Congress is back in session after both chambers were away last week, and they’re picking up their negotiations regarding the size and scope of the Build Back Better (BBB) Act. As we’ve written about previously, Community Catalyst has been closely monitoring the health care proposals in the package because they would advance racial justice and health equity, and therefore would advance our organizational priorities and vision for the health care system. In particular, there are four proposals regarding the Medicaid program that would significantly advance justice and equity:
1. A “Direct Coverage Option” to close the Medicaid coverage gap
Currently, there are more than two million individuals in the Medicaid coverage gap – the gap between a state Medicaid program’s income-eligibility limit and 100 percent of the federal poverty level, the minimum income eligibility level for financial assistance through the Affordable Care Act’s marketplaces. People of color make up about 60 percent of those in the coverage gap due to structurally racist policies and practices that have been put into place throughout our country’s history. These policies have caused longstanding, harmful effects on the health and wellbeing of individuals, resulting in racial health disparities. Medicaid expansion has been shown to reduce racial health disparities by both improving access to care as well as improving health outcomes. Moreover, since Medicaid expansion has been shown to be economically beneficial for state budgets and economies, and since racial justice and economic justice are inextricably linked, closing the coverage gap will help undo the effects of structural racism in multiple ways. Currently, the BBB bill proposes a federal solution to closing the coverage gap. While the details of this solution remain unclear, we hope this will be an important step to permanently closing the coverage gap in states where people have no realistic access to health care coverage at present.
2. Extending Medicaid coverage from 60 days to 12 months postpartum
Pregnant individuals with low incomes are eligible for their own category of Medicaid coverage, but this type of Medicaid is currently only available for up to 60 days postpartum under federal law. Recently, some states, like Illinois, have requested to extend postpartum Medicaid coverage on their own, but changing the federal law would make this extension available nationwide. It’s now well established that the United States has an egregious maternal health crisis for Black and Indigenous individuals, and that one third or more of pregnancy-related deaths occur in the postpartum period, up to a year following childbirth. Therefore, extending postpartum Medicaid coverage is a necessary and proactive, but by no means sufficient, step toward addressing the racial disparities in maternal mortality rates that are the result of systemic racism and implicit bias.
3. Expanding Medicaid to individuals 30 days before release from incarceration
Federal law known as the inmate exclusion policy prohibits Medicaid coverage for people in jail or prison, causing 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. Ensuring individuals have health coverage a month prior to their reentry to the community would make it easier for them to access the care they need and improve health outcomes. 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. To learn more, check out Community Catalyst’s Medicaid Reentry Act infographic here.
4. Increasing access to home and community-based services and supporting the critical direct and home care workforce
The Build Back Better Act proposes to make a historic investment in Medicaid home- and community based services (HCBS), long-term care services that are provided to individuals in their homes or other community-based settings. States can receive this increased funding if they enact policies to both improve access to HCBS as well as support the home and direct care workforce. This proposal would therefore 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.
To be clear, a policy that expands access to Medicaid coverage or benefits does not automatically advance racial justice simply because many individuals of color are enrolled in Medicaid, uninsured, or have low incomes as a result of structural racism. Rather, advancing policies that improve health, specifically for Black and brown people, takes a step towards undoing the harmful effects of racism, discrimination, poverty and other forms of oppression. We hope Congress will seize these opportunities in the Build Back Better Act.