September 17, 2021 5:30 am

Labor, aging, and disability advocates are fighting to get lawmakers to put at least $250 billion toward a plan to expand home and community-based care for the elderly and disabled and improve conditions for the poorly paid workers that tend to them.

The plan, which the White House wants funded at $400 billion over eight years, could fail, though, if Congress ultimately approves an amount that’s less than what states deem adequate. In that case, states could choose not to take the money and leave their Medicaid programs running as is.

“In order for states to take that on, they need to know that the funding will be there, and the funding will be robust enough to allow them to both set up the infrastructure and to deliver the services and the improved wages,” Ai-jen Poo, co-founder and executive director of the National Domestic Workers Alliance, said.

The proposed cash infusion into Medicaid’s Home and Community Based Services program has two goals: reducing waiting lists for support for older and disabled Americans who want to stay in their homes rather than go into assisted living facilities or other institutions, and raising pay for home health care’s largely female, minority workforce.

Medicaid is the largest payer of long-term support services such as home care for the elderly, but states are not required to participate in the home and community-based program.

Home care, though, is much cheaper, overall. The yearly average cost, per person, of a nursing home to Medicaid is $90,000 compared with $26,000 for home care workers, according to Poo.

And although home health workers are one of the fastest-growing segments of the labor market, they typically earn about $17,000 per year, often without benefits, Poo said.

Boosting the program “would be the single largest direct investment in the creation of good jobs for women and women of color in the history of the country,” she said.

Budget Number

The home care initiative began to draw attention when then-candidate Joe Biden put it on his campaign platform. He’s proposed the $400 billion as part of his $2 trillion infrastructure proposal known as the American Jobs Plan.

Advocates, worried after hearing that just $150 billion would be included for the program in the House’s $3.5 trillion budget reconciliation package, succeeded in getting the amount bumped up to $190 billion before the provision was approved by the House Energy and Commerce Committee, said Nicole Jorwic, senior director of public policy at The Arc, a nonprofit that advocates for people with intellectual and developmental disabilities.

“I was really concerned when some people were putting the number 150 on it. That was a level where we wouldn’t be confident we could do it right,” Sen. Robert Casey (D-Pa.) said in an interview. The Congressional Budget Office told Casey’s office that, based on its experience with Medicaid expansion under the Affordable Care Act, states won’t expand their HCBS program unless they get enough funding.

“You have to make sure you build something where you’re going to both increase services, but you have enough resources to build wages also,” said Casey, the chief architect of the plan and lead sponsor of the legislation behind it.

“When budgets are tight, states lean towards services as opposed to raising wages, and it’s always the workers who get left behind,” Poo said.

It’s possible that funding came in at $190 billion in the House bill because multiple committees have jurisdiction over health-care funding, Jorwic said.

She said she was “hopeful” that, ultimately, the program would be funded at a higher level when the reconciliation bill goes to the Budget and Rules committees. Groups that work on the issue say the White House, Speaker Nancy Pelosi (D-Calif.), and Senate Majority Leader Chuck Schumer (D-N.Y.) all appreciate the importance of providing enough funding to get states on board, she added.

$400 Billion Push

Although advocates are fighting for $250 billion, the program really requires $400 billion to deal with “the scale and scope of the problem,” and to allow the U.S. to “turn home care jobs into good living wage jobs and expand access to care,” Mary Kay Henry, president of the Service Employees International Union, said. SEIU represents about 740,000 home-care workers.

SEIU doubled its ad campaign Tuesday in support of the home care plan, spending another $3.5 million to call on Congress to support ample funding. $400 billion would fuel 1.4 million direct and indirect jobs, and expand access to care for 3 million people, Henry said.

“The additional money gives us a fighting chance at the state level to make these poverty jobs living wage jobs” with sick leave and medical benefits, she said.

Meanwhile, the urgency underscoring the issue stems not just from a need to expand access to home services and improve wages but by the fact that 10,000 people are aging into retirement per day, Poo said.

“What we’re hearing is that the vast majority of Americans, 88%, want to age at home and in the community. And we just are not prepared for that,” Poo said.

The current access crisis “could become a catastrophe if we don’t invest in home and community-based care,” she said.

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Democrats Prepare for Next Phase of Budget Fight as House Readies Package and Biden Meets with Senate Skeptics

September 15, 2021 7:14 pm

With the sound of one final gavel, House Democrats on Wednesday completed the mammoth task of translating President Biden’s economic vision into a $3.5 trillion tax-and-spending proposal — marking a major milestone in a fight that’s still far from finished.

Assembling the House package proved to be an enormous undertaking, as Democrats raced over the past week to produce roughly 2,600 pages of legislative text spanning the party’s vast policy ambitions. The measure seeks to shepherd major changes to federal health care, education, immigration, climate and tax laws, introducing a sprawling set of federal programs that Democratic leaders have described as historic in their size and scope.

But the fruits of lawmakers’ labors quickly seemed overshadowed by political reality. A proposal that would try to lower the cost of prescription drugs for millions of seniors appeared in fresh jeopardy, after a small group of Democrats dealt it an early blow in the House. The fuller $3.5 trillion plan, meanwhile, faced even more significant hurdles in the Senate — prompting Biden to embark on a renewed effort Wednesday to try to reassure wavering members of his own party.

In a burst of personal outreach, Biden huddled with Sen. Kyrsten Sinema (D-Ariz.) in the morning, then met withSen. Joe Manchin III (D-W.Va.) later in the day. Both centrists have signaled they are unwilling to vote for a final package unless Democrats come down in cost. Their opposition has infuriated liberal lawmakers, including Sen. Bernie Sanders (I-Vt.), who has rebuffed their attempts to whittle down the size of the plan — putting Democrats on a collision course in a chamber where they simply have no votes to spare.

“The president certainly believes there’ll be ongoing discussions,” White House press secretary Jen Psaki said Wednesday. “Not that there’s necessarily going to be a conclusion out of those today, but that was the primary focus and purpose of these meetings.”

If Democrats ultimately choose to reduce their spending, it may force the party to compromise on some of its core ambitions, a prospect that was not lost on Rep. John Yarmuth (D-Ky.), the House’s top budget-maker. He described the renewed objections as a “source of great frustration,” adding in an interview earlier this week that the caucus is holding firm.

“A significant number of our caucus — at least half, and probably significantly more than half — wanted to do more than $3.5 trillion,” he said. “It’s very frustrating for most of us, and I think it strengthened our resolve to move forward.”

For now, at least, House Democrats have secured the general policy objectives Biden outlined in the two blueprints he unveiled earlier this year. The president and his congressional allies have framed their $3.5 trillion agenda through the prism of history, likening it to the Great Society and New Deal investments from generations past.

The Build Back Better Act aims to expand Medicare, offering seniors access to hearing, dental and vision benefits. It also would extend a flurry of tax credits and other programs that make insurance more accessible and affordable, including for low-income Americans who seek coverage under Medicaid.

“It also finally closes the Medicaid coverage gap, which will expand coverage to more than four million uninsured Americans,” promised Rep. Frank Pallone Jr. (D-N.J.), the leader of the Energy and Commerce Committee, which debated the matter this week.

Democrats further set in motion a plan for roughly $750 billion to improve education and child care, including a new program that guarantees prekindergarten for all children ages 3 and 4. They authorized 12 weeks of paid family and medical leave for most working Americans, remedying a patchwork that leaves many without benefits today. And they crafted what lawmakers have described as the most significant set of legislative reforms ever to combat climate change, including a flurry of programs that reward clean energy, penalize polluters and help Americans finance more environmentally friendly homes and vehicles.

Much of the work is financed through a series of tax increases targeting wealthy Americans, profitable corporations and investors. The tax hikes stop short of what Biden initially had recommended, including by omitting new taxes targeting inheritances passed between family members. But they generally accomplish Democrats’ aims to unwind the tax cuts enacted under President Donald Trump four years earlier — all while raising about $2.9 trillion in revenue to cover the cost of the bill. Democrats contend the entire measure is financed in full since it fosters economic gains that essentially pay for themselves.

“Millions of Americans’ lives will change for the better thanks to these provisions,” said Rep. Richard E. Neal (D-Mass.), who chairs the tax-focused House Ways and Means Committee, during a hearing Tuesday. He said the tax increases ask the “biggest companies and the ultrawealthy to contribute more to the common good.”

Republicans unanimously have opposed the $3.5 trillion package, swiping at it repeatedly over the past week as reckless and wasteful. GOP leaders have alleged the combination of spending and tax increases would worsen the deficit, intensify inflation and erase the economic gains they secured before the pandemic under Trump.

“This is exactly what we said was coming: an economic surrender,” said Rep. Kevin Brady (R-Tex.), the top Republican on the Ways and Means Committee, during an interview on Fox Business. “We’re going to lose jobs to China, Russia, Europe and other countries. They’re going to clean our clock.”

Democrats still plan to fine-tune the proposal before bringing it to the House floor, all the while continuing negotiations with the Senate on a package that can clear both chambers. They face a race against the clock to finish their work before Sept. 27, at which point House Speaker Nancy Pelosi (D-Calif.) has promised she would move the House to begin considering a roughly $1 trillion effort to upgrade the nation’s infrastructure.

To pass it, Democrats intend to use the process known as reconciliation, which will allow party lawmakers to sidestep a Republican filibuster — but only if Pelosi and Senate Majority Leader Charles E. Schumer (D-N.Y.) can keep their caucuses together. Pelosi has only three votes to spare in the House, and Schumer has none in a Senate where Democrats can only break ties, leaving the party unable to afford defections.

With time tight, and the margin for error increasingly slim, Pelosi issued a plea to her caucus earlier this week, writing in a letter that Democrats must “stay united in our quest to reach our goal and honor our values.”

Already, though, there are signs that Democrats have started to stray.

As House lawmakers finalized their work Wednesday, Sinema and Manchin individually met with Biden at the White House. Manchin only a day earlier reiterated his opposition to a $3.5 trillion bill, as he instead proposed a package that could be only half that size. Manchin also has taken aim at key elements of Democrats’ plans to combat climate change, setting up further infighting as the debate shifts to the Senate.

Officials on Capitol Hill and at the White House said the separate meetings marked the first substantive chance for Biden to engage directly with the two pivotal senators and declined to discuss the sit-downs in much detail. Sinema spokesman John LaBombard said only that her meeting with Biden was “productive” and added: “Kyrsten is continuing to work in good faith with her colleagues and President Biden as this legislation develops.”

Publicly, though, White House chief of staff Ron Klain said at an event Wednesday that the $3.5 trillion package could be scaled back by cutting down the size of some new programs or trimming the duration of some of the spending. But he also made the case — aimed at the deficit-minded centrists in the Democratic Party — that the package at its current size ultimately would be paid for.

“The truth is, the cost of the Build Back Better plan is zero,” Klain said Wednesday during remarks at the SALT conference for investors and financiers.

House Democrats have spent the past week preemptively trying to ward off cuts to the cost, fearing that a smaller tax-and-spending package could imperil some of their most prized programs. That includes an extension of the expanded child tax credit, a program that aims to cut child poverty by allowing families to obtain bigger tax benefits paid on a monthly basis. Democrats opted to sunset the proposal in 2028, rather than extend it permanently as they initially hoped, to respond to spending concerns.

“I think the focus on a top line number is distracting from focusing on the substance of the bill,” said Rep. Suzan DelBene (D-Wash.), the leader of the moderate-leaning New Democrat Coalition. “You’ve got to look at what the other bill does.”

Senate Democrats have sought to tinker with a wide array of additional programs in the proposal. Manchin has raised the need for new work requirements on the child tax credit, an idea liberal lawmakers see as unacceptable. Other tensions linger among Democrats over climate change, as a subset of Democrats continue to push for a border tax targeting pollution and additional funding for other elements to combat emissions.

And Sen. Ron Wyden (D-Ore.), the leader of the chamber’s top tax committee, has pursued a series of additional tax increases targeting offshore earnings, stock buybacks and family inheritances that Neal in the House opted not to include in the proposal he advanced through the committee. Otherwise, Wyden maintained in a recent interview that the chambers are “rowing in the same direction” on taxes.

With significant swaths of the reconciliation bill still unsettled, Yarmuth, the House’s budget chairman, said he anticipated the chamber may have to proceed in two steps.

“I think that it looks right now like we’ll probably proceed to do our own bill and see if we can get 218 votes in the House to pass it, rather than wait for the Senate to act,” he said. “It looks like right now we’re going to end up getting the bill back from the Senate. The Senate is not as far along with some of their deliberations.”

Even more severe headaches emerged this week over Democrats’ plans to try to pursue prescription drug pricing reforms as part of an up-to $3.5 trillion reconciliation package. Lawmakers including Pelosi, a fierce advocate for the proposal, say they must empower Medicare to negotiate friendlier rates for seniors. But they have faced immense opposition from the pharmaceutical industry, which has run ads attacking party lawmakers, as well as a set of centrist Democrats.

The tensions flashed publicly Tuesday, as three Democrats on the House Energy and Commerce Committee pledged they would vote against the drug pricing plan. Reps. Scott Peters (Calif.), Kathleen Rice (N.Y.) and Kurt Schrader (Ore.) ultimately kept their promise a day later, leaving the panel deadlocked and unable to advance the policy.

“I want to be clear — I support Medicare drug price negotiations,” Schrader said this week. In response, he put forward his own counter offer that would limit Medicare’s power to negotiate to “the most expensive subset of drugs on the market.”

The pricing policy also has added significance, serving as a major financing piece of the broader $3.5 trillion package, as Democrats estimate it could raise billions of dollars to offset their spending. Another House committee has adopted the proposal, giving party leaders additional options to advance it — provided they can overcome dissent within their own ranks.

The still-widening schisms ultimately did not seem to faze Pelosi, who sent a second letter to House Democrats on Wednesday in the hours before lawmakers concluded their work.

“The vision and knowledge of President Biden and Congressional Democrats,” she began, “has enabled us to be on schedule in delivering the Build Back Better agenda.”

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What’s in the House Reconciliation Package

September 15, 2021 5:27 pm

House Democrats have taken their first steps to advance a sweeping social spending and tax package that would implement President Joe Biden’s economic agenda.

Thirteen committees approved legislation to be included in a reconciliation package that can be used to try and pass Democrats’ policies without Republican support. The fiscal 2022 budget resolution (S. Con. Res. 14) adopted in August gave the panels until Sept. 15 to report legislation that would increase or decrease the deficit by specified amounts over 10 years.

The House Budget Committee will assemble the measures approved by the various committees into the reconciliation bill that could be considered by the House later this fall.

Below are highlights of the approved measures.

Ways and Means (Target: $1 billion reduction)

The budget resolution directed the Ways and Means Committee to reduce the deficit by $1 billion over 10 years, a “nominal” amount intended to give the panel flexibility to draft its legislation, including offsets for the reconciliation package.

The measure covers taxes, health care, drug pricing, paid leave, infrastructure financing, community development, retirement, child care, and trade.

Tax Increases: The Ways and Means package includes sweeping tax changes to raise revenue for other portions of the package, including:

• Raising the top marginal personal income tax rate to 39.6%, from 37%, for individuals making more than $400,000 and joint filers making more than $450,000. A 3% surtax also would be imposed on individuals with adjusted gross incomes of more than $5 million.
• Increasing the capital gains tax rate to 25% from 20% for “certain high-income individuals.”
• Replacing the flat 21% corporate income tax rate with graduated rates: 18% on the first $400,000 of income, 21% on income up to $5 million, increasing to 26.5% for income after that.
• Generally requiring investment funds to hold assets for more than five years, rather than three years, for managers to get a preferential tax rate on their share of profits, known as carried interest.
• Reinstating a 16.4 cents-per-gallon tax on crude oil and imported petroleum products to fund Superfund cleanups of hazardous sites. It also would double the tax rate on sales of certain chemicals.
• Barring taxpayers from claiming losses on digital assets, such as cryptocurrencies.
• Increasing the current rate of excise taxes on cigarettes, small cigars, and roll-your-own tobacco, as well as on nicotine that’s been extracted, concentrated, or synthesized in tobacco products.
• Providing $78.9 billion in additional funding for the Internal Revenue Service to increase audits on wealthy individuals.

Tax Credits: Other tax provisions in the measure are designed to aid certain households and industries, such as:

• Extending an expanded version of the child tax credit through 2025 and making it permanently refundable.
• Making permanent expanded versions of the earned income tax credit for childless workers and the child and dependent care credit under the American Rescue Plan Act, Public Law 117-2.
• Making permanent the expanded availability under ARPA of the Affordable Care Act’s premium tax credits for health insurance purchased through the exchanges. It also would allow individuals who receive unemployment benefits to receive premium-free insurance plans through 2025.
• Temporarily expanding the ACA tax credits to individuals with income below 100% of the federal poverty level, and providing enhanced cost-sharing subsidies to those below 138% of the federal poverty level, until a federal Medicaid program is established in 2025 (see below).
• Creating a refundable income tax credit for union-made electric vehicles placed into service before Jan. 1, 2027, and extending several tax credits related to renewable energy production, including the production and investment credits.

Drug Pricing: The measure would create a “Fair Price Negotiation Program” for the Centers for Medicare and Medicaid Services to negotiate the price of 250 covered drugs and insulin. Prices couldn’t exceed 1.2 times the average price of the drug in six other countries. They would also be available to private insurance plans.

Drugmakers that don’t negotiate successfully would face an excise tax of as much as 95%. Those that charge more than the negotiated maximum price would pay as much as ten times the difference in prices.

The measure would also:

• Require drugmakers to repay the government their profits if they raise the price of a drug above inflation.
• Cap the cost of prescription drugs under Medicare Part D for beneficiaries.
• Block the drug rebate rule published under former President Donald Trump in November 2020.

Medicare Coverage: The measure would expand Medicare coverage to include dental benefits beginning in 2028, hearing benefits beginning in 2023, and vision benefits beginning in 2022. For dental benefits, Medicare would cover 50% of the cost of major treatments and 80% of the cost of preventive services. Hearing coverage wouldn’t include over-the-counter hearing aids.

Reinsurance Program: The measure would provide $10 billion annually for a fund to provide reinsurance payments to insurers operating in marketplace exchanges and assistance to individuals to reduce out-of-pocket costs.

Paid Leave: The measure would provide up to 12 weeks of paid leave for eligible workers for the birth or adoption of a child, a personal health condition, caregiving for a family member, circumstances related to a family member’s deployment, and bereavement. Benefits would be administered by the Treasury Department and would begin in July 2023.

Infrastructure & Community Development: The measure includes several tax changes related to infrastructure financing and community development, such as:

• Allowing state and local governments that issue qualified infrastructure bonds to receive a tax credit for a portion of the interest they pay, similar to Build America Bonds under the 2009 American Recovery and Reinvestment Act (Public Law 111-5). The credit would be 35% of interest paid for bonds issued from 2022 through 2024, phasing down to 28% for bonds issued in 2027 and later years.
• Restoring a tax exemption for interest on advance refunding bonds, which was repealed by the 2017 tax overhaul (Public Law 115-97). State and local governments used those bonds to refinance their debt and access lower interest rates.
• Establishing a 30% tax credit for state, local, and tribal governments to operate and maintain government-owned broadband systems.
• Making permanent and expanding the New Markets Tax Credit, offered to taxpayers that invest in lower-income communities.
• Establishing a 30% tax credit for individuals and businesses that participate in a qualified wildfire resilience program.
• Increasing state Low-Income Housing Tax Credit (LIHTC) allocations.
• Establishing a neighborhood homes credit for rehabilitating homes in certain lower-income areas.

Child Care: The measure would provide:

• $15 billion in state grants to help providers improve child care facilities.
• Such sums as necessary for grants to supplement the wages of qualified child care providers.

Retirement: The measure would require employers with more than five workers to automatically enroll new hires for retirement benefits. Employees could choose to opt out of the savings plan or modify contributions. Employers would be subject to an excise tax of $10 per day for each employee who isn’t covered by an automatic retirement plan.

Trade: The measure would reauthorize Trade Adjustment Assistance (TAA) programs for seven years and provide $3.4 billion annually for those programs, including $1 billion annually through fiscal 2026 for new grants to help communities affected by global trade.

Education and Labor (Target: $779.5 billion)

The measure includes provisions on education, child care, labor, and child nutrition programs.

Education: The measure would provide roughly $111 billion for higher education, including by:

• Providing two years of free community college through grants to states and eligible tribal colleges and universities. The federal share of costs would start at 100% in the first year and decrease to 80% by the 2027-2028 award year.
• Increasing the maximum Pell grant by $500.
• Allocating $9 billion for retention and completion grants to states and tribal colleges and universities to support students.
• Providing additional support to historically Black colleges and universities and minority-serving institutions.

It also would provide $82 billion to rebuild public elementary and secondary schools that have fallen into disrepair. That would include $40.9 billion for grants for school districts to construct or repair facilities, improve energy efficiency, and reduce health and safety hazards.

Child Care: The measure would provide $450 billion for child care and early childhood education, including by:

• Capping child care costs at a maximum of 7% of family income, using a sliding scale that would apply to all income levels. It would provide $90 billion over the first three years and then such sums as may be necessary for the next three years.
• Requiring child care providers that receive federal assistance to provide at least a living wage to staff.
• Providing free preschool to all three- and four-year-olds. States would submit plans to participate and receive federal funding, which would start at 100% in the first three years and decrease to 60% by fiscal 2028.

Labor: The measure would provide:

• About $80 billion for workforce development and training programs.
• Impose increased civil penalties for employers who violate labor laws.

Child Nutrition: The measure would provide almost $35 billion for child nutrition programs and other activities to address child hunger, including:

• Expanding eligibility for free school meals, among other changes that would increase the number of children receiving them by almost 9 million, according to a fact sheet from the House Education and Labor Committee.
• Appropriating such sums as may be necessary for a Summer Electronic Benefits Transfer (EBT) for Children program, which would sunset in 2029. The program would provide children eligible for free or reduced-price school meals with $75 per month in food benefits when school is out of session for the summer.

Energy and Commerce (Target $486.5 billion)

The measure includes language related to health care, energy and environmental matters, telecommunications, and manufacturing. The panel didn’t agree to drug pricing provisions, similar to what’s in the Ways and Means package, in a tie vote with three Democrats joining Republicans in opposition.

Medicaid: The measure would close the Medicaid coverage gap for lower-income individuals in states that didn’t expand the program under the Affordable Care Act by:

• Temporarily expanding the ACA’s premium tax credits to individuals below 100% of the federal poverty line and providing further cost-sharing subsidies.
• Creating a federal Medicaid program, operated by third-party entities, for nonexpansion states beginning in 2025 to cover those individuals.

Reinsurance Program: The measure would provide $10 billion annually for a fund to provide reinsurance payments to insurers operating in marketplace exchanges and assistance to individuals to reduce out-of-pocket costs.

Medicare Coverage: The measure would expand Medicare coverage to provide dental benefits beginning in 2028, hearing benefits beginning in 2023, and vision benefits beginning in 2022.

CHIP: The measure would make the Children’s Health Insurance Program (CHIP) permanent and appropriate “such sums as are necessary” for it. It also would allow states to increase the income level needed for families to participate in CHIP and require states to provide one year of continuous eligibility for children enrolled in CHIP.

Other Health Programs: The measure would provide:

• $35 billion for public health infrastructure, including $10 billion for hospital infrastructure projects and $10 billion for community health center grants.
• $15 billion for pandemic preparedness, including $1.25 billion for the Centers for Disease Control and Prevention to strengthen vaccine confidence.
• $3 billion to establish the Advanced Research Projects Agency for Health (ARPA-H) to invest in breakthrough technology and advancements in medicine.

Energy and Environment: Funding for clean energy and environmental initiatives would include:

• $150 billion for a Clean Electricity Performance Program that would charge or pay electric utilities based on the share of clean energy they supply to consumers. Utilities would be eligible for grants if they increase the share of clean energy in their portfolios by at least four percentage points each year. Utilities that don’t meet that benchmark would pay a fee.
• $30 billion to replace every lead water service line in the U.S.
• $27.5 billion to support nonfederal financing of zero-emission technology deployment.
• $18 billion to support home energy efficiency and appliance electrification rebates.
• $17.5 billion to decarbonize federal buildings and vehicle fleets.
• $13.5 billion for electrical vehicle charging infrastructure.
• $10 billion for cleanup activities at priority Superfund sites where federal agencies are the responsible parties.
• $9 billion to improve the reliability and resiliency of the electric grid.
• $5 billion for grants to replace school buses, garbage trucks, and other heavy-duty vehicles with zero-emission vehicles.

The measure would establish a fee on methane emissions from the oil and gas industry, the proceeds of which would be used to monitor and reduce greenhouse gas emissions at oil and gas operations.

Communications: The measure would provide:

• $10 billion to implement Next Generation 911 services that facilitate sending text messages, photos, and videos to emergency responders.
• $4 billion for the Emergency Connectivity Fund, established under Public Law 117-2, to supply students, teachers, and others with internet-connected devices.
• $1 billion to the Federal Trade Commission to establish a new bureau focused on data privacy and identity theft.

It also would direct the Federal Communications Commission to auction 200 megahertz of spectrum to offset the cost of other provisions.

Manufacturing: The measure would provide $10 billion for efforts to strengthen and diversify critical manufacturing supply chains that affect interstate commerce.

Financial Services (Target: $339 billion)

Housing: The measure would provide:

• $77.3 billion for formula and needs-based public housing programs.
• $75 billion for incremental Housing Choice Vouchers and support services, including for individuals at risk of homelessness and for survivors of domestic violence and sexual assault.
• $36.8 billion for the Housing Trust Fund and $34.8 billion for the HOME Investment Partnerships Program to fund the construction of affordable housing for low-income people.
• $15 billion for project-based rental assistance.
• $10 billion to offer down payment assistance to first-generation homebuyers.
• $10 billion to address lead paint and other health hazards in housing for low-income families.
• $10 billion for a new Housing Investment Fund to leverage private-sector investments to create and preserve affordable homes.

Flood Insurance: The measure would wipe out $20.5 billion in debt owed by the Federal Emergency Management Agency for money it borrowed to pay claims through the National Flood Insurance Program. It also would provide $3 billion for flood mapping and $1 billion for FEMA to offer flood insurance discounts to low-income policyholders.

Judiciary (Target: $107.5 billion)

Immigration: The measure would make green cards and a pathway to citizenship available to Dreamers who were brought to the U.S. as children and reside here illegally, essential workers, and holders of Temporary Protected Status and Deferred Enforced Departure.

It also would roll over green cards from year to year, allowing for additional visas to be issued following years when the numerical caps aren’t reached—as happened during the Covid-19 pandemic.

Other Programs: The measure also would provide:

• $2.8 billion to U.S. Citizenship and Immigration Services to address visa processing backlogs.
• $2.5 billion to the Justice Department for grants and contracts to support community violence reduction programs.

Agriculture (Target: $89.1 billion)

The measure would provide:

• $40 billion for forestry programs, including $9 billion for forest restoration and resilience grants and $4.5 billion for the Agriculture Department’s portion of a Civilian Climate Corps.
• $18.7 billion for rural development programs, including $9.7 billion for green upgrades to rural utilities.
• $7.75 billion for agricultural research.

House Agriculture Chair David Scott (D-Ga.) said he’d work to add $28 billion in aid to farmers and ranchers related to climate and conservation before the House votes on the full package, Bloomberg Government reported.

Transportation and Infrastructure (Target: $60 billion)

The measure would provide funding for a variety of transportation projects, including:

• $10 billion for high-speed rail corridors.
• $9.9 billion for new transit routes and expanded services in low-income and disadvantaged areas.
• $6 billion for unspecified local surface transportation priorities.
• $5.5 billion for the Economic Development Administration, including to develop regional economic growth clusters.
• $4 billion to reduce transportation greenhouse gas emissions.

Science, Space, and Technology (Target: $45.5 billion)

The measure’s funding for science and technology programs would include:

• $15.6 billion for Energy Department laboratory infrastructure; research, development, and demonstration activities; nuclear energy projects; and energy efficiency and renewable energy initiatives.
• $11 billion for National Science Foundation research infrastructure and STEM research awards, scholarships, and fellowships, including $1 billion for minority serving institutions.
• $4.4 billion for NASA infrastructure modernization efforts and climate change research and development activities.
• $4.3 billion for National Oceanic and Atmospheric Administration weather, ocean, and climate research, in addition to instrument and spacecraft delivery development and delivery.
• $4.2 billion for National Institute of Standards and Technology facility construction and renovation and advanced manufacturing research.

Natural Resources (Target: $25.6 billion)

The measure would provide around $31 billion over a decade for climate resilience, conservation, and other environmental initiatives. That total would be partially offset by increased fees on oil and gas companies to reach the $25.6 billion net spending target set by the budget resolution.

The spending would include $9.5 billion for environmental restoration in coastal areas and around the Great Lakes, $3 billion to create a Civilian Climate Corps at the Interior Department, and $2.5 billion for cleanup activities at abandoned mines.

Revenue raisers and other provisions aimed at the drilling and mining industries would:

• Increase leasing fees and royalty rates for onshore and offshore oil and gas extraction and require royalties to be paid for methane that’s vented or flared.
• Establish an oil and gas leasing moratorium on the Atlantic and Pacific coasts and in the eastern Gulf of Mexico.
• Repeal a previous authorization for drilling in the coastal plain of the Arctic National Wildlife Refuge and void nine leases in the area issued this year.
• Increase the royalty rate paid to the federal government on mining revenue.
• Withdraw more than 1 million acres around the Grand Canyon from mineral leasing.

Veterans’ Affairs (Target: $18.0 billion)

The measure would provide $15.2 billion for infrastructure improvements to national cemeteries and memorials, medical facilities, and other property. It also would include $1.81 billion for major medical facility leases.

The measure would extend through fiscal 2026 the Veterans Affairs Department’s authority to enter into enhanced-use leases, which provide underutilized real estate to the private sector for supportive housing for homeless and at-risk veterans. They would be expanded to include leased property that provides services or benefits for veterans.

Small Business (Target: $17.5 billion)

The measure would include the following amounts for the Small Business Administration:

• $9.5 billion to increase equity investment in underserved markets and key industries through a new subprogram within the Small Business Investment Company program.
• $4.47 billion for a direct loan product under the 7(a) Loan Program.
• $2.75 billion to create a direct lending subprogram under the 504 lending program that would allow Certified Development Companies to provide loans to small businesses, contractors, and manufactures in underserved markets.

Oversight and Reform (Target: $7.5 billion)

The measure would provide $7 billion for the U.S. Postal Service to purchase electric delivery vehicles and related infrastructure, and $5 billion for the General Services Administration (GSA) to procure electric vehicles for other federal agencies.

Other funding for the GSA would include $1 billion for the Technology Modernization Fund, which was established to upgrade federal agency IT systems.

Homeland Security (Target: $500 million)

The measure would provide $865 million for the Cybersecurity and Infrastructure Security Agency, including to assist federal agencies with multi-factor authentication, endpoint detection and response, improved logging, and securing cloud systems.

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Scrap Proposed Medicare Pay Cuts, House Members Ask of HHS

September 14, 2021 6:50 pm

More than 70 bipartisan House members have joined a slew of medical organizations in calling for the Biden administration to nix portions of a proposed rule that would cut Medicare payment rates for some specialists by up to 20% next year.

The lawmakers say the cuts in the proposed 2022 Medicare Physician Fee Schedule would undermine Health and Human Services Department efforts to improve health equity by cutting reimbursements for specialists who treat cancer, kidney failure, artery disease, and other diseases that disproportionately affect Black and Latino beneficiaries.

In a letter sent on Monday to Meena Seshamani, deputy administrator and director of the Center for Medicare within the Centers for Medicare & Medicaid Services, the lawmakers blamed the proposed cuts on the “budget-neutrality effects of a CMS proposal to update clinical labor data.”

The fee schedule requires that any pay increases be offset by payment reductions of equal amounts elsewhere.

“Because of the aforementioned physician fee schedule ‘budget-neutrality,’ the incorporation of new clinical labor data actually results in massive cuts of up to 20 percent to critical services,” the lawmakers wrote. “These impacts also will have profoundly negative effects on health equity.”

The letter, led by U.S. Representatives Bobby L. Rush (D-Ill.) and Gus Bilirakis (R-Fla.), urges the CMS not to finalize the fee schedule’s clinical labor policy and to “work with Congress on fundamental reform to the physician fee schedule.”

Some reimbursement updates currently proposed include a 23% cut for a venous ulcer treatment; a 22% cut for certain treatments for peripheral artery disease; a 21% pay cut for a uterine fibroid treatment; an 18% pay cut for certain kidney failure treatments; and a 15% cut for radiation oncology treatments.

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HHS Distributes Additional $25.5B In COVID-19 Relief To Providers

September 10, 2021 7:58 pm

HHS on Friday (Sept. 10) announced it will distribute an additional $25.5 billion in COVID-19 relief funds to health care providers, including $17 billion in a phase 4 distribution from the provider relief fund and $8.5 billion in American Rescue Plan Act funds set aside for rural providers. The Biden administration has faced growing pressure from lawmakers, including Senate Minority Leader Mitch McConnell (R-KY), and providers to release the funds.

American Hospital Association President and CEO Rick Pollack praised the move. “The AHA appreciates the Administration for announcing plans to get additional critical relief funding for providers out the door. Virus cases and hospitalizations continue to climb across the country so providers will continue to need support.”

But Pollack also said hospitals hope HHS will provide additional support moving forward because the most recent funding doesn’t account for the spring and summer surges due to the Delta variant.

 Providers can apply for both sets of funds through a single application process, which will open Sept. 29, according to AHA. Providers must document revenue loss and expenses associated with the pandemic to get the phase 4 funding.

There’s nearly $44 billion left in the $178 billion provider relief fund, though HHS typically says it’s only $24 billion, excluding what’s leftover from specifics projects.

McConnell, along with four colleagues, had pressed the administration a little over a week ago to swiftly distribute the remaining provider relief and to announce by Sept. 23 whether it would change the initial spending deadline for provider relief recipients who are slammed with a new surge in COVID-19 cases.

The Republicans’ letter to HHS Secretary Xavier Becerra on Sept. 2 came as lawmakers, nursing homes and hospitals also pushed the administration to immediately distribute the estimated $43.7 billion remaining in provider relief, plus the $8.5 billion lawmakers allocated under the American Rescue Plan for rural providers.

“[The provider relief fund] has served as a targeted lifeline to the hospitals and providers on the frontlines who are providing care to patients during the pandemic,” wrote McConnell and Sens. Mike Crapo (R-ID), Roy Blunt (R-MO), Richard Burr (R-NC) and Richard Shelby (R-AL). “Yet, during the first seven months of this Administration, the Department has refused to issue any PRF distributions. Our question to you is simple: Why?”

The senators criticized the administration for its missing strategy to disseminate remaining provider relief and reminded Becerra that he had told the House Ways & Means Committee and Senate Appropriations Committee in June that his goal was to avoid mistakes of the past when distributing relief.

“Yet nearly three months later, no substantive changes have been made and no PRF funding has been distributed,” the senators wrote Sept. 2, a little more than a week before HHS released additional funds.

The senators had asked the administration to provide by Sept. 23 exact dates and timelines for spending what’s left of the $178 billion provider relief fund. They also asked what steps HHS had taken to identify how to spend provider relief and to identify providers in need additional relief and how it would calculate the distributions.

They also asked for details on how the administration has engaged stakeholders and acting on their feedback.

Plus, they wanted to know whether the administration would adjust the June 30 spending deadline — a delay advocated by providers and lawmakers.

“Some hospitals and health care providers continue to experience increased expenses, delayed elective surgeries, and lost revenues,” the senators wrote. “In addition, they are incurring the costs associated with vaccinating Americans, particularly partnering with the Department to fovus on those in vulnerable communities.”

Provider relief recipients who received more than $10,000 in relief before June 30, 2020 are required to submit a report of how they used their funds by Sept. 30. Those providers then have 30 days to return any unused relief to HRSA.

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New Nursing Home Oversight Measures Advance in House Committee

September 10, 2021 4:29 pm

Nursing homes would get help in retaining workers and also face tougher federal oversight in a slate of elder-care measures advanced by a House panel Friday.

The House Ways and Means Committee approved the elder justice legislation by a 24-18 vote and the nursing home bill by a 24-17 vote. Both pieces will be included in Democrats’ $3.5 trillion sweeping domestic policy package, which the House and Senate aim to send to President Joe Biden‘s desk this month. Stephanie Murphy (Fla.) was only Democrat to vote no – Republicans all voted no.

The quality of nursing home care has come under question since last year, when Covid-19 hit seniors in long-term care facilities the hardest. The virus killed more than 186,000 residents and staff of nursing homes, according to an AARP database.

“The U.S. population is aging, and to help Americans age and live safely in place without facing the risk of experiencing various forms of maltreatment,” Rep. Richard Neal (D-Mass.), chairman of the Ways and Means Committee, said.

The committee’s proposal would open up $400 million in grants per year for three years to bolster pay for nursing home workers and help long-term care facilities retain staff through student loan repayment or child-care programs.

It would also empower the government to reduce payments to nursing homes that lie to authorities about their number of workers to hide understaffed facilities. The package would create ombudsman programs to flag elder abuse and neglect.

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Democrats Plot Shutdown-Prevention Patch into December

September 10, 2021 1:52 pm

House Democrats plan to pass a stopgap spending bill the week of Sept. 20 to wave off the threat of a government shutdown at month’s end.

Majority Leader Steny Hoyer (D-Md.) privately told Democrats of the plan on Friday, according to sources on the call. Party leaders are eyeing Dec. 10 as a possible end date for a continuing resolution to keep the government open beyond Sept. 30, although the length of that patch has yet to be finalized.

Democratic leaders are thinking about combining that funding bill with action to handle the debt ceiling, in addition to funding for hurricane and flood damages, Afghan resettlement efforts and other priorities. That move would be the majority party’s first step in forcing Republicans to either pony up the votes to avert the impending debt cliff or sink the combination plan to wave off multiple national crises.

Hoyer warned lawmakers on Friday that House leaders might have to add extra voting days in October to accommodate a jam-packed schedule, including passage of President Joe Biden’s massive social spending plan.

“While the House has already completed the vast majority of our appropriations work, Congress must pass a continuing resolution to keep government open and serving our communities as we negotiate final funding bills that invest in working families,” House Appropriations Chair Rosa DeLauro (D-Conn.) said in a statement.

Republicans do not appear to be fazed byDemocrats’ attempts to tie action on the debt ceiling to a must-pass government funding bill. GOP leaders have vowed no help in raising or suspending the cap on how much money the government can borrow while Democrats pursue a multi-trillion spending package without GOP support.

A limit on the nation’s ability to borrow money was reinstated on Aug. 1. Since then, the Treasury Department has taken “extraordinary measures” to conserve funds and keep paying the government’s bills on time.

Treasury Secretary Janet Yellen warned earlier this week that those measures will be exhausted sometime next month. The Bipartisan Policy Center predicted on Friday that the government could default on its debt between mid-October and mid-November.

Such a breach would lead to economic turmoil, and Yellen has warned that even last-minute action could “cause serious harm to business and consumer confidence, raise short-term borrowing costs for taxpayers, and negatively impact the credit rating of the United States.”

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Health Providers Eligible for $25 Billion in Covid Relief Funds

September 10, 2021 12:33 pm

Doctors, hospitals, and other health-care providers are eligible for a new release of $25.5 billion in pandemic assistance, the Health and Human Services Department announced Friday.

Of the funds, $17 billion will go to providers who can show they have lost revenue and expenditures between July 1, 2020 and March 31, 2021. Another $8.5 billion, included in the March $1.9 trillion pandemic-related stimulus package known as the American Rescue Plan Act, will go to doctors and other health workers who serve rural Medicare and Medicaid patients.

“This funding critically helps health care providers who have endured demanding workloads and significant financial strains amidst the pandemic,” HHS Secretary Xavier Becerra said in a statement. “The funding will be distributed with an eye towards equity, to ensure providers who serve our most vulnerable communities will receive the support they need.”

The $17 billion will go to smaller providers “who tend to operate on thin margins and often serve vulnerable or isolated communities” at a higher rate than larger providers. Facilities that serve Medicare and Medicaid patients will also get bonus payments, at Medicare payment rates, “to ensure equity for those serving low-income children, pregnant women, people with disabilities, and seniors.”

The $8.5 billion will go to providers based on the amount of services they provide to rural Medicare and Medicaid patients, also based on Medicare payment rates.

Acting Health Resources and Services Administrator Diana Espinosa said, “We are committed to distributing this funding as equitably and transparently as possible to help providers respond to and ultimately defeat this pandemic.”

Providers can begin applying for funds Sept. 29.

The HHS also released how it calculated previous payments from the last phase of the Provider Relief Fund, the congressionally approved fund administered by the HHS that’s designed to help health-care entities that have financially struggled during the pandemic. Providers can request their payments be reconsidered if they believe it wasn’t calculated correctly.

Health providers will also have an additional 60 days to meet the fund’s reporting requirements due to “recent natural disasters and the Delta variant,” the HHS said.

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HHS Calls for Authority to Negotiate Medicare Drug Prices

September 9, 2021 9:44 am

The Biden administration is calling for Congress to pass a set of proposals already backed by Democrats to lower prescription drug prices, including one to let the government negotiate prices with drugmakers.

The proposals unveiled Thursday are part of a long-awaited report from the HHS to the White House that offers a wide-ranging series of recommendations on curbing rising drug costs. Lawmakers have pushed for much of these proposals for years, and former President Donald Trump took action on some.

The Health and Human Services Department attributed the high cost of prescription drug prices in the U.S. to “lack of competition,” and said Americans pay more than $1,500 per person a year for medications.

The HHS said the pharmaceutical industry is “characterized by multiple market failures,” attributable to several factors, including “monopolistic or oligopolistic behavior” and “legal abuses.”

U.S. prescription drug prices are 1.9 times as high as those in other Organisation for Economic Co-operation and Development countries, including rebates, according to a RAND study. U.S. insulin prices are about four times higher. Spending on retail prescription drugs represented 10% of national health spending and 13% of out-of-pocket spending in 2019.

“Life-saving prescription medication should not cost anyone their life savings. Yet too often, many low-income families cannot take their prescription medications because of cost concerns,” Health and Human Services Secretary Xavier Becerra said in a statement. “By promoting negotiation, competition, and innovation in the health care industry, we will ensure cost fairness and protect access to care.”

Backing House Democrats’ Proposal

The plan backs a proposal that House Democrats have long wanted to see pass, allowing the HHS secretary to negotiate the price of drugs in Medicare—both those administered in a doctor’s office and those obtained in a retail pharmacy—with drug companies and making those prices available to commercial insurance plans and employer-based plans.

Employers have urged the administration to allow Medicare to negotiate drug prices that private sector purchasers would also have access to, a policy included in the Biden administration’s plan.

“If price protections aren’t extended to employers and employees, the cost balloon will be pushed down for Medicare and everyone else will pay for it,” Elizabeth Mitchell, chief executive of the Purchaser Business Group on Health, said in a statement Tuesday. The group includes large employers like Walmart, Boeing, and Intel.

House Democrats are expectedto reveal their policy agenda for drug pricing as soon as Friday, Democratic aides and lobbyists told Bloomberg Government. The House plan will align closely with their signature drug pricing bill (H.R. 3), which the House has already passed in a previous session. Senate Finance Chairman Ron Wyden (D-Ore.) has said allowing the government to negotiate with drugmakers will be a key part of his bill.

Drugmakers are vocally opposing H.R. 3 and its excise tax on drugmakers that won’t negotiate with the government.

If industry doesn’t agree to the prices proposed by the HHS secretary, under H.R. 3 there would be a penalty of 95% of sales. Ken Frazier, executive chairman of Merck’s board of directors, told reporters Wednesday that is not negotiation, but a “substitute for the words price controls.”

“We cannot support, and we will not support the very dangerous idea of allowing the government to simply set prices,” Frazier said.

However, the drug giant would support “mechanisms that would give the government—specifically Medicare—the negotiated prices in the private sector, the best prices available commercially.”

Advocacy groups are ramping up campaigns to influence lawmakers and public opinion. The group Patients For Affordable Drugs Now launched fresh TV ads this week urging Congress to support the drug-price negotiation plan.

The HHS plan is in response to a July executive order from President Joe Biden that called for a plan to “combat excessive pricing of prescription drugs and enhance domestic pharmaceutical supply chains, to reduce the prices paid by the Federal Government for such drugs, and to address the recurrent problem of price gouging.”

Other Recommendations

The HHS plan also calls for legislation to create:

• a cap on out-of-pocket spending for the Medicare prescription drug benefit;
• “slow price increases over time on existing drugs;”
• hastening the entry of generic and biosimilar drugs to the marketplace; and
• Biden’s proposal for a new special projects agency to be housed within the NIH that aims to speed up game-changing biomedical discoveries, known as the Advanced Research Projects Agency for Health.

The HHS will also look at putting into place several policies that don’t require action from lawmakers, including:

• paying for Medicare drugs based on the clinical value they provide patients;
• collecting data from insurance companies and pharmacy middle managers about prices, rebates, and out-of-pocket spending; and
• developing a program to allow the importation of drugs from other countries, among others.

The plan suggests Medicare can use existing authority to bring down prices by linking payments for physician-administered drugs to patient outcomes. That may be relevant as the agency weighs how to reimburse for Biogen Inc.’s new Alzheimer’s drug. Regulators granted the the $56,000-a-year therapy accelerated approval despite uncertainty about its ultimate clinical benefits to patients.

Medicare’s innovation center could use mandatory models that tie drug reimbursements “to factors such as improved patient outcomes, reductions in health disparities, patient affordability, and lower overall costs,” the drug price plan says. The document doesn’t refer to Aduhelm specifically.

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Democrats Reopen Old Health Care Wounds with $3.5T Mega-bill on the Line

September 8, 2021 11:48 am

Hours after House Democrats launched a major, health care-focused piece of their pitch to turn $3.5 trillion of social spending dreams into law, it ran smack into a political brick wall.

The party’s growing problem is twofold: On one hand, the White House and Senate are keeping their distance from the House’s proposal to divvy up hundreds of billions of dollars between a progressive push for a massive expansion of Medicare benefits and a leadership-driven quest to permanently strengthen Obamacare. On the other, progressives who got a lot of what they wanted in draft legislation the House Ways and Means Committee released Tuesday night are still unhappy with colleagues who would rather use the party’s health care dollars on making expanded subsidies for Affordable Care Act coverage permanent.

The speed with which Democrats’ health care drama leaked from behind closed doors underscores just how bumpy the ride will be as they attempt, in just a few weeks, to muscle through the most expansive shakeup of the social safety net in decades.

Democrats on the Ways and Means Committee are set to begin considering a huge chunk of their party-line bill on Thursday, yet are already privately predicting they’ll end up getting strong-armed by the White House and Senate into taking the Medicare expansion championed by Sen. Bernie Sanders at the expense of the ACA.

And the angst on the left is more complicated than the typical progressives-versus-moderates dynamic — it’s the latest chapter in a long-running debate between those who want to focus on shoring up Obamacare and those who want to move toward a “Medicare for All”-style model. As both factions battle, the bulk of President Joe Biden’s domestic agenda is hanging in the balance.

“I’m not going to be quietly sitting on the sidelines and watching all the people eligible for Medicare treated royally and the people who depend on Medicaid be neglected,” House Majority Whip Jim Clyburn (D-S.C.) said, noting he’s made Biden aware of his preference for solidifying an Obamacare Medicaid expansion aimed at low-income Americans, including minority communities in red states like his. “I’ll stand up to anybody with that position. I don’t care who it is.”

On its surface, the health careclash pits Sanders, the Senate Budget Committee chair, against House Speaker Nancy Pelosi and her leadership team, who are leading the charge to shore up the Affordable Care Act. Yet its roots go deeper: Senate Majority Leader Chuck Schumer, who never signed onto Sanders’ Medicare for All bill, is in his corner for the current clash as the upper chamber digs in to defend its approach to the multitrillion-dollar social spending bill. Schumer touted a “robust and historic expansion of Medicare” to reporters on Wednesday morning.

While Pelosi and her allies also support the Medicare benefits — a senior Democratic aide noted that they’ve been part of the speaker’s drug bill for years — they and several outside advocacy groups are pushing the party to prioritize the populations most vulnerable to prospective GOP rollbacks of the health law.

On Wednesday, Pelosi publicly downplayed the battle, saying “both will be present; that’s not a problem.” But behind the scenes, the House leadership camp argues that taking away benefits from seniors on Medicare would be more politically difficult for a future Republican Congress.

Meanwhile, the House progressive camp wants to spend significant money on expanding Medicare to cover vision, hearing and dental benefits for seniors. But despite the massive size of Democrats’ bill, there’s not enough money in their pot to please everyone. Even the ambitious draftplan released by Ways and Means Chair Richard Neal (D-Mass.) Tuesday night, which a source close to the negotiations warned had not received White House or Senate buy-in, caused agita on the left.

That’s because the Ways and Means proposal wouldn’t fully phase in dental benefits until 2032.Progressives say they’ve already compromised enough, arguing that they’ve already backed down on Medicare for All and lowering Medicare’s eligibility age.

“We need to be 100 percent for universal health care, and we are so far from that today,” said Rep. Pramila Jayapal (D-Wash.), the Progressive Caucus chief who is pushing for Medicare to cover more people with more generous benefits. “We need to recognize that while the ACA did many good things, just providing subsidies to private insurance is not the way to move forward.”

The left’s disappointment extends beyond the pace of the dental benefits roll-out, though negotiations are ongoing. Only half the cost of major dental procedures would be covered — far less than the 80 percent some advocates had demanded. And many key expenses, like over-the-counter hearing aids, wouldn’t be covered atall.

Rep. Lloyd Doggett (D-Texas), who chairs the Ways and Means subcommittee that will begin marking up the legislation on Thursday, is concerned that the limited coverage previewed Tuesdaywould put the new dental benefits out of reach for low-income seniors.

“It’s false hope for poor people,” he lamented. “They won’t be able to use the service.”

But while skimping on new Medicare benefits may anger progressives, it frees up scarce dollars for shoring up Obamacare and expanding Medicaid to cover 2 million uninsured people in red states that didn’t expand their programs under Obamacare — top priorities for Pelosi and House moderates, as well as progressives like Doggett who represent states that have refused to expand Medicaid on their own.

House leadership argues that the enhanced Obamacare subsidies Congress approved in March, which are set to expire at the end of next year, have to be made permanent given the likelihood that a future Republican majority could refuse to extend them later on. ACA supporters point to the fact that the temporary Obamacare enhancements were a major reason why the rate of uninsured people didn’t soar when millions lost their jobs during the pandemic.

“I’m not going to pick among my children,” said Rep. Diana DeGette (D-Colo.), referencing the different Democratic health components of the social spending bill. “But we need to keep the ACA subsidies — that’s what is enabling millions of people to get health care coverage.”

The House committee markups that willlast through this week and next won’t fully resolvethe dispute. Not only does the full House still have to debate, amend and pass its bill, but the Senate — where Democrats have a much slimmer majorityand a more centrist caucus that will likely chafe at the Ways and Means approach — will have its say in the coming months.

And the health care question is just one of many consequential policy battles Democrats will have to litigate quickly if they want to get the social spending plan to Biden’s desk this fall, as planned. The ambitious legislation will try to encompass everything from paid family leave to action on climate and an overhaul of the nation’s immigration laws.

But the mounting tension over health care goals is pushing leadership to investigate every option. Aides to Pelosi this week embarked on a long-shot search for more sources of revenue or savings in addition to the hundreds of billions of dollars expected from the bill’s bid to let Medicare negotiate the price of some drugs, according to two Democratic sources. If that pays off, itcould allow more spending on both public and private insurance.

Yet most Democrats see inevitable and tough choices on how to spend the health care dollars on the table.

“I’m very much aware of the competing priorities here, and they’re all meritorious,” Doggett said. “But there’s clearly not enough revenue to do all that needs to be done.”

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Half of Hospitals Couldn’t Share Data with Public Health Agencies, Survey Says

September 7, 2021 4:15 pm

Half of privately owned U.S. hospitals lacked the ability to electronically share data with public health agencies in the run up to the Covid-19 pandemic, potentially hampering agencies’ response to the virus, according to newly released survey findings.

The hospitals in question were either unable to send the data or agencies were unable to receive it in 2018 and 2019. Forty percent of hospitals surveyed in 2019 said issues such as technology cost or complexity complicated sending the data.

The American Hospital Association data, which was published in an Office of the National Coordinator for Health Information Technology report, also showed interoperability worsened during the period studied due to differing vocabulary standards. Nearly three quarters of hospitals reported at least one challenge in sharing data with agencies.

“A majority of hospitals experienced public health reporting challenges that could impact public health agencies’ ability to monitor and respond to disease outbreaks,” the report said.

Rural and critical access hospitals surveyed were disproportionately likelier to face issues with pulling pertinent EHR information from records and confusion over where to send data, according to the report.

Background: The survey comes after the pandemic exposed the nation’s patchwork public health data system. States failed to control the virus due to outdated surveillance systems that prevented them from using real-time data in decision-making, a six-month POLITICO investigation found.

The investigation found that some hospitals didn’t report data to agencies or didn’t do so in a timely enough manner. The Trump administration attempted to address some of the problems by requiring hospitals to submit data to a private contractor as well as the CDC. But CDC officials said they were left out of the process and unable to verify the data.

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Intraparty Squabble Casts Shadow over Democrats’ Fiscal Agenda

September 7, 2021 6:00 am

House Democrats secured a temporary truce last month in their internal dispute over economic priorities, but the solution to their standoff all but guarantees another clash by the end of September.

The disagreement between the party’s moderate and progressive wings is ostensibly over the sequencing of two big bills that make up the bulk of President Joe Biden’s economic agenda. A Senate-passed bipartisan infrastructure bill would provide $550 billion in new spending on roads, bridges, transit, broadband and water projects, and a mostly unwritten partisan budget reconciliation package could add another $3.5 trillion on “human” infrastructure, including subsidies for child care, education, paid leave, health care, clean energy programs and more.

The crux of the dispute, however, is about which faction would have the most leverage over the reconciliation package, which House committees are putting together in markups that began last week. The filibuster-proof reconciliation process allows Democrats to pass their economic priorities without Republican support, but they must be unified since they can’t lose a single vote in the Senate or more than three in the House. 

Progressives want the infrastructure and reconciliation bills linked to ensure moderates don’t sink or water down the latter. Speaker Nancy Pelosi, D-Calif., embraced the strategy, repeatedly promising the House would not take up the infrastructure bill until the Senate passed the reconciliation package. But moderates balked, saying Democrats should claim the win from the infrastructure bill and then have a debate about the size and scope of the reconciliation package. 

The tensions came to a head in late August as the House considered the fiscal 2022 budget resolution containing instructions for the reconciliation bill. Ten moderates publicly threatened to vote against the budget without the House voting first on the infrastructure bill, the same order that occurred in the Senate.

The moderates relented after securing language ensuring the House will consider the infrastructure bill by Sept. 27. They also received a separate commitment from leadership that the House will “pre-conference” the reconciliation package with the Senate.

The initial group of nine moderates who threatened to vote against the budget — Reps. Josh Gottheimer of New Jersey, Ed Case of Hawaii, Kurt Schrader of Oregon, Carolyn Bourdeaux of Georgia, Jared Golden of Maine, Jim Costa of California and Texans Filemon Vela, Henry Cuellar and Vicente Gonzalez — issued a statement claiming their strategy succeeded. 

“This agreement does what we set out to do: secure a standalone vote for the bipartisan infrastructure bill, send it to the president’s desk, and then separately consider the reconciliation package,” they said. “It will receive standalone consideration, fully delinked, and on its own merits.”

But progressives didn’t see it that way. 

“Our position remains unchanged: we will work to first pass the … reconciliation bill so we can deliver these once-in-a-generation, popular, and urgently needed investments to poor and working families, and then pass the infrastructure bill to invest in our roads, bridges, and waterways,” Congressional Progressive Caucus Chair Pramila Jayapal, D-Wash., said in a statement. “The two are integrally tied together, and we will only vote for the infrastructure bill after passing the reconciliation bill.” 

Both sides believe they’ve got the leverage needed to execute their dueling strategies.

“What this little ‘private equity caucus’ has shown is that they’re erratic,” Rep. Alexandria Ocasio-Cortez, D-N.Y., said of the moderate rebels, in an apparent dig at some members’ ties to financial services and investment firms. “And there’s not much you can do with kind of an erratic group like that, aside from keep a steady course.” 

Progressives say a majority of their 96-member caucus is willing to vote against the infrastructure bill unless the Senate first passes a reconciliation package that fulfills their top priorities — such as affordable housing and climate programs, lowering prescription drug costs and expanding Medicare and providing a path to citizenship for certain categories of undocumented immigrants. 

“The commitment on this strategy to move both of these pieces simultaneously still remains,” Rep. Ilhan Omar, D-Minn., the Progressive Caucus whip, said.

The only thing that would take away progressives’ leverage is if enough House Republicans support the infrastructure bill to offset their opposition. 

If the infrastructure bill had been brought up for a vote last month as moderates initially demanded, there would have been “a significant number” of Republicans supporting it, “potentially” more than 40, according to Rep. Brian Fitzpatrick, R-Pa. But now he’s not sure if those numbers will hold.

“A lot of them, their support was contingent upon it not being in any way, shape or form tied to reconciliation. Now, many of them are going to view this as being tied,” Fitzpatrick said. “Some of them will view it as not being tied. And that’s what I need to find out.”

Fitzpatrick, who co-chairs the Problem Solvers Caucus with Gottheimer, said his Democratic colleagues in the caucus made a deal they felt was necessary but it’s “certainly not the way I would have played my hand.”

Timing matters 

Democratic leaders are trying to avoid those obstacles to the infrastructure bill by getting the reconciliation bill done first. Although they’ve not officially made any scheduling decisions, leaders indicated they want to bring the reconciliation package to the floor the week of Sept. 20. 

“That is ambitious given the amount of conversations that need to be had between the two chambers,” Rep. Stephanie Murphy said. The Florida Democrat became the 10th moderate to publicly threaten to oppose the budget after leadership rebuffed her efforts to negotiate privately on scheduling the infrastructure vote and de-linking it from reconciliation.

One of the things Murphy and others successfully pushed for is to have the House pre-conference the reconciliation package with the Senate. The moderates want to ensure whatever the House passes can get the support of all 50 Senate Democrats, with Vice President Kamala Harris able to break a tie.

“We’re not going to vote on a measure that doesn’t have 51 votes in the Senate,” Costa said. 

The reconciliation package won’t be ready to assemble until the House committees finish their individual markups, the last of which are expected to wrap up by the nonbinding Sept. 15 deadline written into the budget resolution. It’s likely to take more than a week to get Democrats in both chambers to unify around a final product, especially with Sen. Joe Manchin III, D-W.Va., calling to “hit the pause button” on the measure given a variety of economic unknowns.

One thing that could take some time is getting the Senate parliamentarian to issue opinions on which provisions comply with the Byrd rule, named for its author, former Sen. Robert C. Byrd, D-W.Va. The rule requires policies included in reconciliation to have a budget impact that is not just “merely incidental,” among other stipulations.

There are several policies Democrats want to include that Republicans are likely to challenge under the Byrd rule, like providing a path to citizenship for millions of undocumented immigrants, extending Medicare-negotiated prescription drug price limits to private insurers and taxing carbon-intensive imports.

Moderates want any language that doesn’t comply with the Senate rules removed before the House votes on it, unlike in March when the House passed a coronavirus relief measure including a provision to raise the minimum wage that was stripped in the Senate after the parliamentarian deemed it merely incidental.  

The group of 10 moderates, plus allies who never took their concerns public in the budget fight, are also planning to make sure the House doesn’t assemble a package that’s too big to get through the Senate. Manchin and fellow moderates Sen. Kyrsten Sinema of Arizona have said they won’t support the $3.5 trillion topline leadership and the White House have set.

The House centrists are working with their Senate counterparts to identify “what revenues are acceptable and where spending should be,” Murphy said. “We are having these conversations, irrespective of what our committees and the committee staff are doing.” 

But Murphy, the only member of the moderate group who serves on the tax-writing Ways and Means panel, communicates regularly with committee staff and leadership about what policies are unlikely to get enough moderate votes. “I think it’s my responsibility to send up an early signal,” she said.

If moderates’ input isn’t incorporated in committee markups, they will have leverage to influence the final product before it reaches the floor. They’re prepared to reluctantly oppose the reconciliation package or the House rule that will be needed to bring it to the floor as a last resort.

“My hope is that leadership is open to all the voices within their caucus, so that we can avoid any last-minute scrambles,” Murphy said. 

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