The outlook for Democrats’ health care priorities was boosted by the party’s two final Senate victories in Georgia this week, yet exactly what the party may accomplish remains to be seen.
President-elect Joe Biden said in a statement Wednesday that “the bipartisan COVID-19 relief bill passed in December was just a down payment,” signaling that another pandemic response bill is on tap.
Democrats have also made expanding health insurance coverage and lowering prescription drug prices top priorities. New York Sen. Charles E. Schumer, the chamber’s top Democrat, said $2,000 relief checks for Americans was a top priority, but didn’t discuss other specific policies Wednesday.
Democratic leaders will have to navigate differences between factions of their own party and the narrowest of margins in the Senate, where Republicans still retain the right to filibuster. Some Democrats argue they should eliminate the 60-vote threshold, while others oppose that idea.
Those dynamics are likely to prompt Democrats to use the reconciliation process, a budgetary tool allowing lawmakers to pass legislation with a simple majority. While many Democrats urged the use of compromise in striking legislative deals, some also recognized that reconciliation might be the best tool at their disposal.
Sen. Ron Wyden, D-Ore., who is poised to chair the influential Senate Finance Committee, told reporters Wednesday that reconciliation is on the table.
“We’re going to, right now, look at a variety of issues. Obviously, reconciliation is something I’m going to be spending a lot of time on,” he said.
Democrats’ priorities are unlikely to change significantly from recent years. House Democrats passed legislation last year to expand the size of premium tax credits to help people afford their monthly health insurance exchange premiums, as well as to allow Medicare to negotiate prices for some prescription drugs. That could serve as a starting point for health care legislation.
Still, a COVID relief package could be a vehicle for some proposals. Allison Orris, a partner at the legal and consulting firm Manatt Health, said provisions to expand subsidies, raise states’ Medicaid Federal Medical Assistance Percentages or encourage states to expand Medicaid eligibility could be discussed as part of a relief package.
Other policies to expand coverage that Biden campaigned on, including lowering the Medicare eligibility age and implementing a government-run public option, will likely be more difficult for Democrats to advance given their narrow majorities in both the House and Senate.
“Things like the public option, lowering the Medicare eligibility age don’t feel as likely to me as some more targeted expansions,” Orris said.
Rep. Stephanie Murphy, D-Fla., co-chair of the Blue Dog Coalition, a group of moderate Democrats, did not shy away from reconciliation if bipartisanship fails. Clearing another COVID-19 relief package will be the group’s first priority, she said.
“My hope is that we can start in a bipartisan way, using regular order, in order to get relief to the American people but we do have a responsibility to the American people to use whatever tools necessary to help them,” she said on a call Wednesday with reporters.
The party’s strength will rely on the unity of its members, which includes an increasingly vocal left wing. Rep. Ed Case, D-Hawaii, who also co-chairs the Blue Dogs, professed faith in the party’s “common set of values” to get work done on health care. Democrats have been “pretty darn unified” on the 2010 health care law, he added, noting that prescription drug prices and protecting coverage of pre-existing conditions will likely be “very, very high” on the party’s priority list.
The downside of using the reconciliation process is its limitations. The procedure only applies to mandatory spending, and the so-called Byrd rule in the Senate blocks extraneous provisions that don’t materially affect changes in revenue. Qualifying provisions sometimes depend on how they’re worded.
“It can be quite hard to know whether any particular item is going to pass the Byrd rule test, which again, makes specific predictions hard,” said Molly Reynolds, a senior fellow and expert on congressional procedures at the Brookings Institution.
Most recently, Republicans fell short in attempts to repeal the health care law in 2017 using reconciliation, but later that year succeeded in overturning the law's mandate to buy insurance as part of a tax law.
Democratic priorities that could conceivably be accomplished via reconciliation include capping patient spending in Medicare Part D’s prescription drug benefit and “probably” lowering Medicare’s eligibility age, she said.
Senators also may seek to use the process to change the 2010 law’s subsidies.
That leaves larger issues up in the air, like dramatically expanding the health law by creating a public insurance option. The pull from progressives expanded the House Democrats’ drug pricing bill significantly last year, and they’re seen as somewhat more powerful now that Democrats hold a slim 11-seat majority in the chamber.
“If we learned anything from the Republicans’ failed effort to repeal and replace the ACA using reconciliation in 2017,” Reynolds said, using the acronym for the health law, “it’s that if you can’t get a majority of your party to agree on what they want to do, the rules won’t solve that problem for you.”