Politics is Personal & Other Lessons (Re)Learned in Reconciliation

10/25/21 01:28PM EDT

Editor's Note: Below is a brief excerpt from a complimentary Health Policy Unplugged note written by our Health Policy analyst Emily Evans. Click HERE to learn more about Emily's research process and the analysis subscribers receive.

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Passage of some reconciliation bill is expected this week.

No matter what comes out in the wash, the result will more likely than not represent a blow to the Biden administration’s goal to remake the U.S. economy. With some shredding of the Biden agenda will come the relearning of certain eternal truths of politics. Politics, after all, is very personal.

Lesson One: Unless you are in a senior leadership position and have some control over the legislative process, never trade votes. The core of the Progressive Caucus, many of them new to elected office demanded passage of the not-so-popular Build Back Better Act, as proposed apparently, before a vote on a long overdue infrastructure bill. The move was not well received, slowed the process down and allowed doubt to creep in as COVID receded and other, more serious problems have emerged.

Lesson Two: Don’t threaten a primary for the more moderate members of your party unless you can figure out a way to avoid getting caught. Most consultants, including those most instrumental in fundraising, will not work with a candidate that challenges an incumbent. Most tenured members know their districts and have a long-developed sense of what sells at home. Interference in local politics makes you untrustworthy especially if you lose (which you will).

Lesson Three: Stay out of the district/state represented by a colleague with whom you disagree unless invited (you won’t be). Op-eds penned for a district or state newspaper hundreds of miles from the one you represent will not be well received by your colleague or the voters he/she represents.

These mistakes and others will lead to a Build Back Better Bill that is probably a mere shadow of its former self. Health care policies are likely to fare better than those for climate, if President Biden’s comments at the CNN townhall meeting last week are interpreted correctly.

We should see some changes to Medicaid including a massive funding of Home and Community-based Services, filling the Medicaid gap in non-expansion states and maybe another short-term extension in ACA policy eligibility threshold.

Or maybe there will be no bill at all.

Personally, if I were a moderate in the House, I would take my phone off the hook until after the Terry McAuliffe v. Glenn Youngkin Virginia Governor’s race is decided.

Politics is Personal & Other Lessons (Re)Learned in Reconciliation - 20211024P3


Home and community-based services are provided under Medicaid state plans to provide non-institutional care primarily to the Intellectually/Developmentally Disabled (IDD) and the Aged and Disabled.

Home and Community-based services are usually provided in the home or in a community day-care type setting.

The program has many merits. It de-institutionalizes patients and places them in a setting that is often safer and socially and mentally stimulating, resulting in happier, healthier patients.

It addresses an ongoing crisis of care created as elderly parents of IDD patients age and become unable to provide the full range of home-based care they could when they were younger.

It also addresses the secular decline in nursing facility care brought on by patient preference and labor availability, accelerated by the COVID-19 pandemic.

Politics are also playing a role. One reason many states have previously ignored the option of Home and Community-based services is the strength of the nursing facility lobby which rightly points out that, after hospitals, their taxes play a significant role in financing all Medicaid services. The proposed $150-$400B would ease the concerns many state legislatures would have.

Another political consideration is the time-honored tradition of carving out constituencies that will support and defend the program long after the current administration is gone. (As an aside, next time you are in Austin, TX stop by the LBJ presidential library and listen to his tape-recorded conversations about civil rights and health care legislation. You will see what I mean.)

Home care and community-based service programs frequently permit reimbursement to family members to whom patient care has fallen. Both groups will enthusiastically support the program’s passage and its persistence.

It isn’t the dumbest policy in the world, but the robust funding is certain to drive up costs associated with the program – another time-honored tradition in health policy – making labor woes more acute.

Another important question that hangs in the air is just how long this policy will be necessary. The largest portion of people on HCBS wait lists are for intellectually and developmentally disabled individuals.

Advances in prenatal testing now mean that 67% of pregnancies are terminated when the presence of common causes of intellectual disabilities, like Down’s Syndrome, are detected.

Advances in perinatal care have nearly eliminated traumatic births that have, in the past, led to both developmental and intellectual disabilities of an intensity that limits or prevents independent living. Increasingly catastrophic injuries that once led to loss of independence are being addressed by medical advances.

Could the HCBS become a policy priority in search of a problem?


The biggest criticism being leveled at increased funding for the Home and Community-based Services program, is that states have placed a priority on funding Medicaid services for able-bodied childless adults through the ACA expansion instead of fulfilling the original intent of the Medicaid program.

Could be true except that the vast majority (on an absolute and per capita bases) of the wait list for Home and Community-based services can be found in Texas and Florida, two states that have not expanded Medicaid. (2018 data).

If that data holds up, the biggest recipient of the reconciliation bill’s largess will be…. Texas.

The irony.

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