Biden reconciliation framework includes Medicaid workaround, no Medicare dental or vision benefits

The White House-backed social spending framework will feature a pared-down expansion of both Medicare and Medicaid coverage as President Biden seeks to secure enough support to advance the legislation.

The framework, previewed for reporters Thursday morning ahead of Biden’s meeting with House Democrats, would offer four years of subsidized private health insurance on the Affordable Care Act (ACA) exchanges for people with lower incomes living in states that did not expand Medicaid under the health care law.

According to the White House, the plan would provide $0 premiums for 4 million people in the “coverage gap,” meaning they don’t earn enough to qualify for ACA subsidies but, since they live in a nonexpansion state, also make too much to qualify for Medicaid. 

The temporary plan is more industry-friendly than the proposal offered by House Democrats in September, which would have created an entirely new “Medicaid-like” government program to provide coverage in the 12 nonexpansion states.

While many Democrats backed the idea, it was opposed in recent days by Sen. Joe Manchin (D-W.Va.) and other lawmakers from states that have been paying for expanded Medicaid for years. They argued it wouldn’t be fair for their constituents if the federal government paid the whole cost of the holdout states to expand.

But at the same time, the temporary plan could be easier to set up and may avoid pushback from industry groups that worry a new federal program is a stepping stone to a larger-scale, government-run “public option.”

Backers of Medicaid expansion, including House Majority Whip James Clyburn (D-S.C.) and Georgia Democratic Sens. Raphael Warnock and Jon Ossoff, wanted it to run for as long as possible.

On Medicare, the framework will expand coverage for hearing benefits, which is just one-third of what progressives were pushing for. 

Sen. Bernie Sanders (I-Vt.) has drawn a line in the sand in recent days, saying that adding dental, hearing and vision benefits to Medicare in Democrats’ social spending package is “not negotiable.”

Progressives have long been pushing for expanding the Medicare benefits, but dental benefits especially were some of the most expensive.

The framework does include the extension of enhanced financial assistance to help people afford premiums under the ACA, a key part of Speaker Nancy Pelosi’s (D-Calif.) legacy.

According to the White House, the framework will reduce premiums for more than 9 million Americans who buy insurance through ACA exchanges by an average of $600 per person per year.