President Biden’s proposed massive expansion of Medicaid home-based long-term care is running into trouble in the Senate. And it may be done in, not by hard-core conservatives, but by a small group of self-styled Senate moderates.

In his American Jobs Plan, Biden proposed increasing the federal share of Medicaid’s home and community-based services (HCBS) program by $400 billion—the largest increase n the program’s history. Following more than 150,000 covid-19 related deaths in long-term care facilities, Biden moved aggressively to encourage states to create alternatives for older adults and younger people with disabilities who are able to live at home, rather than in nursing facilities.

Biden pitched his bill as an infrastructure plan. And it included spending on traditional roads and bridges, a federally-funded expansion of broadband, and what Biden and many Democrats have come to call the “caring infrastructure,” including the long-term care provision.

Real infrastructure

Not surprisingly, the congressional GOP leadership never bought the idea. They have countered with a far smaller alternative that includes only what they have come to call “physical infrastructure” or “real infrastructure.”

But Democrats, who hold 50 seats in the Senate plus the vote of Vice-president Harris to break a tie, don’t need the majority of Republicans to pass the Medicaid HCBS expansion. They can do it with the 60 votes (including 10 Republicans) required to prevent opponents from blocking the bill through arcane Senate rules. Or they can do it with all 50 Democrats and no Republicans if they use a process called budget reconciliation.

The Democratic leadership, many on the party’s left flank, and probably Biden himself, would be happy to go the all-Democrats route.

Reluctant Democrats

The problem is that a small group of party moderates, led by West Virginia Senator Joe Manchin, will not support Biden’s ambitious plan, at least not now. They still are seeking a bipartisan compromise and with their support, Biden won’t even have 50 Senate votes..

The problem is that the compromises that have been floated so far are focused entirely on that  GOP definition of physical infrastructure and appear to exclude the Medicaid’s HCBS expansion. Biden and these Republicans are fighting over how much traditional infrastructure to fund and how to pay for it. But any expansion of Medicaid HCBS appears to be entirely off the table in these talks.

The Senate GOP negotiators, led by West Virginia’s other senator, Republican Shelly Moore Capito, released their latest alternative today. But the discussions appear to be going nowhere. One member of that group, Sen. Pat Toomey (R-PA) made the group’s position clear:  “An infrastructure agreement has to be about actual infrastructure, it’s about physical infrastructure,” he said following a meeting with Biden earlier this week.

Biden’s choices

With those negotiations foundering, Manchin helped put together yet another group of senators, this one with four Democrats and four Republicans, to try to find a compromise. But they too appear to be focusing on only physical infrastructure. They likely will settle on a spending number somewhere between the GOP offer and Biden’s latest proposal. But still without the Medicaid provision, which is a non-starter for Republicans.

So far, Biden continues to hold firm to his HCBS expansion but its fate is highly uncertain. Yet, his chances of getting even 50 Senate votes for his very large infrastructure bill, including the Medicaid HCBS expansion, seem close to zero.

The president can—and probably will– try to build a majority for a bill that includes only physical infrastructure and drops for now the HCBS expansion. If he goes that route, he could try to repackage Medicaid HCBS funding as part of a second bill that would almost certainly have to pass with Democratic  votes only. But it is not clear if Manchin and a few other Senate Democratic moderates would vote for that one either.

West Virginia

Manchin is in an interesting spot. He sees himself as a power broker, but he represents a state with  the second largest share of residents over age 65, about 45 percent of  them with a disability, and one-third receiving Medicaid assistance for long-term care.

Those extra long-term care dollars would seem awfully hard for Manchin to walk away from. Similarly, Susan Collins of Maine, a swing Republican vote and a member of the eight-senator task force, also represents a state that is both very old and very poor.

Progressive Democrats are getting increasingly impatient with ongoing infrastructure talks that they see as a pointless charade. They believe Republicans will never support a Biden infrastructure bill, no matter what is in it. But until he gets his own party in line, Biden’s ambitious Medicaid home-based care expansion will remain in real jeopardy.