One of Obamacare’s early political problems was that it took just about forever to implement. The subsidized insurance coverage? Protections for patients with preexisting conditions? Its Medicaid expansion? Americans generally didn’t get to enjoy them until 2014, almost four years after the Affordable Care Act passed.
There were some understandable reasons for the long lead-up. The government needed time to create healthcare.gov, for instance (though it didn’t exactly ace the job). But parts of the program, like the Medicaid expansion, probably could have snapped into place quicker. And as a result of the delays, voters mostly had to imagine how the law would work, all while Republicans spent President Barack Obama’s first term demonizing it.
I bring this up because, at the moment, Democrats are once more debating how to fix up the health care system—not to mention the wider safety net—as part of the massive reconciliation bill they are now pulling together in the House. And once again, some members of the party seem intent on slow-rolling the reforms, risking a repeat of the party’s stumbles with Obamacare.
Take this example: At the moment, one of Democrats’ top health care priorities is to add dental, vision, and hearing benefits to Medicare. It’s a reasonable policy move and even better politics. According to the Kaiser Family Foundation, almost half of Medicare beneficiaries don’t have any sort of dental coverage right now—privately managed Medicare Advantage plans often include it, but the traditional, fee-for-service Medicare program does not—and the elderly can get stuck with huge bills taking care of their aging teeth. Seniors also vote, and it’s not lost on anybody that helping them afford some new glasses and crowns for their molars might win Democrats points during the next couple of elections.
Except under the plan now officially under consideration in the House—which the Ways and Means Committee is set to mark up on Thursday—the dental benefits wouldn’t kick in until 2028. Vision would start in 2022, and hearing in 2023, but seniors wouldn’t get help with their tooth care until Joe Biden’s potential last year in office.
Now—putting aside for a moment that expanding seniors’ care is a worthy policy goal to begin with—if you’re going to bribe a bunch of voters with the promise of affordable dentistry, telling them that it’s seven years away, when they might not be alive to take advantage of it, doesn’t seem like the soundest approach. So why the delay?
There seem to be two reasons, as the Washington Post reports. The first is that lawmakers believe it could take a good while to actually design the benefit. The second is that dental benefits are potentially expensive—the Congressional Budget Office has projected that adding them to Medicare could cost $238 billion over a decade—and pushing off their start date could shave down the reconciliation bill’s 10-year cost at a moment that moderates are signaling they want to spend far, far less than the $3.5 trillion Democrats have made room for.
Senate Democrats would apparently like to get these benefits to seniors sooner: They’re considering a plan that would send Medicare beneficiaries a voucher for dental, hearing, and vision benefits, maybe in the form of a debit card, while getting the insurance benefit up and running. It’s unclear whether the House or Senate Democrats’ approach will prevail, though only one has the advantage of immediately reminding voters that the party just did them a major solid.
A somewhat similar issue seems to be cropping up when it comes to child care benefits, another major pillar of the Democrats’ legislative agenda. There, the House is considering a plan that would cover the cost of care for families on a sliding scale, capping it at 7 percent of a family’s income for those making up to double the state’s median income. But again, the benefits for middle and higher earners would be phased in over six years, partly because of budget issues. “We have to keep it under a certain cost,” Rep. Bobby Scott, chair of House Committee on Education and Labor, said. “You are limited by the top line.”
Scott isn’t wrong. Democrats are trying to get the most out of this reconciliation bill while staying under a somewhat arbitrary 10-year budget number they’ve set for themselves. One way to do that is to make some permanent spending programs start a bit later in order to make room for the big, one-time cost of the climate legislation they also want in the package. Democrats are essentially slaves to the CBO here, which leads to things like dental benefits that don’t kick in for almost a decade—and the possibility that Democrats will do a good thing and get no political credit for it.
All of this underlines one of the fundamental choices Democrats will ultimately need to make as they try to pass this potential bill-of-the-century. With nearly limitless ambition, but a set pool of cash, Democrats could choose to essentially half-ass a lot of different programs by passing them with less funding than they need to succeed, then hope to build on them down the line (this turned out to be the approach with Obamacare, in the end). Alternatively, they could fund fewer programs, but do them properly from the start. Or they could try to take a middle ground, designing solid programs but delaying their start dates for the sake of short-term budget math, which seems to be the House’s approach. There’s a logic to it. But I wouldn’t count on the path winning many votes.