The White House is facing diverging pressure from two powerful allies — House Speaker Nancy Pelosi (D-Calif.) and Senate Budget Committee Chairman Bernie Sanders (I-Vt.) — over whether to use an upcoming spending package to strengthen the Affordable Care Act or expand Medicare eligibility.

Pelosi’s office is pushing the White House to make permanent a temporary expansion of Affordable Care Act subsidies that were included in the $1.9 trillion stimulus legislation last month, according to a senior Democratic aide who spoke on the condition of anonymity to describe internal conversations.

Sanders said in an interview that he is arguing for lowering the age of Medicare eligibility to 55 or 60 and expanding the program for seniors so it covers dental, vision and hearing care.

The contrasting visions for the next phase of President Biden’s legislative agenda reflect divisions within the Democratic Party about how Biden should further overhaul health insurance in the United States. Pelosi is looking to double down on the ACA, which has become more popular in recent years as it offers insurance subsidies to people well above the poverty line. Sanders, meanwhile, is looking for an opportunity to make progress on his longtime efforts to make government health insurance universal.

Either approach would offer more health insurance to lower-income Americans. But the choice facing Biden will allow him to decide whether he wants to continue to focus on the ACA, which operates largely through private insurers, or use political capital on a government-run program.

The pressure comes as the White House works to formulate what it is calling the American Families Plan, a sequel to the infrastructure and jobs plan announced last month. The new program, which is likely to be focused on child care, higher education, anti-poverty initiatives and health care, is expected to propose cutting spending on prescription drugs by as much as $450 billion over 10 years.

That money, in turn, could be used for the health insurance expansions. White House officials have not said which direction they will pursue. A White House spokesman declined to comment.

“We cannot continue to deal with millions and millions of seniors — primarily low-income seniors — who cannot afford to go to a dentist, so cannot ingest the food they eat, or the millions of seniors who live in isolation because they can’t hear,” because they cannot afford hearing aids, Sanders said in an interview. He declined to discuss the push from Pelosi, but he said, “It is fair to say there are differences of opinion as to how we prioritize health-care needs.”

The divergent paths charted by Pelosi and Sanders point to one of many underlying tensions within the Democratic Party that the White House is being forced to navigate as it figures out its next major agenda item.

The path to passing either plan remains steep. Congressional lawmakers are just now taking up Biden’s $2 trillion jobs and infrastructure plan, which has faced a barrage of criticism from congressional Republicans and some centrist Democrats. The appetite in Congress for yet another $1 trillion or $2 trillion effort on top of the infrastructure package is unclear, although liberals in the Congressional Progressive Caucus have called for trying to move the two plans in unison.

Congressional Progressive Caucus Chair Rep. Pramila Jayapal (D-Wash.) says the group's policies push the Democratic Party left, despite moderate power brokers. (Blair Guild/The Washington Post)

Still, the early jockeying reflects how Democrats are already looking to the next legislative fight, as well as friction within the party over how best to expand health care.

Democratic leaders have celebrated the durability of the ACA, which has withstood more than a decade of criticism from congressional Republicans and seen its popularity rebound. The White House also has trumpeted figures showing that as many as 500,000 Americans have enrolled in the ACA exchanges during a special enrollment period the Biden administration created.

Asked by a reporter on Thursday about making the ACA expansion permanent, Pelosi cited the Biden administration’s pending families plan and the $500 billion that could be saved for “further expanding access to health care.” She also kept the door open to other forms of health-care expansion, saying the savings “could be used for other purposes,” too.

For Sanders, however, Biden has a unique opportunity to expand on the $1.9 trillion stimulus plan by offering tangible economic benefits to millions of older voters. Sanders helped popularize the single-payer proposal that would enroll every American in Medicare, and lowering the eligibility threshold represents a step in the direction of universal government-provided insurance.

“Some Democrats are all in on solidifying the Affordable Care Act, while progressives want to use their majority to push the health agenda further in the direction of Medicare-for-all,” said Larry Levitt, executive vice president for health policy at the Kaiser Family Foundation, a nonprofit organization.

As a presidential candidate, Biden campaigned on introducing a public option through which Americans could enroll in a government health system, as well as making the ACA subsidies more generous.

But the “unity task force” between Sanders and Biden aides after the 2020 primary produced policy recommendations that included dropping the Medicare enrollment age from 65 to 60. The task force report also said that gaps in dental, vision and hearing services “can lead to severe health consequences for Medicare patients” and stressed that “Democrats are committed to finding financially sustainable policies” to close those gaps.

The expected White House support for the prescription drug effort has helped create an opening for debating how Democrats want to expand health care. As The Washington Post previously reported, the administration is planning to include a measure to force pharmaceutical companies to reduce their prices or pay a steep penalty. Those plans are likely to be similar to the prescription drug bill House Democrats introduced in 2019, although its exact scope remains unclear.

The nonpartisan Congressional Budget Office has estimated that the House Democrats’ bill would save the government about $450 billion over the next decade. It does so by lowering the cost of prescription drugs, which allows the government to spend significantly less on Medicare and other public health programs.

Under House Democrats’ proposal, these savings are redirected to expand Medicare to cover costs for dental, vision and hearing care through Medicare, while also limiting yearly out-of-pocket spending on prescriptions to $2,000, said Alex Lawson, executive director of the advocacy group Social Security Works, which supports the prescription drug reform.

Congressional aides say the savings may be smaller if Democrats, as expected, are forced to pass the measure through the parliamentary procedure known as budget reconciliation.

Conservatives said the United States should use any easily recouped savings to help pay down the existing federal debt. Even passing the measure may be difficult, given warnings from powerful pharmaceutical groups that it would stifle innovation around lifesaving drugs.

“Any low-hanging-fruit budget savings should go to addressing the baseline deficit of $15 trillion,” said Brian Riedl, senior fellow at the Manhattan Institute, a conservative-leaning think tank. “If there’s $500 billion in heath-care savings, shouldn’t we be using that to pay for the programs we already have?”

Others played down the extent of the divisions. The disagreement about the policy direction has not been described by aides as acrimonious, and there may be room for a compromise that incorporates elements of both plans.

“Either one would be a blessing. There’s good arguments for both,” said Harold Pollack, a public health researcher at the University of Chicago, of the bids by Sanders and Pelosi. “I hope Democrats coalesce around whichever is most politically feasible and get it done.”

Still, tensions persist.

Biden’s rescue plan included expanded subsidies for very poor Americans and also extended them to those whose income is above 400 percent of the federal poverty level. That cost about $45 billion for two years, according to the Committee for a Responsible Federal Budget, a nonpartisan group.

“There’s been a robust conversation in the health-care [space] about the best uses of the savings,” said Leslie Dach, an Obama administration health official who is now chair of Protect Our Care, which advocates ACA expansion.

Dach said focusing on expanding the ACA delivers “the most health care for the buck,” noting that having insurance throughout one’s life improves long-term health outcomes. “Getting those folks covered really delivers a lot of health care, particularly to communities of color. … There’s a sense the ACA and Medicaid, which get people in the program early, have a lot of benefits.” Dach said there is also agreement on limiting out-of-pocket drug costs for Medicare enrollees.

Still, some advocacy groups are adamant that Biden increase the scope of public health programs, rather than putting more funding into plans that run through private health insurers.

Lawson said it was a “no-brainer” for Biden to demonstrate to seniors, a crucial voting demographic, that he was working on their behalf.

About half of Americans ages 65 to 80 lack dental insurance, according to University of Michigan researchers. As many as 23 million Americans would newly qualify for health insurance if the Medicare enrollment age is lowered to 60, Sanders’s office said in a statement, adding that half of Medicare recipients have not seen a dentist over the past year.

“Before the next election, we need the American people — and particularly seniors, who have suffered so much during this pandemic — to see that this government is working for them,” Lawson said. “People would get hearing aids, get their teeth checked, before the next election. That will show them Biden is on their side. Democrats have to deliver for seniors if they are going to win.”