House Makes Historic Investments to Improve People’s Health, Time for the Senate to Follow

The American Rescue Plan Act included temporary provisions that eliminate or reduce premiums for millions of Marketplace enrollees through an increase in premium support tax credits. Under this provision, premiums are eliminated for those below 150% FPL. Premiums are lowered for everyone else currently eligible for premium tax credits and a new cap on the total amount of income a person would have to pay would end the “subsidy cliff” under which a small change in income could result a large premium spike.     

The bill also includes the creation of an affordability fund. The bill makes available $10 billion annually to states for calendar years 2023 through 2025, providing the option for states to establish a state reinsurance program or use the funds to provide financial assistance to reduce out-of-pocket costs. 

The increased ACA tax credits have lowered the cost coverage for 3.7 million more people and made coverage free or nearly free for more than 46% of people who are uninsured.    

While low-income people have seen the biggest coverage gains of any income group, they still have highest uninsured rate and comprise the largest share of uninsured people.  

This is especially true for Black and brown people, who face discrimination in employment and education. As a result, they are more likely to work in low-wage jobs without good benefits like health coverage.  

Despite the progress afforded by the ACA and the Build Back Better agenda, millions are forced to make choices between basic needs and health care – from seeing a doctor to affording prescriptions to managing a chronic illness. One in four persons taking a prescription drug reported skipping doses or cutting pills in half due to affordability issues.  

Recent polling shows that reducing health care costs is a top priority for voters, regardless of political affiliation.   

To lower out-of-pocket costs, Congress should pass the S. 499, the Health Insurance Affordability Act sponsored by Sen. Shaheen.  

Under this provision, the Build Back Better Act would close the coverage gap through 2025 by making people in non-expansion states eligible for federal Marketplace plans. The enrollment would be open year-round similar to the current Medicaid program and in years 2024-25 would provide additional benefits to be more Medicaid-like, including non-emergency medical transportation (NEMT) and family planning services.  

For states that rely on this federal pathway for coverage, there will be a reduction in their federal contribution to hospital uncompensated care since the federal government will be providing health coverage to the uninsured through Marketplace plans. 

States that have already expanded Medicaid will receive a 3% increase to their federal Medicaid contribution through 2025.  

We can’t go back. In four years, people who have been able to gain coverage from Build Back Better should not lose it. In fact, it should get better. 

It’s not an accident that eight of the 12 states that haven’t expanded Medicaid are in the South, a region that’s long borne the brunt of health inequities and the political disenfranchisement of Black and brown people. Those living in non-expansion states should have equal coverage to those in expansion states, which could be made possible with a permanent, federal Medicaid program. 

State-administered Medicaid expansion programs continue to have many benefits, including allowing states to build programs that most effectively serve their unique residents. Therefore, the bill offers further encouragement for the remaining 12 states to expand Medicaid, and state leaders should take a serious look at that. 

The House bill appropriates a total of $150 billion for states to enhance, strengthen and improve their Medicaid home- and community-based services (HCBS) programs by expanding access to services and self-directed care programs, supporting the workforce through updated payment rates, and requiring states to adopt and report on HCBS quality measures. The majority of this $150 billion will go towards increasing the federal reimbursement rates states receive for the HCBS programs, so long as states implement activities to improve their programs and support the direct and home care workforce.  

By both increasing access to home-based care and supporting the home and direct care workforce, this proposal would advance racial justice in the long-term care system in two ways. 

First, although most older adults would prefer to age in their homes and communities, Black older adults are more likely to receive long-term care in nursing facilities, and unfortunately, nursing homes that provide low-quality care, due to several structurally racist policies.  

Additionally, supporting direct and home care workers through increased wages or payment rates would advance the economic justice of the workforce, which is primarily comprised of women of color. Lastly, because HCBS involves services such as non-medical transportation, home-delivered meals and home modifications such as shower “grab-bars” to make someone’s residence safer to live in, HCBS is an important way that the Medicaid program addresses the social determinants of health.  

The COVID-19 health crisis places the populations who receive and rely on HCBS, including older adults, people with disabilities and individuals with complex care needs, at heightened risk of infection and death. Not only that, but the COVID-19 pandemic has highlighted and increased the need for home-based care, as more than one-third of the nation’s deaths from COVID-19 have been linked to nursing homes and other long-term care facilities.   

Additionally, since most older adults would prefer to age in their home and community, increasing access to HCBS would go a long way towards making long-term care in Medicaid more person-centered.  

Home and community-based services are (unfortunately) an optional benefit in Medicaid, and even though every state provides HCBS, many have waiting lists for this critical service. Increasing funding for HCBS will help states alleviate their waiting lists so more individuals can live and age at home and in their communities. 

Therefore, investing in and increasing access to HCBS is not only long overdue, since it better allows individuals who receive long-term care to do so in the way they would most prefer, but it’s also incredibly necessary in this moment for reducing illness and death from COVID-19.  

The House Build Back Better Act builds on the state option for 12-month Medicaid coverage postpartum by making the option permanent. The change would take effect one year after the bill is enacted.  

Other provisions in the bill are important to maternal health. The bill includes a Medicaid maternal health home option for states, recognizing the importance of care coordination and comprehensive care for pregnant people. If a state takes up the option for a health home, they receive a 15 percentage-point increase in federal Medicaid contribution for the first two years of implementation.  

The bill also includes a number of provisions from the Momnibus that support workforce development, specifically funding community partners that are providing needed care to Black and brown people. In the case of birthing people, Medicaid saves lives.   

Studies have demonstrated the year following the end of a pregnancy to be a concerning period for postpartum people. In fact, one-third of pregnancy-related deaths occur during the first year after the end of a pregnancy, disproportionately among Black women.   

Mandating Medicaid postpartum coverage for 12 months is a necessary step toward ensuring birthing people can adequately address their medical and behavioral health concerns during this critical period. In addition, addressing workforce needs for Black and brown pregnant and postpartum people is critical. 

Federal law known as the inmate exclusion policy prohibits Medicaid coverage for people in jail or prison, adding to barriers to physical, mental health and addiction services. Because of mass incarceration of Black and brown people, especially through the punitive policies of the War on Drugs, the prison and jail population is disproportionately Black and brown people, so they are more likely to experience the fragmented health care that can result from incarceration.  

This is especially important for incarcerated individuals with substance use disorders, as many are forced into withdrawal while in prison and are at increased risk of fatal overdose upon release.  

Starting Medicaid coverage to individuals 30 days before release – known as the Medicaid Reentry Act – is therefore a racial justice issue and would be an important step toward undoing the harms of systemic racism in both the criminal legal system and health system. 

Additionally, providing Medicaid coverage during 30 days before release from incarceration will keep our communities healthy. Incarcerated individuals are also at particular risk of contracting COVID-19 because of jail/prison conditions. Making sure these individuals have uninterrupted health coverage, particularly during the transition period when they are reentering their communities, is essential for keeping them healthy, limiting spread of the virus and protecting the health of the community overall.  

The CHIP program currently insures over 80 million people, with nearly 10 million enrolling since the beginning of the ongoing public health emergency; more than half its enrollees are children of color.  

Although states have the option to provide continuous eligibility for children in Medicaid and CHIP programs, the majority do not.  

The Build Back Better bill would require all states to provide 12-month continuous eligibility for children in both Medicaid and CHIP. Because Black and brown children are overrepresented in the Medicaid program, this is an important provision that advances health equity, ensuring all children get access to the health care they need year-round.  

Specifically, the bill empowers Medicare to negotiate prices for select drugs purchased at the pharmacy counter and administered at a doctor’s office.  

In addition, the bill caps out-of-pocket spending for older adults, protecting them from high drug costs often associated with conditions like cancer, multiple sclerosis and rheumatoid arthritis. Insulin co-pays for Medicare beneficiaries will also be capped at $35 each month.  

Finally, the bill bars pharmaceutical companies from raising prices faster than inflation. This will translate into meaningful savings for older adults that rely on Medicare Part D.