Democrats must reconcile to pass reconciliation

As the Democratic leadership moves forward with their slim majorities in Congress, they must agree among themselves on trillions of dollars of health care programs, including universal health care, Medicare expansion, and more tax subsidies for the Affordable Care Act.

As fall approaches, will Democratic lawmakers, who hold small majorities in both the House and the Senate, be able to successfully navigate two large pieces of legislation that will invest trillions of dollars into both human and physical infrastructure? Their ability to reconcile legislative priorities and garner support among themselves is critical to passing the $1.2 trillion Infrastructure Investment and Jobs Act and a $3.5 trillion budget reconciliation bill.

If successful, their efforts will be transformative on the scales of President Lyndon B. Johnson's Great Society programs and President Franklin D. Roosevelt's New Deal in extending the health care safety net for millions of Americans, as well as focusing on the well-being of middle- and working-class families and veterans, improving climate change, building roads and bridges, reducing prescription drug costs, and providing educational benefits for students.

To pull off this feat, Democrats must address the wish list of its 95-member Progressive Caucus in the House, who desire universal health care, a public option, lower prescription drug prices, a “Green New Deal,” and expansion of Medicare for All to include dental, hearing, and vision benefits. The progressives' priorities must be weighed against the more moderate voices in the party who may prefer a reconciliation package that is smaller in scope, duration, and benefits.

It will be a testament of their skills for Senate Majority Leader Chuck Schumer (D-NY) and House Speaker Nancy Pelosi (D-CA) to guide the reconciliation and infrastructure bills through Congress. We all remember the consequences and what happened last year when the container ship Ever Given blocked the Suez Canal, disrupting global trade and supplies. The course Mr. Schumer and Ms. Pelosi must navigate is fraught with curves, bends, and challenges that could delay, sink, or dramatically alter one or both bills.

Where is the infrastructure bill in the process? It passed the Senate on Aug. 11 and awaits a House vote by Sept. 27. A group of 10 moderate Democrats persuaded Speaker Pelosi to bring the bill to a vote on the House floor in September, while her progressive members preferred tying the reconciliation and infrastructure bills together as a package in the fall.

Where does the budget resolution to start the reconciliation process stand? The House and Senate passed a budget resolution containing reconciliation instructions to congressional committees who will write the legislative language on how the $3.5 trillion is to be spent. The budget resolution is a shell that instructs the various committees to draft specific recommendations in response to those instructions up to the $3.5 trillion limit.

As the Democratic leadership moves forward, their first challenge is getting members to agree on what to include in the reconciliation bill. While it won't be clear which specific proposals will be included until after Sept. 15, when the committees report out their legislation, we know the framework might include the following items of interest to ACP members:

  • building on Democrats' goal of providing universal health care,
  • adding a new dental, hearing, and vision benefit to the Medicare program,
  • extending the recent expansion of the Affordable Care Act in the American Rescue Plan Act providing premium tax subsidies to those above 400% of the federal poverty line,
  • investing in home- and community-based services to help seniors, persons with disabilities, and home care workers,
  • creating a new federal health program for Americans in the “Medicaid gap” to allow those who live in states that did not expand Medicaid under Obamacare to receive Medicaid benefits,
  • reducing prescription drug costs for patients and saving taxpayers hundreds of billions of dollars by enabling Medicare to negotiate drug prices and reducing consumer out-of-pocket costs,
  • expanding paid family and medical leave,
  • addressing health care clinician shortages through support for graduate medical education,
  • providing long-term care for seniors and persons with disabilities, and
  • improving health equity through maternal, behavioral, and racial justice health investments.

The bill may also increase the maximum Pell Grant awards; provide for investments in primary care, including community health centers, the National Health Service Corps, the Nurse Corps, and Teaching Health Center Graduate Medical Education; upgrade Veterans Affairs facilities; and improve our pandemic preparedness.

The second challenge facing Democratic leadership as they navigate these bills through the legislative canals of Congress is how much of the cargo will get jettisoned in the process. To garner the support of moderates like Senators Joe Manchin (D-WV) and Kyrsten Sinema (D-AZ) or Rep. Josh Gottheimer (D-NJ), leadership may have to push forward a smaller reconciliation bill to lower costs.

They might also make some of the bill's benefits and provisions temporary or limit their scope. Lowering costs will also ensure that reconciliation does not add to the federal deficit over a 10-year period, which could trigger additional spending cuts under Congress' PAYGO rules, which have already triggered a 4% cut in spending created by President Joe Biden's American Rescue Plan Act.

A third navigational challenge facing leadership is gaining the support of the entire Democratic caucus. All 50 Democrats must support the measure in the Senate, along with Vice President Kamala Harris, and Speaker Pelosi can only lose three votes in the House if reconciliation is to pass. Democratic leadership has committed to discussing social spending in the reconciliation bill with moderates before finalizing it. The fourth challenge to successful passage is for leadership to withstand fierce opposition to the reconciliation proposals. The pharmaceutical industry is expected to wage a large campaign against provisions to lower prescription drug costs. Large corporations, hedge funds, and wealthy Americans may lobby against any provisions to roll back the Trump-era tax cuts as a way to pay for the reconciliation bill.

While these bills are expected to pass, navigating them through Congress fully loaded with cargo consisting of the wishes of Congress is not at all certain. If the bills pass, they can have a transformational effect on the lives of Americans and in rebuilding the nation's infrastructure.