Trapped in his California house by worsening paralysis, Ady Barkan has a fervent wish: that Congress spend $400 billion so more poor and disabled Americans can get home health aides of their own.

“Home care is keeping me alive. I don’t think I could tolerate my paralysis if I were isolated in a nursing home instead of surrounded by the love of my children and wife every day,” Barkan wrote to The Washington Post, in a message the ALS patient typed using eye movement. “But millions of disabled people and their families aren’t as lucky as me.”

House Democrats say they agree with Barkan’s goal, if not its scope: Their plan to boost home care would cost $190 billion, a funding infusion they argue will be plenty transformative — especially because lawmakers are desperately trying to balance dozens of health priorities, from fighting obesity to pandemic preparedness, in their upcoming $3.5 trillion tax-and-spending package.

That package represents Democrats’ best opportunity in more than a decade to make sweeping alterations to the U.S. health-care system — which is why advocates, lobbyists and lawmakers are wrestling over each possible change, often making their cases in starkly personal terms.

And as Democrats attempt to construct a bill that can pass both chambers of Congress, delicately shifting policies as if they’re Jenga blocks, the legislative logjam is exposing fissures within the party over which priorities are most important for patients, which provisions are most politically beneficial and how much the government should spend.

Jane Morgan is the sole caregiver to her boyfriend, Conner Slevin, who was paralyzed last year. If they marry, her salary for caregiving will get reduced. (Amber Ferguson, Derek Knowles/The Washington Post)

At the moment, the House and Senate disagree over how to increase dental coverage, how much to fund federal subsidies for health insurance, how to help some of the nation’s poorest leave the ranks of the uninsured — and which of those long-standing areas of Democratic consensus are most crucial. Meanwhile, a few key Democratic defections over a drug-pricing plan now threaten the entire package.

This jockeying is playing out within a budget process known as reconciliation, which, given the slender majority Democrats command in both chambers, means virtually every member must stick together for measures to succeed. Democrats have a sense the stakes are high and urgent, as they fret the party could lose control of Congress in next year’s midterm elections.

As a result, and over Republican objections, Democratic lawmakers are pushing to load the package with the party’s health-care aspirations, from expanding the social safety net to putting new constraints on the drug industry — and competing for a share of the multitrillion-dollar package.

Some of the party’s biggest names are pushing their longtime priorities. House Speaker Nancy Pelosi (D-Calif.), an architect of the Affordable Care Act, wants to extend Medicaid to millions of Americans in the dozen states that have rejected the option to expand the program through the ACA. Sen. Bernie Sanders (I-Vt.) and other backers of single-payer health care are seeking to upgrade Medicare benefits. President Biden, who has said the package known as the Build Back Better Act is key to his agenda, wants to follow through on a slew of campaign promises such as lowering drug prices.

“If even half of what they’re talking about happens, it’s huge,” said Bill Sweeney, senior vice president for government affairs at AARP, an advocacy group for older Americans.

Democrats are aiming to finalize the bill by Sept. 27, and the House met a Sept. 15 deadline to advance its broad health-care expansion policies out of two powerful committees. But they face days — and some predict, weeks or more — of complicated negotiations to shape the package and comply with budget reconciliation’s arcane rules.

House Speaker Nancy Pelosi (D-Calif) is facing down threats from the moderate wing of her party, as the House returns for a series of key votes. (Zach Purser Brown/The Washington Post)

Pelosi’s push for Medicaid expansion — estimated to cost at least $250 billion over a decade — has received a cooler reception in the Senate, with some aides worried about the limited political benefits of helping states that traditionally elect Republicans. Sanders has suggested sending vouchers to Medicare beneficiaries so they can quickly take advantage of their new benefits — a strategy that has discomfited some Democrats who panned a similar plan from former president Donald Trump.

But it is the pursuit of lower drug prices that is emerging as the most formidable barrier to enacting the larger package.

The drug-pricing provision would empower the federal government for the first time to negotiate directly with pharmaceutical companies over the prices they charge Medicare, the health insurance program for older Americans. That alone would cut federal spending by nearly $500 billion, scorekeepers at the Congressional Budget Office predicted when an earlier version of the drug-pricing plan passed the House in 2019.

Democrats had seized on those potential savings as a way to subsidize other priorities, such as their coverage expansions — but at least three House Democrats who voted for the drug-price plan in 2019 now back a narrower rival proposal. The plan suffered a stunning defeat in a key House committee Wednesday, underscoring the fine line leadership has to walk if they want to enact Biden’s massive social spending agenda.

One of those defectors, Rep. Kathleen Rice (D-N.Y.), is “looking at this in a pragmatic way,” said Stuart Malec, her spokesman. “What is going to pass the Senate? What is the fiscally responsible thing to do?”

The fractures emerging in House committee hearings last week proved surprising, said Rodney Whitlock, a vice president at McDermott+Consulting and a former Senate Republican aide.

“They were expected to work out all their fights down the road, not be forced to confront them the first week,” Whitlock said. Liberals still face a looming clash with Sen. Joe Manchin III (D-W.Va.) and other centrist Democrats in the Senate, who have signaled they want to shrink the package.

This story draws on interviews with more than two dozen lawmakers, aides, lobbyists and others involved in the budget reconciliation process. Many are backing long-held priorities, such as permanently expanding health insurance subsidies included in the Affordable Care Act. Democratic staff estimate the cost of that provision, which would lower the cost of premiums for ACA insurance coverage, to be roughly $200 billion.

“Everybody knows this is important. It’s just about the limited resources that we’re working with,” said Rep. Lauren Underwood (D-Ill.), who last month organized dozens of lawmakers to plead that congressional leaders permanently expand the ACA subsidies, arguing that it would lower millions of Americans’ insurance premiums and help close coverage gaps in communities of color.

If Democrats can advance their package through a thicket of committee hearings, lobbying fights and backroom deals, outside experts insist it could be a pivot point for the nation’s $4 trillion health-care sector and the hundreds of millions of Americans who depend on it.

“It’s really a moment for the country,” said Frederick Isasi, executive director of Families USA, a liberal consumer health lobby. “This is the most important moment we have seen for health care since the passage of the Affordable Care Act.”

Among the moving parts in the debate:

Medicaid expansion

Democrats want to extend Medicaid coverage to roughly 2.2 million poor, uninsured adults — an effort to bypass Republican officials in the dozen states that for nearly a decade have refused to expand the safety net program as the Affordable Care Act envisioned. If the expansion takes effect, some insured people in those states are expected to give up their private health plans and switch to the safety net health program, according to several forecasts.

Between the uninsured who get coverage and those who switch from private plans, it would enable 4 million people to “have access to affordable health care, regardless of where they live,” predicted House Energy and Commerce Committee Chairman Frank Pallone Jr. (D-N.J.), whose panel oversees Medicaid and advanced legislation to fill in the gap. “I don’t want these same people to fall through the cracks because they are offered some lousy health insurance or some health insurance that they can’t afford,” he said.

The policy is a huge priority for key leaders and caucuses in the House — such as House Majority Whip James E. Clyburn (S.C.), the third-ranking Democrat and a key Biden ally — and supporters in the Congressional Black Caucus and Congressional Hispanic Caucus argue that it is “one of the single most important steps” to reducing the country’s stark racial inequities in health care.

But the policy isn’t cheap. A House Democratic aide projected it may cost roughly $250 billion to $300 billion over a decade, though congressional scorekeepers haven’t officially weighed in on the price.

The Senate is a different story, and advocates for expanding the insurance safety net worry that the length of the new Medicaid benefits may get pared down in the upper chamber. Only three Democratic senators represent states that have not embraced expansion, though expanding the program is an urgent priority for Sen. Raphael G. Warnock (D-Ga.) — whose reelection next year in a competitive state is key to Democrats keeping control of the chamber. The policy could give roughly 270,000 people in Georgia new health benefits, according to the nonprofit Kaiser Family Foundation.

“What I’ve been saying to my colleagues is this: Can you imagine Social Security or Medicare in only 38 states? It’s unimaginable,” said Warnock, who sent a letter to Senate leadership Wednesday pushing for a permanent fix.

Medicare expansion

While some centrist Democrats focus on the long-running Medicaid fight or shoring up the Affordable Care Act, liberals such as Sanders have prioritized expanding Medicare benefits so that the program starts to include hearing, vision and dental services.

It could take federal health officials three to five years to establish Medicare dental benefits, and Sanders and his allies have argued that an interim policy is needed so older Americans in desperate need of services can access them as quickly as possible. Their tentative plan is to send them vouchers laden with hundreds of dollars.

A House Democratic aide, who spoke on the condition of anonymity to detail private negotiations, poured cold water on that possibility, calling it a “terrible idea” and “not a good use of federal dollars,” given the challenge of setting up a federal coupon program. The aide invoked Trump’s failed effort to give seniors $200 discount cards to buy prescription drugs, which was announced just weeks before the 2020 election — and panned by several high-ranking Democrats.

Meanwhile, some liberals want cuts to Medicare Advantage, the private-sector version of the government’s federal insurance arm long championed by the GOP, arguing that the program’s payouts to private insurers are too generous and that cutting spending would help pay for other priorities.

In-home care

The coronavirus tore through nursing homes, killing more than 135,000 older adults and 2,000 staff. The devastation ignited a massive advocacy effort to push for more money for in-home care for older Americans and people who are disabled, and for better wages for nursing home staff.

In the spring, Biden pledged to invest $400 billion in home care, but congressional negotiators appear unwilling to spend that much. The House Energy and Commerce panel proposed spending $190 billion — higher than advocates had anticipated after some in the Senate flirted with spending as little as $150 billion to pay for home care, according to four people familiar with the negotiations who spoke on the condition of anonymity to describe the talks.

The Senate is still hashing out how much it will put toward these services, which include help with eating and dressing, physical therapy, nursing care and other services. Sen. Robert P. Casey Jr. (D-Pa.) is pushing for roughly $250 billion as he shepherds the legislation through the Senate, believing that amount would spur changes to the system that he is seeking, according to a Senate aide.

The Service Employees International Union, a labor giant, is threatening to withhold support from lawmakers who don’t back a robust infusion of cash into home care under Medicaid.

“We are going to press our case until the last possible moment in Congress and then our members will take stock of how we’ve reached this goal,” said Mary Kay Henry, international president of SEIU.

Drug-price changes

To pay for the expansions of Medicaid, Medicare and home-care coverage, Democrats have been counting on savings from the drug-price bill, which would cut federal pharmaceutical spending by hundreds of billions of dollars. The legislation that House committees voted on last week included an array of provisions, including linking U.S. drug prices to the prices paid by other countries. But if a fourth Democrat joins the three holdouts, the entire package will need to be rewritten to pass the House.

The dust-up over drug pricing has helped slow the House’s debate over the broader social spending package, putting Democrats’ aggressive timeline at risk. The Energy and Commerce panel’s debate stretched into a third day Wednesday, with members offering passionate defenses of the need to support the party’s drug plan — or come up with a new one — even as Pallone, the committee’s chair, openly fretted that the discussion was stretching too long and would prevent some members from being able to vote because of the Jewish holiday.

“Today, we have the historic opportunity to readjust how seniors and others go into the drugstore or the counter and then have to walk away because they can’t afford what their doctors say they need to take,” said Rep. Anna G. Eshoo (D-Calif.), who chairs the panel’s health subcommittee.

Eshoo was countered by fellow Golden State Rep. Scott Peters (D-Calif.), one of the holdouts who has argued that the plan will cut into the drug industry’s profits and hurt companies’ ability to develop new therapies.

“This bill can be fixed, it needs to be,” Peters insisted — a message that may begin to sound familiar in coming days, as other Democrats try to win their own changes to Medicaid, Medicare and other provisions. “I hope my colleagues on both sides will consider a different approach.”