People talk about the cost of that big federal bill but don’t know what’s in it

by Michael Hiltzik

The most glaring flaw in media coverage of Washington is that it focuses heavily on process and seldom on substance. That’s certainly been the case with coverage of the Build Back Better Act, the comprehensive reform package now being dickered over on Capitol Hill.

If you’re following the debate via the news, you probably have heard about the measure’s overall price tag, most often placed at $3.5 trillion; the media aren’t always careful to specify that that’s the estimate of spending over 10 years.

What you may not know as much about is what’s actually in the act — in other words, what all that spending will pay for. That’s important because thanks to the way Washington is covered, Americans tend to turn negative about big legislative measures, even though they’re in favor of the individual provisions.

A CBS News/YouGov poll taken this month found that 57% of respondents either didn’t know what’s in the spending plan or have only a general, nonspecific impression; only 10% knew “a lot of the specifics.”

So we’ll fill you in. What follows is a piece-by-piece rundown of some of the most important provisions of the Build Back Better Act. Not all the provisions, of course — the measure weighs in at 2,456 pages, so a lot in there won’t make it into this column.

A closer look at how the act would remake America’s approach to health care, childcare, global warming, education and taxes might show how impertinent the cheeseparing complaints of deficit hawks like Sen. Joe Manchin III (D-W.Va.) are to the goal of making the U.S. economy more responsive to the interests of all Americans, not just the wealthy.

The middle class, working class, children and the medically underserved have been left behind during the last several decades of economic growth. The Build Back Better Act would start to redress the imbalance.

Let’s start with health care

Two provisions of the bill — making enhanced subsidies for purchases of Affordable Care Act health plans permanent, and filling in the gaps left by the refusal of 12 states to expand Medicaid under the ACA — would reduce the ranks of America’s medically uninsured by 7 million, or 25%, in 2022. That’s according to the Commonwealth Fund.

The bill would make permanent the ACA premium subsidy changes enacted in March by the American Rescue Plan, the Biden administration’s COVID relief act. That act eliminated the subsidy cliff of the original ACA, which cut off subsidies for households that earned even a penny more than 400% of the federal poverty level (that is, $106,000 for a family of four this year).

The subsidies were redesigned so no household would have to pay more than 8.5% of its income for a benchmark silver ACA plan. The subsidies were therefore made theoretically available to everyone. Lower-income families would still be entitled to more help: Those earning from 100% to 150% of the poverty line ($26,500 to $39,750 for a family of four) went from a maximum premium of 4.14% of income to a zero premium, for instance.

The COVID relief act also offered Medicaid holdout states greater incentive to expand that program for low-income residents by giving them a 5 percentage-point boost in the federal reimbursement for their traditional Medicaid spending — a sum that would exceed their costs in expanding Medicaid to cover residents earning less than 150% of the federal poverty level, the target population for the expansion. The cost of the expansion program would still be 90% covered by the federal government.

If all 12 holdout states accepted that deal, they’d receive a total of $16.4 billion in federal funds over two years for the cost of about $6.8 billion in expansion. Texas, for example, would spend less than $3.2 billion on expansion but gain more than $5 billion from the increased share.

Republican leaders in the 12 holdout states are still too dense or ideologically addled to have taken the government up on its offer, so the Build Back Better Act tries a different approach.

The act would take the issue out of the states’ hands by creating a new entirely federal Medicaid program to serve the roughly 2.2 million uninsured adults who fall into the gap in non-expansion states — chiefly Florida, Texas, Georgia and North Carolina — starting in 2025. Some 60% of those uninsured adults, by the way, are people of color.

The act would appropriate $75 million over the next three years for education and outreach about ACA plans, reversing actions by the Trump administration that cut that important spending effectively to nothing as part of Trump’s determined sabotage of the ACA.

The measure would also significantly expand Medicare by adding vision, hearing and dental coverage beginning in 2022, 2023 and 2028, respectively.

Medicare members would be eligible for subsidized eye tests and frames every two years and up to two oral exams and cleanings a year, as well as subsidies for treatments up to and including bridges and crowns.

As my colleague David Lazarus has reported, the dental benefits have run into opposition from the American Dental Association because it would involve lower reimbursements for dental services than dentists can charge now. Plainly they should stick their objections in their pockets.

Michael Hiltzik is a columnist for the Los Angeles Times.

EDITOR’S NOTE: Due to its length, Michael Hiltzik’s column will be continued tomorrow, Oct. 19.