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The Sophie's Choice of the Reconciliation Bill

Democrats may have to decide whether to do a few things well or a bunch
of things not so well. 

 

Senate Majority Leader Chuck Schumer speaks to reporters at the Capitol
as work continues on the Democrats' Build Back Better Act, September
14, 2021. (Andrew Harnik/AP Photo)

 

By David Dayen

The Build Back Better Act promises to finally remedy the disastrous way
we take care of the elderly in America. The pandemic revealed the perils
of warehousing seniors in understaffed and even dangerous nursing homes.
Large majorities prefer to age in place or receive assistance with a
disability at home, but the supportive care needed for this is
outrageously expensive and scarce. Poorer people must literally drain
all of their resources to get Medicaid to pay for home care, and even
then they can languish on a wait list for years. Moreover, while home
care work is one of the fastest-growing professions in the economy,
it's also one of the lowest-paid, averaging about $12 an hour.

Fixing home and community-based services (HCBS) involves two essential
stages: increasing affordable access to services, and raising the living
standards of the direct-care workforce. Making care work more
remunerative doesn't matter if not enough people can afford it, and
increasing access won't happen if the work is so low-paying that
people must constantly leave the profession.

Fixing both requires a lot of money. In the American Jobs Plan
,
the Biden administration put support for HCBS at $400 billion. But this
promise ran up against artificial scarcity
,
as reluctant conservative Democrats resisted the overall spending and
tax measures. First, the rumor was that only $150 billion

would be made available for HCBS. In the House Energy and Commerce
Committee markup of the bill, that expanded to $190 billion
, after a
concentrated push from activists.

But those activists maintain that the new figure is insufficient. A memo
that has been circulating around Congress and the White House explains
that you simply cannot meet HCBS goals on access or worker pay without
at least $250 billion, based on projections from the Congressional
Budget Office. Anything below that and states will opt out of the
provisions intended to make care work remunerative and accessible. "If
you don't have enough money, the first thing that will fall off is
direct-care wages," said Nicole Jorwic, senior director of public policy
at The Arc, an advocacy group for people with disabilities.

This would create a vicious cycle, Jorwic explained. The states that
aren't making the effort to improve care infrastructure on their own
won't get enough to fix it. And the states that are making the effort
may not see a lowball amount of federal support as worth adding a state
match to obtain.

The disability community has other goals in the legislation, including
changing the rules to bolster Supplementary Security Income

and ensuring better access to affordable prescription drugs
.
Given how an inadequate amount of money would fail to improve HCBS, I
put the question to Jorwic that nobody really wants to answer: Would you
rather get half of everything you want, or a workable policy on one of
your priorities?

She hesitated. "We're not going to ever say 'no thanks'" to money
for HCBS, Jorwic explained. "But after a pandemic where one-third of the
deaths were in nursing home facilities, you can't do a half-funded
proposal. It's not like other policies where you can truncate it."

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THIS HOBSON'S CHOICE, figuring out whether to live with less on every
policy in the Build Back Better Act, or to jettison some and make sure
the policies remaining actually work and are politically potent, is
agonizing for advocates and members of Congress. In a better world, this
choice wouldn't exist; the policies reflect critical human needs, and
deciding to punt on them yet again should be unacceptable. But the axis
of Sens. Joe Manchin (D-WV) and Kyrsten Sinema (D-AZ) has decided that
they must have a cap on both spending and revenues, which is forcing
these difficult conversations.

Adding to the frustration is the sheer number of policies in the
legislation. When you put all your priorities as a party into one bill,
you draw in every member who's been fighting for one part or another
for years. But when the overall toplines get cut, nobody wants to take
out their pet project. The only other option is to cut everything across
the board, which can lead to a slew of ineffective half measures.

We're seeing this play out in several ways. Some programs, like HCBS,
are just being cut. Others, like the dental benefit in Medicare
,
are being delayed for several years. This makes it look cheaper within
the ten-year budget window.

But that exacts a political cost. "Our investments need to be, number
one, transformative, and number two, felt immediately," said Rep.
Pramila Jayapal (D-WA), chair of the Congressional Progressive Caucus.
"People need to see that giving us the House, Senate, and White House
matters, literally feel it in their bones that their lives and
livelihoods are transformed."

Jayapal noted the victory

in the House Education and Labor Committee for a coalition of
progressive and frontline Democratic members, securing a universal child
care program (capping child care costs for all Americans at 7 percent of
income) over leadership objections. But she acknowledged that the
subsidies that would carry out that universal program phase in over six
years
.
"We're trying to get as many subsidies out in the first year as
possible," Jayapal said. But ultimately, it'll be a slow ramp-up, and
many will wonder what the child care benefit did for them.

Democrats have also worked the other end, forwarding policies that
sunset in a few years rather than making them permanent. The House
version of the expanded Child Tax Credit (CTC), for example, sunsets in
2025. Senate Democrats may opt for a year earlier
.

Manchin wants to add work requirements

to the CTC, which would limit it for the poorest families, a
self-destructive notion. Separately, the paid leave proposal in the
House acts as a stopgap on top of existing state and employer-based
programs. This also makes it cheaper but creates a logistical nightmare

for individuals and businesses.

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And so Democrats can either settle for these chinks in their programs,
making them in some cases not work for a lot of people, or they can
decide to do a few things well. It's a tough choice to make.

"We don't want half measures, we want stuff that's effective and
works," said Rep. Andy Levin (D-MI) on a press call on Monday. "The
Congress that's elected in 2026 will decide what happens in 2027 and
2028. The way we affect them is by creating programs that working
families say are right."

Rep. Mondaire Jones (D-NY) agreed with Levin on the call. "It's better
that we do programs well than do half measures that turn out not to
materially improve the lives of most people and do not engender the
broad support of programs like Social Security and Medicare."

Even moderates like Rep. Suzan DelBene (D-WA), who chairs the New
Democrat Coalition, have stressed the importance

of doing "a few things really well," singling out the CTC. But this
theory slams headlong into the realities of pitting programs against one
another, and nobody wanting their top priority to be put on the wait
list.

One of the reasons this becomes so hard is that the needs are so acute.
"All of these pieces are decades-long problems that the federal
government hasn't taken a look at," Jorwic said.

There is a possible safety valve. As the

**Prospect**'s Bob Kuttner reported this week
,
a potential deal is emerging that would allow Manchin to scale down
direct spending in the reconciliation bill, while including up to $1.5
trillion in "middle-class tax cuts." Some of these, like the CTC and
other low-earner taxes, were already in there. But you could fashion
child care subsidies as a tax cut, or do it for Section 8 housing
vouchers, or even create a tax cut for union membership
.
In short, do the spending through the tax code. That would potentially
allow something like $3.5 trillion in total outlays to meet Manchin's
approval.

But even if you did that, not everything can be translated into a tax
cut, and there will still be some hard choices. The question is whether
Democrats and their allies are willing to make them, or whether half
measures, which nobody seems to want, will rule the day.

To read more about infrastructure and the Build Back Better Act, check
out our series Building Back America
.

 

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