Under pressure to cut the bill’s cost, Democrats disagree over whether to offer more benefits to older Americans or to cover more of the working poor.WASHINGTON — Democrats are facing tough moral and political decisions over how to pursue their century-old dream of universal health care now that their ambitious $3.5 trillion social safety net bill will almost certainly have to be trimmed back.As they try to reduce the bill’s cost, members of the party disagree over whether to prioritize expanding coverage to more poor adults in states whose leaders have refused to do so or to give new Medicare benefits to older people across income levels.Southern Democrats, in particular, are urging their leaders to prioritize insurance coverage for 4.4 million working poor people in the 12 states, mostly in the South, with Republican or divided leadership that have refused to expand Medicaid under the Affordable Care Act. But progressives, led by Senator Bernie Sanders, the Vermont independent and former presidential candidate, are adamant about giving older Americans dental, hearing and vision coverage.Many provisions of the delicately constructed bill are interconnected, and division over how to lower prescription drug costs and raise taxes will likely prevent the party from acting boldly on both fronts.“I believe that health care is a human right, and if you believe it’s a human right, you don’t believe it’s a human right for 38 states,” said Senator Raphael Warnock, Democrat of Georgia, whose push for Medicaid expansion in his state was central to his special election victory last year, and who is eager to bring such an achievement to voters when he stands for re-election next year. “People are literally dying for lack of access to any care at all.”Health care has long been a winning issue for Democrats. It delivered them the House in 2018 and contributed to their taking the Senate in 2020, thanks largely to the runoff victories in Georgia of Mr. Warnock and Senator Jon Ossoff.But in raw political terms, most of the states that have refused to expand Medicaid — like Alabama, Mississippi, South Carolina, South Dakota, Tennessee and Wyoming — are out of reach for Democrats. Older Americans, on the other hand, are consistent voters, increasingly up for grabs. Those voters would like Medicare to start paying for dental, vision and hearing care.Some Democrats, moreover, say Congress should not reward states that refused to expand Medicaid by creating a separate insurance program, financed entirely by the federal government, for their working poor. Under the Affordable Care Act, states that expand Medicaid pay 10 percent of the cost. The topic came up during a recent policy luncheon for Senate Democrats.“Some members have raised the question of, if we do a Medicaid benefit for states that didn’t expand, those that did expand are going to feel like, ‘Hold on a second,’ ” said Senator Tim Kaine, Democrat of Virginia, though he said that was not his view.The provision allowing Medicare to negotiate prices with drug makers is in jeopardy and would mean a loss of about $500 billion that Democrats hoped to spend on expanding both Medicare and Medicaid.Paul Ratje for The New York TimesDemocratic leaders envisioned four major health care components to the bill: It would close the so-called coverage gap for Medicaid, reaching poor adults who earn too much to qualify for traditional Medicaid, but too little to qualify for private, subsidized insurance under the 2010 health care law. It would, for the first time, give Medicare recipients dental, vision and hearing care. It would extend recently enacted subsidies that help middle-income people buy insurance under the Affordable Care Act.All of that would be paid for by a provision allowing Medicare to negotiate prices with drug makers and tying drug prices to those paid by other developed countries.Republicans are largely absent from the conversation; they oppose the budget measure in its entirety, and thus are not weighing in on whether to expand Medicare or Medicaid. But they have long been opposed to letting Medicare negotiate drug prices, which they argue would stifle innovation in the pharmaceutical industry.That piece of the bill is now in danger. Last week, three Democrats sided with Republicans in the House Energy and Commerce Committee to strip it from the legislation. The House Ways and Means Committee did approve it, with one dissent, but if the prescription drug measure cannot survive a full House vote, it will mean a loss of about $500 billion in savings that Democrats hoped to spend on expanding both Medicare and Medicaid. The total cost would be about $600 billion over 10 years.Caught between those competing imperatives are lawmakers like Representative Lloyd Doggett, a senior Democrat on the Ways and Means Committee whose home state, Texas, has not expanded Medicaid. In a fight for scarce resources, he said, seniors who already have good coverage for most of their health needs under Medicare must take a back seat to the working poor who have no coverage at all.“I prioritize those who have been left out entirely,” he said. “They are desperate.”As committees in both the House and Senate work on writing their versions of the bill, Democrats across the philosophical spectrum are struggling to decide where their own priorities lie.Representative Charlie Crist, a Florida Democrat who was once his state’s Republican governor, noted that 800,000 of its residents do not have health insurance because the state leadership refuses to expand Medicaid. But Florida also has a significant older population that wants expanded coverage under Medicare.“I think you advocate for both; that’s my position,” he said. “It’s extremely important. We’re the richest country in the world and one of the few industrialized countries that do not provide health care for all our people, and we have to.”Senator Elizabeth Warren, Democrat of Massachusetts, said that “drug companies have the best lobbyists in town,” but that the party should not abandon clamping down on rising prescription costs to free up money for both priorities.“I say the choice is between the billionaires and people who don’t have health care,” she said.Pragmatists realize that some concessions will have to be made. Mr. Kaine said it was possible that Democrats would expand both Medicare and Medicaid in more modest ways, perhaps by phasing in benefits.The four House Democrats who have expressed opposition to the drug measures — Kurt Schrader of Oregon, Scott Peters of California, Kathleen Rice of New York and Stephanie Murphy of Florida — are enough to bring down the whole bill in the narrowly divided House. And more defections are likely from representatives with pharmaceutical interests in their districts, who have not had a chance to weigh in.Senator Raphael Warnock, Democrat of Georgia, made insurance expansion in his state central to his campaign last year.Stefani Reynolds for The New York TimesDemocrats who favor Medicare expansion have largely stayed quiet, given the sensitivity of the issue. But they see a political boon in the expansion approved by House committees last week. Seniors would see immediate coverage of vision care. In 2023, hearing would be added. Dental coverage, which would have to be created from scratch, would not begin until 2028.Medicare proponents say Congress has given the states that have not expanded Medicaid ample time and incentive to do so, and it is time to focus on other priorities. The $1.9 trillion pandemic rescue bill this year included huge new subsidies for those states if they agreed to expand Medicaid. Not one did.States pay as much as half of traditional Medicaid costs, but under the Affordable Care Act, the federal government pays 90 percent of costs for the expansion population.The two Georgia senators and Senator Tammy Baldwin of Wisconsin, which has also not expanded Medicaid, initially envisioned a Medicaid look-alike program run from Washington that would offer recalcitrant states even more federal funding if they finally joined Medicaid, relieving them of virtually any fiscal responsibility.Two House committees — Ways and Means and Energy and Commerce — adopted a measure last week that for now would extend existing premium subsidies under the Affordable Care Act to those now too poor to qualify for them, covering 94 percent of their total health care costs, rising to 99 percent in 2023. By 2024, the Department of Health and Human Services will have stood up a Medicaid-like program along the lines of the Senate proposal for those 4.4 million people.To some liberal Democrats, the plan seems unfair to the 38 states that have expanded Medicaid under the original terms of the health law — at a higher cost to those states.Mr. Warnock has a ready answer for that: “I would remind my colleagues that Georgia gave us the majority.”“We wouldn’t have the privilege of debating these priorities and a package that we’re putting forward if the people of Georgia had not stood up and sent me and Jon Ossoff to the United States Senate,” he added. “So we owe it to them to give them the coverage that they deserve.”

As the coronavirus’s Delta variant rips through conservative communities, most Republicans remain reluctant to confront vaccine misinformation and skepticism in their midst.WASHINGTON — As the coronavirus surges in their states and districts, fanned by a more contagious variant exploiting paltry vaccination rates, many congressional Republicans have declined to push back against vaccine skeptics in their party who are sowing mistrust about the shots’ safety and effectiveness.Amid a widening partisan divide over coronavirus vaccination, most Republicans have either stoked or ignored the flood of misinformation reaching their constituents and instead focused their message about the vaccine on disparaging President Biden, characterizing his drive to inoculate Americans as politically motivated and heavy-handed.On Tuesday, Representative Steve Scalise of Louisiana, the No. 2 House Republican who said he had received his first Pfizer vaccine shot only on Sunday, blamed the hesitance on Mr. Biden and his criticism of Donald J. Trump’s vaccine drive last year. Senator Tommy Tuberville, Republican of Alabama, said skeptics would not get their shots until “this administration acknowledges the efforts of the last one.”And Senator Roger Marshall of Kansas pointed the finger at the White House press secretary, Jen Psaki, and the director of the National Institute of Allergy and Infectious Diseases, Dr. Anthony S. Fauci.“Every time Jen Psaki opens her mouth or Dr. Fauci opens his mouth,” he said, “10,000 more people say I’m never going to take the vaccine.”Some elected Republicans are the ones spreading the falsehoods. Representative Jason Smith of Missouri, a Senate candidate, warned on Twitter of “KGB-style” agents knocking on the doors of unvaccinated Americans — a reference to Mr. Biden’s door-to-door vaccine outreach campaign.Such statements, and the widespread silence by Republicans in the face of vaccine skepticism, are beginning to alarm some strategists and party leaders.“The way to avoid getting back into the hospital is to get vaccinated,” Senator Mitch McConnell of Kentucky, the Republican leader and a polio survivor, pleaded on Tuesday, one of the few members of his party to take a different approach. “And I want to encourage everybody to do that and to ignore all of these other voices that are giving demonstrably bad advice.”Nationally, the average of new coronavirus infections has surged nearly 200 percent in 14 days, to more than 35,000 on Monday, and deaths — a lagging number — are up 44 percent from two weeks ago. The director of the Centers for Disease Control and Prevention estimated on Tuesday that the Delta variant accounted for 83 percent of all new cases.The political disparity in vaccine hesitancy is stark. The Kaiser Family Foundation reported at the end of June that 86 percent of Democrats had at least one shot, compared with 52 percent of Republicans. An analysis by The New York Times in April found that the least vaccinated counties in the country had one thing in common: They voted for Mr. Trump.“There’s a big gap, and it’s growing,” said Jen Kates, a senior vice president of the Kaiser Family Foundation. “We know that more of the unvaccinated are self-identified Republicans, so they are much more at risk of illness, death and continued spread than fully vaccinated people.”A teenager received his first shot of the Pfizer vaccine in Laplace, La., last month. The C.D.C. has said everyone over 12 should be vaccinated.Emily Kask for The New York TimesConservative swaths of the country are being hit particularly hard. Intensive care units in southwestern Missouri and northern Arkansas are filled or filling fast, while 40 percent of new cases are cropping up in Florida.At the Capitol on Tuesday, where a vaccinated aide to Speaker Nancy Pelosi tested positive for the coronavirus, the in-house physician warned lawmakers and staff members that the Delta variant is now present. He begged unvaccinated lawmakers to get their shots, and warned that a mask mandate may have to be reimposed.Amid those troubling trends, Representative Marjorie Taylor Greene of Georgia was suspended from Twitter temporarily for writing that Covid-19 was not dangerous for people unless they were obese or over age 65. On Tuesday, she refused to answer a reporter’s question about whether she had been vaccinated, calling it a violation of the federal law governing the privacy of health care information. (The law does not bar an individual from speaking about her own medical status, or prohibit anyone from inquiring.)Representative Madison Cawthorn, Republican of North Carolina, suggested that the Biden administration’s door-knocking effort was just a first step. Next, he said in an interview with Right Side Broadcasting Network, they would “go door to door to take your guns.”“They could then go door to door to take your Bibles,” he added.Yet many leading Republicans are paying little heed to the resurgence. At a hearing before the Senate health committee, there was scant mention among Republicans about how to confront vaccine hesitancy, save for the comments of Senator Mitt Romney of Utah, who lamented “spurious conspiracy theories” and wondered whether “enemies of our country” were putting out misinformation.At a news conference by House Republican leaders on Tuesday, the coronavirus was nowhere to be heard amid the “crises” of inflation, the southwestern border and out-of-control spending by the “socialist” Democrats.Dr. Anthony S. Fauci, the director of the National Institute of Allergy and Infectious Diseases, testified during a Senate hearing on Tuesday.Stefani Reynolds for The New York TimesEven those lawmakers who expressed concern said there was little politicians could do.“I’m tracking it daily, and it’s not good,” said Senator Josh Hawley, whose home state, Missouri, is now a Covid hot spot. But he flatly ruled out mandates to get more Missourians inoculated, saying it would only backfire with conservative voters.“Where you run into problems is where they say, ‘You must do the following,’” Mr. Hawley said. “That is why the president’s language about going door to door is so alarming to people that it has the opposite effect.”Mr. Marshall, a physician who organized other elected Republican doctors to encourage constituents to get vaccinated, concluded that “there’s nothing that anyone can say up here that’s going to convince somebody to take the vaccine.”Off Capitol Hill, some conservatives have become considerably more forceful. Utah’s Republican governor, Spencer Cox, accused conservative “talking heads” of “literally killing their supporters” with their vaccine skepticism.The conservative personality Sean Hannity told viewers on Monday night to take the virus seriously and get vaccinated. Steve Doocy, the co-host of Mr. Trump’s favorite news program, “Fox & Friends,” had a similar message on Tuesday morning.But the messages on Fox remain mixed, as do the Republican Party’s.Senator Rand Paul, Republican of Kentucky and a doctor, is trying to change the subject. At Tuesday’s health committee hearing, he escalated his long-running attacks on Dr. Fauci over whether the National Institutes of Health funded “gain of function” research — experiments devised to identify genetic mutations that could make a virus more powerful — at a laboratory in Wuhan, China, where the pandemic began.Mr. Paul accused Dr. Fauci of lying to Congress when he testified in May that the N.I.H. did not fund such work. Dr. Fauci shot back that he was not lying, and accused the senator of spreading falsehoods by implying American scientists were to blame for the pandemic.Mr. Marshall used the hearing to raise questions about whether children should be vaccinated. He said afterward that he would encourage anybody over 50 to get the vaccine, but added that there were “pluses and minuses” for anyone younger than that, directly contradicting guidance from the C.D.C., which has said everyone over 12 should be vaccinated.The senator added that those not yet vaccinated should get tested to see if they had antibodies from a previous infection, and if they did, they might not need a shot. That, too, goes against the C.D.C., which recommends vaccination for those who have recovered from Covid-19.Senator Rand Paul, Republican of Kentucky, accused Dr. Fauci of lying to Congress, and Dr. Fauci in turn accused the senator of spreading falsehoods.Stefani Reynolds for The New York TimesBut Republican concerns are still focused mainly on the tactics of those trying to get more people inoculated.“You’re seeing some people try to bully people into doing things instead of just encouraging them,” Mr. Scalise said. “There’s even talk of putting mask mandates back on people in certain states when the vaccine is widely available, it’s safe and effective.“We should be encouraging people to get it,” he added, “but not trying to threaten people.”