The Work Begins: A Build Back Better Agenda Emerges from House Committees
The fall frenzy feels markedly different this year – emotions are running high as communities wrestle with COVID spikes as children return to school, while the nation reflects on two decades of war and trauma, commemorated by the anniversary of September 11. Cutting through the headlines, however, progress is brewing. Congress is busy at work to deliver a range of policy solutions in anticipation of keeping to a tight September schedule. Last week, House committees released proposed language for the reconciliation package that, overall, takes historic steps in a commitment to health justice. The proposed Build Back Better language reflects a meaningful investment in the infrastructure, programs and services that people need to be healthy and thrive. Further, it signals a deliberate attempt to center racial justice in policy design.
Between late Thursday night and the weekend, the Energy & Commerce Committee and the Ways & Means Committee shared draft language in preparation for this week’s markup on health provisions of the Build Back Better package. The news is good. The policies included in their releases reflect months (and years) of advocacy to build on the Affordable Care Act (ACA) and invest in Medicaid, strengthening both programs at a key moment in time. As people strive to recover from the many impacts of the pandemic, even as many still suffer – disproportionately Black and brown people with no access to health coverage – the proposed policies will make a real difference in people’s lives. This would not have been possible without the dedicated work of advocates across the country fighting for health justice (take a moment).
As hearings unfold this week, the policy details will more fully emerge. Here are the toplines:
1. Close the Medicaid Coverage Gap
The policy proposed to close the Medicaid coverage gap through federal action is a two-step approach. First, leverage Marketplaces to stand up an interim plan quickly by lowering the floor on premium tax-credit eligibility to include people who have been historically excluded from accessing affordable plans (people with incomes below 100 percent of the federal poverty line). Then, pivot to a Medicaid-like plan for people in non-expansion states (see this piece by CBPP and a more technical preview from Katie Keith, here). The approach uses a maintenance-of-effort provision to incentivize current Medicaid expansion states to maintain their existing program standards and, importantly, the solution is permanent. This comprehensive approach sets the bar for the Senate to put aside partisan motives and give people with low incomes access to much needed coverage, once and for all. This proposal is an urgent racial justice priority; the moment to take action is now. Given the history of the 12 remaining non-expansion states and their refusal to help people in the gap, leaving Black and brown people systemically excluded from coverage, a comprehensive solution is paramount.
2. Make the Premium Tax Credits Permanent and Expand Access to Affordable Coverage
The Ways & Means committee ensured their work from the American Rescue Plan Act was codified, making the enhanced tax credits permanent so that no person would lose access to affordable coverage (see this Health Affairs blog for policy details). Further, the committee added another provision to address affordability – cracking open the door for those people stuck in unaffordable employer-sponsored plans. According to the Commonwealth Foundation, 26 percent of people with low incomes spent more than 8.5 percent of their household income on after-tax health care premium contributions. To partly address this problem, the Ways & Means proposal better aligns the definition of affordability with the updated premium tax credit changes included in the American Rescue Plan Act. The proposed draft shifts the current 9.5 percent affordability definition (currently almost 10 percent due to indexing) to a flat 8.5 percent (amount of household income paid toward health insurance premiums); this means more people locked in high-cost employer plans will have a pathway to affordable Marketplace coverage. Finally, another provision included in the draft is $10 billion dollars for a reinsurance program; states could leverage these funds to reduce premiums and out-of-pocket costs for marketplace or Basic Health Plan (BHP) enrollees and/or create a reinsurance program. This is an exciting development for states, promising additional resources to address people’s out-of-pocket expenses that lead to medical debt and reduces their health care utilization, especially during a pandemic.
3. Extend Postpartum Medicaid for 12 Months
The Energy & Commerce committee made a deep investment and held fast to its promises to address the needs of birthing people, specifically Black and Indigenous women. The proposal includes every eligible provision of the Momnibus and mandates postpartum Medicaid coverage for 12 months. This means no matter your state of residence, Medicaid access for a year after pregnancy is assured. These investments in the birthing justice agenda are historic and reflect a resolution from committee staff and leadership to address racial equity. The portfolio of policies also highlights the hard work of a broad spectrum of advocates, as represented in a letter to congressional leadership signed by over 200 organizations. The included policy provisions range from directly investing in community-based organizations, to addressing social determinants of health, and supporting doulas and key workforce priorities. This is an exciting proposal that revises Medicaid policy to reflect equity and offers new direct federal funding pathways for community-based organizations that are leading programs and practices that save lives.
4. Invest in Home & Community-Based Services
The proposal includes a $190 billion investment in home and community-based services (HCBS), critical long-term care services provided by the Medicaid program in individual’s homes and other community-based settings. This new funding is intended to help states increase access to, and improve the quality of, HCBS by increasing funding for state HCBS programs in their current models, as well as allowing states to apply for “HCBS Improvement” grants to enhance and strengthen their programs in ways such as increasing payment rates for home care and direct care workers (learn more here). Further, the policy includes an ombudsman program and quality metrics – two key provisions that pave the way for robust access and accountability. The proposal will also allow states to continue improvements already made to HCBS programs as a result of increased funding that was provided by the American Rescue Plan Act. Overall, the disability and aging community is excited by the potential of this increased funding to make some long overdue and necessary changes to our country’s long-term care system. The pandemic made all the more clear the urgent need for bold policy initiatives that individuals and their caregivers have been advocating for, and awaiting, for a long time.
Getting This Significant Package Across the Finish Line
There are many other elements of the drafts that are exciting and move the needle on racial justice, including ensuring that Medicaid coverage begins automatically 30 days prior to an individuals’ release from incarceration and permanently extending the Children’s Health Insurance Program (CHIP). While coverage expansions are only one step toward improving outcomes, coverage is the doorway to better health and equity. Further, we applaud efforts to draft a broad set of policies that work to better align social services and health services in the spirit of improving health outcomes and reducing inequities; notably including the child tax credit, immigration reform and housing supports. Together, they compose a robust and comprehensive approach to health and well-being for people across the country. It is important to reflect on the significance of the Build Back Better release and put on our fight to ensure it makes it over the finish line. We are just getting started.
A note of thanks to the policy team at Community Catalyst including Rachelle Brill, Kelly Bumgarner and Rachel Rosales.