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."

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.

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.