Debate on Medicare Coverage Expansion

Whether to prioritize the health of the elderly or the impoverished has come to the fore of a moral, political, and economic dilemma facing lawmakers in recent weeks. All 50 members of the Democratic party must vote in favor of the massive, 10-year “Build Back Better Act” for it to become law, but with more conservative members of the party balking at its proposed $3.5 trillion price-tag, some parts of the reconciliation bill — including ambitious plans for both Medicare and Medicaid expansion — will likely need to be eliminated.1    

The expansion of Medicare to include dental, hearing, and vision coverage for older adults was established early on as one of President Joe Biden’s domestic policy priorities. Dental coverage has been fiercely defended, with Vermont Independent Bernie Sanders emphasizing that “[d]ental care is health care, and dental care must be part of any serious health care program in the United States.”2  

California Democrat Nanette Diaz Barragán, who introduced the Medicare Dental Benefit Act of 2021, called dental care “a crucial part of health care” and “not a luxury.”3,4 A Kaiser Family Foundation poll published in July 2021 found that nearly half of all Medicare beneficiaries lack dental coverage, as of 2019. Out-of-pocket spending on dental services for Medicare beneficiaries averaged $874 in 2018, and Black and Hispanic individuals were more likely to forgo a dental visit over the course of a year.5  

Dental coverage would be by far the most expensive measure of Medicare expansion, which could cost as much as $350 billion over a decade.6 According to the Congressional Budget Office, dental coverage could require a budget of $238 billion over ten years, compared with $89 million for hearing and $30 million for vision.7 

Centrist Democrats like Joe Manchin of West Virginia have expressed opposition to expanding Medicare before stabilizing its funding base: by 2026, he emphasized, “[T]he trust fund is going to be insolvent.”8 Moreover, the Congressional Budget Office speculates that insolvency may accelerate to 2024 as a result of the COVID-19 pandemic and reduced revenue from Medicare payroll taxes during the associated economic recession.9 Manchin is a key hold-out on the $3.5 trillion plan and is at the forefront of efforts to shrink it to under $2 trillion.8 

Industry players have also complicated efforts to expand Medicare. The American Dental Association has advocated for limiting benefits to only those earning less than 300 percent of the federal poverty line, worrying that its members will otherwise face more severe financial shocks. Insurers that sell supplemental dental, vision, and hearing coverage, as well as private Medicare plans, are also wary of the proposed reforms.6  

Democrats in favor of Medicare expansion are hoping to finance health care reform by allowing Medicare to negotiate prices with drug makers and tie drug prices to those paid by other developed countries, which could save roughly $500 billion over a decade by pushing costs to pharmaceutical companies. This provision was first proposed decades ago but never implemented, testifying to the strength of the pharmaceutical lobby and concerns about disincentivizing clinical innovation.1 Republicans have largely opposed the measure, but three House Democrats (Scott Peters of California, Kurt Schrader of Oregon, and Kathleen Rice of New York) recently voted against the measure.10   

Meanwhile, Democrats remain internally divided over whether limited health care funds are best dedicated to older adults or working poor individuals in the 12 states that have not expanded Medicaid under the Affordable Care Act. Southern Democrats like Georgia Senator Raphael Warnock advocate for assisting those who have been denied affordable health care based on nothing more than the state they live in, but other Democrats are skeptical of policies that may “reward” states for having adopted Medicaid later. That older Americans — those who would be benefitted by Medicare expansion — are a more consistent voting base also influences the balance of the complex equation that will determine health care funding.1 October 31 was previously set as a tentative deadline for concluding Democratic negotiations, but it remains to be seen what decisions will prevail.  

References 

  1. Weisman J, Stolberg SG. Medicare expansion clashes with health care for the poor as budget bill shrinks. The New York Times. https://www.nytimes.com/2021/09/20/us/politics/medicare-health-care-poor-budget-bill.html. Published September 20, 2021.  
  1. Sanger-Katz M. Five decades later, Medicare might cover dental care. The New York Times. https://www.nytimes.com/2021/08/29/upshot/medicare-dental-care.html. Published August 29, 2021.  
  1. Hendrix IV. Dental coverage for Medicare recipients divides parties. The Hill. https://thehill.com/policy/healthcare/medicare/574661-dental-coverage-for-medicare-recipients-divides-parties. Published September 30, 2021.  
  1. H.R.502 – Medicare Dental Benefit Act of 2021. Congress.gov. https://www.congress.gov/bill/117th-congress/house-bill/502/text?q=%7B%22search%22%3A%5B%22hr+8%22%5D%7D&r=98&s=1 
  1. Medicare and dental coverage: A closer look. Kaiser Family Foundation. Published July 28, 2021. https://www.kff.org/medicare/issue-brief/medicare-and-dental-coverage-a-closer-look/ 
  1. Scholtes J, Ollstein AM, Mccrimmon R. Dentists, insurers aim to pare down Dems’ Medicare expansion. Politico.com. Published August 27, 2021. https://www.politico.com/news/2021/08/27/health-lobbies-democrats-medicare-506977 
  1. Osman M, Cohrs R, Brodwin E, Boodman E, Palmer K. Democrats push back on idea that expanding Medicare would bankrupt it. Statnews.com. Published October 20, 2021. https://www.statnews.com/2021/10/20/senate-democrats-push-back-on-the-notion-that-adding-dental-vision-to-medicare-would-bankrupt-it/ 
  1. Carney J. Manchin fires warning shot on plan to expand Medicare. The Hill. https://thehill.com/homenews/senate/573744-manchin-sends-warning-shot-on-plan-to-expand-medicare?rl=1. Published September 23, 2021. 
  1. Ayanian JZ. Saving Medicare for baby boomers and beyond—A looming fiscal crisis. JAMA Health Forum. 2020;1(11):e201387. DOI: 10.1001/jamahealthforum.2020.1387 
  1. Sanger-Katz M. Democrats’ stumble on drug prices shows power of industry. The New York Times. https://www.nytimes.com/2021/09/15/upshot/democrats-stumble-drug-prices.html. Published September 15, 2021.