that insures as many as 2.2 million AmericansLiving below or above the poverty level in one dozen states, most of them Southern. This group is eligible to receive coverage under an expanded version MedicaidThanks to additional federal funding, this government program is now available for low-income people. Affordable Care Actavailable. However, the GOP leaders in those states are not available. refused to take the money

Now Democrats want to have the federal government fill this “Medicaid gap”Somehow covering these people directlyHouse Majority Whip is the most visible advocate for this approach. James Clyburn (D-S.C.), who has promoted it as a way both to reach some of America’s most vulnerable people and to address long-standing racial disparities in health status.

“This is a moral issue for all Americans,” Clyburn wrote in an op-ed for Black Press USAThis week. “I don’t want this President and this Congress to ignore existing racial inequities.”

Other options include boosting MedicareBy adding, you can get the federal senior insurance program. vision, hearing and dental benefitsThis is a. These features are not available to seniors and cause additional costs. This puts it at an advantage over privately-run Medicare Advantage plans, which have been attracting more enrollments.

Sen. Joe Manchin (D-W.Va.), has tried to restrict the Build back Better bill in ways that would make leaders scale back important proposals, and most likely eliminate many.
Bill Clark via Getty Images

Sen. Bernie Sanders (I-Vt.), partly because he sees it as a step toward his ultimate goal: creating a “Medicare for All” program that would seamlessly and generously cover people of all ages. But he has also emphasized the chance to help seniors who currently can’t pay for their dental care. Tooth removal is a common procedure for many people who live with pain. Others end up suffering from more severe medical conditions.

“This, to me, is non-negotiable,” Sanders said at a press conference this week.

Sanders wasn’t directly addressing Clyburn with those remarks, just as Clyburn wasn’t addressing Sanders. They are close friends who have been working together for years to ensure that health care is a fundamental human right.

However, the funding of both programs must be fully financed. shore upThe Affordable Care Act would have a cost. hundreds of billions of dollarsOver the following decade. Even if we consider the $3.5 Trillion legislation Democratic leaders had originally planned, it would still seem a significant amount. $1.5 trillionThis is why Sens are still in prison. Joe Manchin(D.W.Va. Kyrsten Sinema(D-Ariz.), have been very demanding.

Biden’s dilemmas and Democratic leaders over funding health care programs are similar to the ones that they have to face when they consider what they will do about other Build Back better initiatives like those they would be underwriting. early childhood programs housing assistance alternative energyThis is. Do you prefer to invest in programs that are at higher levels of funding or programs that are at lower levels? To invest in universal programs, which might be more simple and directly touch more people with scarce funds.

Because every Build Back better proposal is supported by strong political logic and has strong supporters, there aren’t easy answers. Every one of them addresses an actual need.

A Glimpse Into The ‘Medicaid Gap’

For Clyburn, and many of his allies in Congress, filling the “Medicaid gap” isn’t simply a matter of principle. It’s also a way to help constituents.

It is rough 13% of South Carolina’s non-elderly population had no health insurance as of 2019, according to the U.S. Census Bureau. That figure was several points higher than the national average, and it probably underestimated the number of uninsured in Clyburn’s district, which includes some of Columbia and Charleston’s poorest neighborhoods.

StudiesOver the years, documentedThe hardshipsPeople face many challenges when they don’t have insurance. Stuart HamiltonColumbia-based Columbia Pediatrician, founded by Dr.. Eau Care Cooperative Health system, has seen them firsthand ― often when treating people who are in the advanced Because they didn’t receive basic healthcare, some may be in the final stages of their disease.

“Heart attacks go up, strokes really go up, especially in the near-elderly with untreated blood pressure,” said Hamilton, who retired from active practice three years ago. “And it’s all preventable.”

Lack of insurance also affects people’s finances, by saddling the uninsured with crushing medical bills or making it difficult for them to hold down jobs ― as Jeff Yungman, a staff attorney with a Charleston-based homeless organization called One80PlaceIn an interview, he explained.

“So many of the people we see here in the shelter, it’s not because of drug abuse or mental illness,” he said. “It’s because they haven’t had appropriate health care and they have health issues that have forced them not to be able to work and not to be able to pay their rent.”

“Heart attacks go up, strokes really go up, especially in the near-elderly with untreated blood pressure. And it’s all preventable.”

Stuart Hamilton (a Columbian pediatrician) on the topic of people who live in the “Medicaid Gap”

Many of these individuals are entitled to disability benefits. In reality, Yungman says, many struggle to get those payments because they don’t have the documented medical history that applications require.

“If you say you have a bad back, you have to show that you’ve been seeing a doctor for a bad back,” Yungman said. “And a very high percentage of these folks … they can’t afford a doctor, they can’t afford to go to the clinics, they can’t afford to buy the medication. So we’re hamstrung trying to get them approved for benefits.”

It’s not hard to imagine what a difference Medicaid would make for such people.

Researchers have repeatedly foundThe Medicaid recipients are generally healthier and more financially stable than people without insurance. One especially definitive paper found that Medicaid expansion saved one life for every 200 to 300 adults who got coverage ― which means, in theory, that bringing expanded Medicaid to states that don’t have it could save a few thousand lives every year

“It’s hard to imagine a health policy that would do more good dollar-for-dollar than ensuring people below the poverty line can go to the doctor without worrying about how they’re going to pay for it,” Matthew FiedlerHuffPost spoke with a USC-Brookings Schaeffer Initiative for Health Policy Fellow, Dr..

There are two causes, and there are two iconic champions

Strengthening Medicaid’s life-saving potential, plus the allure of extra federal funding, has been enough to entice GOP leaders in states like Arizona and Michigan to expand the program. However, South Carolina’s state officials are resisting the expansion of the program to their great disappointment. Sue BerkowitzDirector of the South Carolina Appleseed Legal Justice Center

“We are constantly hearing from people who reach out to our office and say, ‘I can’t get health care, what do I do, I applied for Medicaid and I got turned down,’” Berkowitz said.

But if the prospects for action from officials in states like South Carolina haven’t changed, the possibility of federal action has ― and not simply because Democrats finally control both the presidency and Congress for the first time in a decade. Their Senate majority is due to Georgia’s wins. Jon Ossoff and Raphael WarnockBoth of them made health careTheir campaigns make it a central focus. Warnock has become the Senate’s most vocal advocate for filling the Medicaid gap.

House Majority Whip James Clyburn (D-S.C.) has said getting insurance coverage to low-income uninsured people in non-expansion states should be a top priority, especially given the potential to address racial inequities.
James Clyburn, House Majority Whip (D.S.C.), has stated that getting low-income individuals in non-expansion countries insured should be the top priority. This is especially in light of the possibility to reduce racial disparities.
SAUL LOEB via Getty Images

However, the House is the true driving force. And Clyburn is as responsible for that as anybody, casting a Medicaid gap plan as a way to help poor people gain wealth, to shore up the finances of struggling rural hospitals and ― especially ― to promote racial equity. Nearly 60% of the nearly 2.2 million people without insurance who are eligible for Medicaid under expanded states, estimates the Center on Budget and Policy Priorities

Clyburn’s moral authority ― as a longtime civil rights advocate and the second ever African-American to serve as whip ― goes a long way toward explaining how the Medicaid gap is still in the policy mix for Build Back Better. So does Clyburn’s clout with the White House, where everybody remembers the pivotal role his endorsement played in helping Biden win his party’s South Carolina 2020 primaryAnd eventually the Democratic nomination.

Sanders, a progressive champion and organizer who is respected for his persistence has made it possible for Washington to accept his ideas. He also has his own sway with the White House ― in part, again, because of his role in the 2020 primaries, when he passed up opportunities to beat up on Biden as too moderate. The rest of the story will follow. Sanders worked with BidenOn a joint agendaIt was. It didn’t insist upon Medicare for All, but included several proposalsMedicare related.

The most well-known of these, a proposal to lower the eligibility age, has basically fallen out of the legislative conversation ― in part because lawmakers struggled to deal with politically fraught topics like how to avoid undermining existing employer insurance for people who like it. Sanders and his allies in the Senate, including Rep. Pramila Jayapal(D-Wash.), are pushing harder to add benefits, particularly dental.

“Last time I checked, your teeth are part of your body — and should absolutely be covered by Medicare,” Jayapal tweetedIn late August. “Let’s get this done.”

Dental Health, Politics and Teeth

Months ago, experts and advocates warned of the difficulties in funding Medicare and Medicaid gaps plans due to fiscal constraints. And as the possibility has become more real, Clyburn has presented the trade-offs in increasingly stark terms ― seizing on the fact that a Medicare dental benefit would cover all recipients, even wealthy ones, and warning of its racial implications.

“What is the life expectancy of Black people compared to white people?” he told Axios’ Caitlin OwensThis was earlier in the month. “I could make the argument all day that expanding Medicare at the expense of Medicaid is a racial issue, because Black people do not live as long as white people … If we took care of Medicaid, maybe Black people would live longer.”

Majority of Medicare dental supporters have avoided responding publicly to such comments. Nor have they downplayed the importance of reaching people in the Medicaid gap ― partly because they, too, feel strongly about insuring low-income people in places like South Carolina.

They also bristle at what they consider to be a lower value of the dental benefits, considering the many problems associated with elderly dental care.

According to statistics from The, almost half of Medicare beneficiaries do not have dental coverage. Henry J. Kaiser Family FoundationThis is even more for Medicare beneficiaries of color (68%) or Hispanic (61%). Co-pays are common for policyholders.

Sen. Bernie Sanders (I-Vt.) has pushed hard to add a dental benefit to Medicare, noting the large number of seniors who currently lack dental insurance.
Senator Bernie Sanders (I-Vt.), has worked hard for a dental benefit in Medicare. He noted the high number of senior citizens without dental insurance.
Win McNamee via Getty Images

Seniors who are less fortunate end up being more vulnerable. going without dental careBecause an infection in a tooth may spread to other areas of the body via bloodstream, it is possible for problems to become severe and require extractions. This happens all across the nation, including in South Carolina.

“We definitely have quite a few people from an older population, people with Medicare but no dental insurance, who come in,” said Dallaslee Ruquet-Emrich, senior manager of health services at East Cooper Community OutreachThe East Charleston Social Services Organization is a service organization providing social services to low-income residents. “A lot of times they didn’t know they had such serious problems, until it’s too late.”

“It’s pretty woeful, the discrepancy between what older people need and what they can afford,” said Mark Barry, who manages the East Cooper dental clinic. “You see people at the end of the game … they have periodontal disease or they have abscess teeth or they have broken-down teeth that need to be taken out. And so many of those things could have been prevented.”

It is a fact that both most Democrats and advocates who are working in health care would rather take both the steps to fill in gaps for Medicare and Medicaid. Eliot FishmanHuffPost recently heard from a senior Director of Health Policy at Families USA.

“The same low-income communities where women are dying or getting hospitalized after childbirth, and children are losing Medicaid due to eligibility paperwork, are the communities where adults have no access to health care in non-expansion states,” Fishman said. “And they are the same communities where a third of seniors are losing all of their natural teeth.”

That’s one reason Democratic leaders have discussed downsizing the initiatives somehow, so there would be enough funding in Build Back Better for both. It could also mean that Medicaid expansion is funded for just a few more years, or that the dental benefit will be reduced (by for instance, increasing premiums, leaving greater out-of pocket costs, and keeping it limited to prevention, at least during the initial years).

“A lot of times they didn’t know they had such serious problems, until it’s too late.”

Dallaslee Ruquet Emrich, East Cooper Community Outreach on Charleston’s dental issues for the elderly.

Some policy changes could also make it easier. Fiedler from USC-Brookings proposed a change to the dental policy formulaThis could significantly reduce the cost of your product without any adverse effects.

These are exactly the options Democrats will be considering as they try to figure out how they can fund Build Back better programs, even if there is a lot of pressure to cut back. Every option is not without its drawbacks.

“Sunsetting” the Medicaid expansion after, say, five years could mean the program’s renewal would depend on approval from a future Republican Congress or Republican president ― neither of which feels like it could be counted upon, given recent history. The reduction of the dental benefit may lead to seniors feeling frustrated or underwhelmed by their coverage.

Building Back Better: The Big Questions

This is the root of all that Build Back Better examines: Is it worth trying to fund many different options instead of focusing only on one or two and making them work well?

There’s an argument that spreading the money too thinly will create a bunch of unsatisfactory initiatives that simply fuel cynicism about government, without actually making a big impact on any problems. There’s also a counterargument that change in the U.S. is always incremental ― and that scaling up existing initiatives is easier than launching new ones.

Politics is a big consideration, too, and that’s by necessity. Democratic leaders are determined to make programs that can withstand future and almost unavoidable attempts at defunding. repeal by Republicans ― and, ideally, restore the faith in the public sectorOver the last 20 years, that trend has been declining. Democrats want something that voters can see in 2022, 2024 to prove they can govern.

But figuring out which policies would best accomplish those goals is complex, as The Washington Post’s Paul Waldman and Greg SargentRecently, this was noted. A dental benefit for Medicare would reach many more people, targeting benefits at older Americans who vote in high numbers ― and many of whom might not otherwise vote Democratic. Filling the Medicaid gap would matter in states where Democrats have struggled, and let the party’s newly elected Georgia senators deliver on a signature promise.

This assumes policies are as effective as their advocates wish. In the best circumstances, creating new Medicare benefits would not be easy. Neither would establishing a federal substitute for Medicaid. Legislators may attempt to cut costs by creating these policies cheaply, but this could ultimately lead to program failure.

There is one thing certain about this: the choices would be a lot easier if Build Back Better had more funding ― which is precisely what Manchin and Sinema are arguing against.

They object to the legislative policies. The two also claim that all of these programs are more expensive than what the government and, by extension, the taxpayers can afford.

They are reasonable arguments and many Americans support them. Inaction may have its costs, whether it’s for basic healthcare for the poor or dental care for elderly people.


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