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Illustration: Sarah Grillo/Axios

The Democrats' reconciliation bill includes several major health care pieces backed by different lawmakers and advocates, setting up a precarious game of policy Jenga if the massive measure needs to be scaled back.

Between the lines: Health care may be a priority for Democrats. But that doesn't mean each member values every issue equally.

Why it matters: As the party continues to hash out the overall price tag of its giant reconciliation bill, it's worth gaming out which policies are on the chopping block — and which could potentially take the entire reconciliation bill down with them.

There are clear winners of each pillar of Democrat's health plan:

  • Seniors benefit from expanding Medicare to cover dental, vision and hearing benefits.
  • Low-income people — primarily in the South and disproportionately people of color — in non-expansion states benefit if the Medicaid gap is closed, giving them access to health coverage.
  • Affordable Care Act marketplace enrollees benefit if the increased subsidy assistance that Democrats enacted earlier this year is extended or made permanent.
  • Elderly and Americans with disabilities benefit from an expansion of their home-based care options, and their caretakers benefit from a pay bump.
  • Seniors — and potentially anyone facing high drug costs — benefit if Medicare is given the authority to negotiate drug prices, although the drug industry argues it will lead to fewer new drugs.

Yes, but: Each of these groups face real problems with health care access and affordability. But when there's a limited amount of money on the table — which there is — even sympathetic groups can get left in the dust.

Each policy measure, however, also has powerful political advocates. And when Democrats have a razor-thin margin in both the House and the Senate, every member has a lot of power.

  • Seniors are disproportionately powerful on their own, due to their voting patterns. But expanding what Medicare covers is extremely important to progressives — including Sen. Bernie Sanders.
  • Closing the Medicaid gap is being framed as a racial justice issue, given that it disproportionately benefits people of color. And although many Democrats hail from expansion states — particularly in the Senate — some very powerful ones represent non-expansion states.
  • These members include Sen. Raphael Warnock, who represents Georgia and is up for re-election next year in an extremely competitive seat, and Rep. Jim Clyburn, who arguably is responsible for President Biden winning the 2020 primary.
  • The enhanced ACA subsidies are scheduled to expire right before next years' midterm elections. Democrats' hold on the House is incredibly shaky already, making extending the extra help a political no-brainer.
  • Expanding home-based care options was one of the only health care components of Biden's original framework for this package. But aside from the president's interest in the issue, unions care a lot about it as their members stand to gain a pay raise — and Democrats care a lot about what unions care about.
  • And finally, giving Medicare the power to negotiate drug prices has the most powerful opponents, theoretically making it vulnerable to the chopping block. But it also polls very highly, and perhaps even more importantly, produces enough government savings to help pay for these other health care policies.

The bottom line: "From a political perspective, none of these health care proposals seem very expendable," said KFF's Larry Levitt.

  • Most — if not all of them — can be scaled to save money.
  • But there are also powerful constituencies for the other components of the bill that address issues like child care and climate change, meaning these health care measures aren’t only competing against one another.
  • And, Levitt points out, "there's always a difference between members of Congress staking out positions and being willing to go to nuclear war over them."

Go deeper

Texas loses billions to child care breakdowns

Illustration: Sarah Grillo/Axios

A dearth of affordable child care is putting a massive dent in the Texas economy.

  • Parents are missing work or leaving jobs to take care of children in a landscape pock-marked by the pandemic and labor shortages, according to new research by the U.S. Chamber of Commerce Foundation.
Updated Dec 2, 2021 - Axios Events

Watch: A conversation on health equity in 2022

On Thursday, December 2nd, Axios health care reporter Tina Reed and congressional reporter Alayna Treene examined persisting health equity issues and the work underway to close gaps in access, featuring Rep. Robin Kelly (D-Ill.), Baltimore City Health Department Commissioner Letitia Dzirasa, and Brown University dean of the School of Public Health & Professor of Health Services, Policy, & Practice Dr. Ashish K. Jha.

Dr. Ashish K. Jha identified the assumptions policymakers should be making about coronavirus through the winter season, what the pandemic highlighted in terms of health equity issues, and the most powerful tools to funding health inequity solutions.

  • On what policymakers should consider for coronavirus next year: “The big picture point I would make to policymakers is 2022 really should be our pivot year, the year we take this acute phase of the pandemic and turn it into something that we’re going to manage more chronically over the long run. What do we need to do that? Obviously, we need to continue to get more Americans vaccinated.”
  • On the pandemic’s exposure of longstanding health inequities: “It’s taken all of the challenges we’ve had, all of the longstanding inequities we’ve had in our country and really exposed them in a way and made them worse. It hasn’t created new inequities. I would say these inequities have existed for a long time, what it has really done is just highlight them in a way that is now hard to ignore.”

Rep. Robin Kelly discussed the health care initiatives in the Build Back Better agenda, the obstacles to health equity progress, and the policy provisions shaping next year’s health care agenda.

  • On obstacles standing in the way of progress: “People have different lenses, and I think that people know we need to get these things done. There’s no excuse for our maternal mortality rates, the health care disparities. COVID put a great big spotlight on the inequities and the disparities in this country.”
  • On upcoming health care policy priorities: “I think the Build Back Better Act is a great first step, but we’ll still be discussing maternal mortality, we’ll still be looking at health equity, we’ll still be looking at diversifying the health care pipeline, diversifying clinical trials, lowering prescription drug costs.”

Letitia Dzirasa explained potential impacts of the new Omicron variant on public health messaging, addressing health equity issues at a local level, and the public health challenges at the forefront for next year.

  • On looking at data and community input to inform health equity interventions: “I think it’s very important that we look at the data, that we understand the disparities and where they exist. But as we’re planning interventions and how best to implement a particular program or outreach method, we have to be community informed, so we’re looking to the community to plan alongside us.”
  • On the public health challenges defining the year ahead: “I think the important thing to note is that all of our other public health challenges did not go away because COVID came along, and so we’re going to be playing catch up in other public health areas for quite some time. I am encouraged by the increased federal funding going towards public health, but you have to remember this is an area that has been chronically underfunded.”

Axios Chief People Officer Dominique Taylor hosted a View from the Top segment with UnitedHealth Group senior vice president and chief health equity officer U. Michael Currie, who emphasized how addressing social determinants of health helps to advance health equity.

  • “You can’t have a conversation about achieving or advancing health equity and best addressing health disparities without having a real appreciation for what these social factors or social determinants of health have on individuals achieving their best possible health.”

Thank you UnitedHealth Group for sponsoring this event.

Watch: A conversation on pandemic-era innovations' impact on health care

On Dec. 8 at 12:30pm ET, Axios health care reporter Caitlin Owens will unpack pandemic-era innovations and the impact on health care in 2022 and beyond, featuring Rep. Cathy McMorris Rodgers (R-Wash.) and Scripps Research President & CEO Dr. Pete Schultz. Register.