#BuildBackBetter passes the House! Here's a detailed look at the healthcare provisions

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UPDATE 11/19/21: The revised Build Back Better Act passed the House of Representatives this morning, so I'm re-upping this for a few days. It now moves to the Senate where it will likely be tinkered with a bit more; if it passes there, it will then move back to the House for one more final vote before hopefully being signed into law by President Biden. Make sure to also read about some additional revisions to the bill made after I wrote this post.

The legislative text of the updated Build Back Better (BBB) bill is now available, and as I suspected, for all the understandable disappointment about what isn't part of it any longer, there's a lot more healthcare-related stuff in there than most people think. A lot of it gets kind of wonky or may seem like "small potatoes" to most folks, but pretty much everything in it would make a huge positive impact on those it benefits.

Here's a summary of the healthcare section, which starts on Page 437 (the entire bill itself is over 1,600 pages total):

These are mostly listed in the same order as they are in the legislation itself, but I've tried to group together the related sections.

There's four sections devoted to CLOSING THE MEDICAID GAP:

Section 30601. Ensuring Affordability of Coverage for Certain Low-Income Populations.

This section provides temporary enhanced Affordable Care Act (ACA) Marketplace cost-sharing reduction assistance to individuals with household incomes below 138 percent of the federal poverty level (FPL) for calendar years 2022 through 2025. Consistent with current law, individuals who qualify for government sponsored insurance would not qualify for the temporary cost-sharing assistance.

In other words: This would close the Medicaid Gap in 11 of the 12 remaining states whcih are still refusing to expand Medicaid under the ACA (Wisconsin is a special case: They expanded standard Medicaid up to residents earning up to 100% FPL, which means they technically don't have a "gap" population, although it sounds like the enhanced benefits under the BBB bill would still apply to those earning 100 - 138% FPL).

Technically, what this section does is to a) declare the Gap population's household income to be equal to 100% FPL (the lower end of the ACA's subsidy table) and b) bumping up the Actuarial Value (AV) of their Silver plan coverage from 94% to 99%, which basically means they'd pay $0 in premiums and only a nominal amount in cost sharing.

It also adds non-emergency medical transportation services free for this population, along with some other benefits...but only for 2024 & 2025, oddly.

It also provides outreach/educational funding to help get Medicaid Gap folks covered in ACA exchange plans for the 4-year period.

Section 30724. Adjustments to Uncompensated Care Pools and Disproportionate Share Hospital Payments.

This section ends wasteful and duplicative payments to states where individuals below 100 percent of poverty will be able to enroll in Marketplace coverage. It also adjusts Medicaid disproportionate share hospital (DSH) allotments for these states to reflect the lower rates of uncompensated care.

Since 1986, hospitals have been required to provide emegency medical services to anyone regardless of their ability to pay via EMTALA (the Emergency Medical Treatment & Labor Act). Needless to say, this means that hospitals eat a lot of expenses caring for uninsured individuals ("uncompensated care"). In response, the federal government pays a chunk of that cost...and of course those costs are a hell of a lot higher in states which haven't expanded Medicaid under the ACA.

Since BBB would make the Medicaid Gap population eligible for fully-subsidized ACA exchange policies, hospitals in those states should see their uncompensated care costs drop dramatically; this section would prevent the states from double-dipping.

Section 30743. Further Increase in FMAP for Medical Assistance for Newly Eligible Mandatory Individuals.

This section increases the Medicaid expansion FMAP to 93 percent through 2025.

One of the biggest headaches surrounding closing the Medicaid Gap the way that the BBB bill does is that the non-expansion states don't have to pay a dime...while the other 38 states which have expanded Medicaid under the ACA have to pay 10% of the cost of their programs. In essence, this amounts to "rewarding" the states which refused to expand the program while penalizing the states which did the right thing.

Aside from how enraging this situation is, there's also the fear that some states which have expanded the program will not just be resentful of the situation, but that they might even allow their own Medicaid expansion programs to expire altogether in response. To appease those states, the BBB would increase FMAP from 90% to 93% for those states (but only for expansion enrollees, not the rest of their Medicaid populations) for the 4 year period that the BBB Medicaid Gap workaround is in place.

Section 137304. Temporary Expansion of Health Insurance Premium Tax Credits for Certain Low-Income Populations.

Modifies certain eligibility rules and requirements for 36B premium tax credits through 2025 , expands eligibility to taxpayers with household incomes below 100 percent of the FPL, specifies that taxpayers with household incomes below 138 percent of the FPL with access to employer-sponsored coverage or a qualified small employer health reimbursement arrangement can still receive credits, reduces the recapture limitation for taxpayers with household incomes below 200 percent of the FPL, exempts certain taxpayers from having to file a return, reconcile, or repay advance payments of 36B premium tax credits, and modifies when applicable large employers make an employer shared responsibility payment with respect to certain low-income taxpayers.

There's a whole mess of stuff here, so let's break it out.

  • The first item makes sure the Medicaid Gap workaround is feasible.

The thing is, the only ACA enrollees who earn less than 138% FPL are presumably those in non-expansion states in the first place, and they're supposed to be getting nearly-zero cost Medicaid anyway, so in theory this shouldn't really impact anyone in the other 38 states (though there's always exceptions here and there).

  • The "recapture limit" refers to cases where an enrollee's actual annual income ends up being higher than they expected. When that happens, they're supposed to pay back a portion of any ACA tax credits they received to the federal government (recapturing it), but there's a limit on how much can be recaptured. This provision reduces that cap to $300/enrollee if their household income is less than 200% FPL.
  • The exemption on having to file, reconcile & repay tax credits looks like it also refers to the Medicaid Gap crowd as well (income under 138% FPL). Again, they're not supposed to be paying more than a few hundred bucks per year for Medicaid in the first place, so it seems a bit strange to require them to file a bunch of paperwork when they aren't gonna have to pay it back anyway.
  • The Employer Mandate penalty part also seems to refer to the Medicaid Gap enrollees. I'm actually impressed by how many loopholes there are to cover here; I didn't even think about a lot of them.

There's nine sections devoted to dramatically EXPANDING & EXTENDING ACA & OTHER HEALTH INSURANCE SUBSIDIES:

Section 137301. Improve Affordability and Reduce Premium Costs of Health Insurance for Consumers.

Extends the American Rescue Plan section 9661 affordability percentages used for 36 (B) premium tax credits through 2025 to increase generosity for individuals eligible for assistance with household incomes below 400 percent of the federal poverty level (FPL) and provides 36 (B) credits for taxpayers with household incomes above 400 percent of the FPL. Specifies that the applicable percentages are not indexed after 2025.

The American Rescue Plan dramatically expanded and improved the ACA premium subsidy formula so to remove the income eligibility cap (aka the #SubsidyCliff) which forced middle class Americans to choose between paying full price for ACA-compliant coverage or enroll in dirt-cheap #ShortAssPlans or to go without any coverage at all and cross their fingers. The ARP also significantly beefed up the underlying subsidy formula to make it far more generous for those below the 400% FPL threshold. This has already led to an additional 2.8 million people enrolling in ACA exchange policies in 2021 alone.

The expanded ARP subsidies are fantastic, but they have one simple flaw: They're only in effect for 2 years (2021 & 2022). Without further legislation, starting January 1, 2023, the Subsidy Cliff will return, forcing millions of middle-income enrollees back into that ugly choice and jacking up premiums for the other ~10 million enrollees dramatically as well.

This provision would extend the ARP subsidies out by another 3 years, through the end of 2025. It should be locked in permanently, of course, but this is a hell of a lot better than nothing.

The bit about the percentages "not being indexed after 2025" refers to an obscure, wonky thing in the ACA which never made much sense to me: The Premium Adjustment Percentage Index, or PAPI. The short version is that the original subsidy formula maxxed out at 9.5% of household income, but the exact percent was "indexed" so that it increased or decreased slightly from year to year based on average health insurance costs nationally. This resulted in it jumping around to as high as 9.86% in 2019, making the subsidies a bit less generous.

It never made any sense to me, honestly; if the idea was to "save taxpayer money" then why not simply make the percentage itself slightly higher in the first place? Fortunately, the ARP made it lower (maxxing out at 8.5% even), which means more generous subsidies...and it also clarified that the ARP rates would not be indexed. The BBB bill eliminates that indexing permanently, so even if the ARP-level subsidies expire, the "original" ACA subsidy formula would apparently go back to the original hard percentages from 2014. This should save most enrollees several hundred dollars more per year, while also making the formula consistent from year to year (which wonks like myself appreciate!).

Section 137302. Modification of Employer-Sponsored Coverage Affordability Test in Health Insurance Premium Tax Credit.

Revises the thresholds through 2025 to determine whether a taxpayer has access to affordable insurance through an employer-sponsored plan or a qualified small employer health reimbursement arrangement to 8.5 percent of income in order to access 36 (B) premium tax credits. Specifies that the thresholds are not indexed after 2025.

If you work for a company which offers group coverage, you're only eligible for ACA subsidies if the cost of that employer coverage is more than a certain percentage of the employee's household income. That percentage normally matches the indexed percentage under the ACA subsidy formula (see above)...which means it's 9.83% in 2021. The thing is, the American Rescue Plan lowered the maximum applicable percent of income from "9.5% indexed" to "8.5% flat"...but I believe it forgot to change it for the employer-sponsored affordability threshold.

This means a chunk of people who should be eligible for ACA subsidies still aren't because the benchmark plan costs between 8.5 - 9.83% of their income. This provision would fix that...and again, it would remove the indexing thing, so even if ARP subsidies expire, it would revert back to a flat 9.5%, I believe.

Section 137303. Treatment of Lump-Sum Social Security Benefits in Determining Household Income.

Excludes Social Security benefit lump-sum payments for Americans with disabilities, widows, new retirees, and others from calculation of household income for purposes of 36 (B) premium tax credits.

I don't know much about Social Security or SSDI matters, but I do know that a lot of disabled beneficiaries get backdated lump sump payments, which can cause major headaches in their ACA subsidy eligibility for the year the payment shows up. This resolves that issue by saying that such payments don't have to be counted for this purpose.

Section 137305. Special Rule for Individuals Receiving Unemployment Compensation.

Extends section 9663 of the American Rescue Plan through 2025, provides that a taxpayer can receive 36 (B) premium tax credits as if the taxpayer’s household income was no higher than 150 percent of the FPL for individuals receiving unemployment compensation as defined in section 85(B) of the Internal Revenue Code.

This, again, is HUGE. The American Rescue Plan included an interesting provision which stated that anyone who's not otherwise prohibited from receiving ACA tax credits (ie, those who have an offer of employer coverage, are on Medicare or Medicaid, etc.) who received unemployment benefits at any point in 2021 is eligible to have their household income counted as if it's less than 150% FPL.

Now, many of these folks really will have an income below that threshold anyway (due to being, you know, unemployed), but the point is that they might not have lost their jobs until part way through the year, which means they may actually earn more than that, which normally would mean their subsidies wouldn't be as generous. Instead, they now qualify for maximum ACA subsidies...which means they can get a benchmark Silver plan for $0/month!

Even better, since Cost Sharing Reduction (CSR) assistance raises the actuarial value of Silver plans up to 94% for those earning <150% FPL, this means that the Silver plan actually becomes the equivalent of a Platinum plan, with extremely low deductibles and other out of pocket costs!

I assumed that this was gonna be a one-time thing in response to the COVID pandemic, but apparently it was such a hit Congressional Democrats decided to extend it out to 2025! (at least 208,000 people took advantage of it for 2021, and possibly as many as 280,000 nationally).

Section 30604. Cost-Sharing Reductions for Individuals Receiving Unemployment Compensation.

This section provides the ACA cost-sharing reduction assistance to individuals receiving unemployment compensation for calendar years 2022 through 2025.

As I noted a week or so ago, I'm actually a bit surprised that this provision is being extended, but I guess it was successful enough (and costs little enough) that the Dems decided to keep it going. Under the American Rescue Plan, for 2021 only, if you received unemployment benefits at any point during the year, you become eligible for a $0-premium "Secret Platinum" plan. It was originally intended as a response to the COVID pandemic, but up to 280,000 people took advantage of it nationally. If I'm reading this section correctly, it would extend the ARP Unemployment Benefit out by another 4 years. The CBO estimated that doing this would cost about $10 billion.

Section 137306. Permanent Credit for Health Insurance Costs.

Makes the health coverage tax credit permanent, removing the uncertainty of annual extensions, and increases the amount of the qualified health insurance premium covered by the credit from 72.5 percent to 80 percent.

This one had me scratching my head, so I did a quick search and found the following from the IRS and this from TurboTax:

The health coverage tax credit is a program in place for tax years from 2002 to 2013 and was later extended through 2019 to help eligible individuals and families by paying a portion of premiums for qualified health insurance programs.

The HCTC is a federally funded program designed to assist people certified as displaced workers by the U.S. Department of Labor and those receiving benefits through the Pension Benefit Guaranty Corp. over age 55. The HCTC covers a significant portion of participants' health insurance premiums, allowing vulnerable sectors of the workforce to maintain health care coverage. Benefits under the program have been adjusted and expanded several times.

Claiming the HCTC requires that you are an eligible recipient of a qualifying trade adjustment assistance program, currently on an approved break from such training or receiving unemployment insurance in lieu of training. You may also qualify if you are 55 or older and a PBGC payee.

Qualified family members of a deceased person eligible for the HCTC may also be eligible for the credit. As well as the candidate requirements, you must meet general requirements such as enrollment in a qualifying health plan, paying more than 50 percent of the premiums and not being claimed as a dependent on another person's federal tax return.

OK, so this makes the HCTC more generous by increasing it from 72.5% to 80%. Interestingly (and appropriately, I suppose), ACA exchange coverage is not eligible. This is reasonable seeing how most ACA exchange enrollees are already getting a huge chunk (possibly 100%) of their premiums covered via APTC subsidies already.

Section 137307. Exclusion of Certain Dependent Income for Purposes of Premium Tax Credit.

Excludes certain dependent income from the calculation of household income for purposes of determining 36 (B) premium tax credit amounts.

This excludes up to $3,500/year in income from dependents under 24 years old (at least that's my read of it) from being counted as part of enrollees household income when it comes to subsidy eligibility.

Section 30602. Establishing a Health Insurance Affordability Fund.

This section 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 section also requires the Centers for Medicare and Medicaid Services (CMS) to establish and implement a temporary reinsurance program in states that are not expending amounts under the State plan for all individuals described in section 1902(a)(10)(A)(i)(VIII).

This is interesting and potentially a big deal for ACA enrollees, but it seems like an odd use of $30 billion given how much they're trying to squeeze the total package cost down: It would basically provide $10 billion/year for 3 years (2023 - 2025) for states to use in various ways to cut down the cost of ACA coverage. The money could be used for reinsurance (which cuts unsubsidized premium costs) or for state-specific Cost Sharing Reduction (CSR) assistance or some combination of both. In other words, individual states could use this money to further reduce deductibles, co-pays etc. for their enrollees.

For comparison, the expanded ACA subsidies themselves would run something like $21 billion/year via the CBO, so the same money could have been used to bump them out by another year or two instead. Don't get me wrong, the money will help millions of people either way, it's just interesting to see the choices they're making about where to allocate buckets of funding.

Section 30603. Funding for the Provision of Health Insurance Consumer Information.

This section provides $100 million for the ACA’s health insurance consumer information grants for calendar years 2022 through 2025.

God knows the United States needs as much accurate, reliable consumer information about how health insurance works as possible...

There's six sections devoted to funding for Home & Community-Based Services (HCBS):

Section 30711. HCBS Improvement Planning Grants.

This section provides grants to states to develop plans to expand access to home and communitybased services (HCBS) and strengthen the HCBS workforce.

This section would provide $130 million in grants for HCBS improvements by individual states.

Section 30712. HCBS Improvement Program.

This section provides states with a permanent six percentage point increase to the federal medical assistance percentage (FMAP) if the state implements an HCBS improvement program to strengthen and expand HCBS. It provides an enhanced FMAP of 80 percent for administrative costs associated with improving HCBS. It also provides a six-quarter increase to the FMAP of two percentage points if a state adopts an HCBS model that promotes self-direction of care and meets certain other requirements.

Federal Medical Assistance Percentages (FMAP) refers to the percent of Medicaid costs paid for by the federal government (the remainer is paid for by the state in question). FMAP generally ranges between 50 - 75% depending on the state; the exact percent depends on a variety of factors. Basically, the higher the FMAP, the lower the percent of its Medicaid program that a state has to pay for.

Section 30713. Funding for Federal Activities.

This section requires the Secretary of Health and Human Services (HHS) to report on the implementation and outcomes of state HCBS improvement programs, and to provide states with technical assistance to implement HCBS improvement programs.

$15 million for this section.

Section 30714. Funding for HCBS Quality Measurement and Improvement.

This section requires HHS to develop and publish HCBS quality measures for state Medicaid programs.

$22 million.

Section 30715. Permanent Extension of Medicaid Protections Against Spousal Impoverishment for Recipients of Home and Community-Based Services.

This section permanently extends the protection against spousal impoverishment for individuals whose partners receive Medicaid HCBS.

I wrote about this a couple of times before; it's one of those issues which most people never think about but it's a major problem when it impacts you:

The expense of nursing home care — which ranges from $5,000 to $8,000 a month or more — can rapidly deplete the lifetime savings of elderly couples. In 1988, Congress enacted provisions to prevent what has come to be called "spousal impoverishment," leaving the spouse who is still living at home in the community with little or no income or resources. These provisions help ensure that this situation will not occur and that community spouses are able to live out their lives with independence and dignity.

Under the Medicaid spousal impoverishment provisions, a certain amount of the couple's combined resources is protected for the spouse living in the community. Depending on how much of his or her own income the community spouse actually has, a certain amount of income belonging to the spouse in the institution can also be set aside for the community spouse's use.

The 1988 protection is currently set to expire at the end of 2023; this would lock it in permanently.

Section 30716. Permanent Extension of Money Follows the Person Rebalancing Demonstration.

This section provides permanent funding for the Money Follows the Person Rebalancing Demonstration to help states transition folks out of institutions and into HCBS.

Via Medicaid.Gov:

...supports state efforts for rebalancing their long-term services and supports system so that individuals have a choice of where they live and receive services. From the start of the program in 2008 through the end of 2019, states have transitioned 101,540 people to community living under MFP.

MFP Program Goals

  • Increase the use of home and community-based services (HCBS) and reduce the use of institutionally-based services
  • Eliminate barriers in state law, state Medicaid plans, and state budgets that restrict the use of Medicaid funds to enable Medicaid-eligible individuals to receive support for appropriate and necessary long-term services and supports in the settings of their choice
  • Strengthen the ability of Medicaid programs to provide HCBS to people who choose to transition out of institutions
  • Put procedures in place to provide quality assurance and improve HCBS

Section 30721. Investments to Ensure Continued Access to Health Care for Children, Pregnant Individuals, and Other Individuals.

This section makes several improvements to expand access and continuity of care to some of our most vulnerable citizens, including low-income children and new moms. It requires that state Medicaid programs provide 12 months of continuous Medicaid and CHIP eligibility to postpartum women; 12 months of continuous eligibility to children enrolled in Medicaid and CHIP; and coverage to justice-involved individuals 30 days prior to their release.

It also allows states to smoothly transition out of the coverage requirements put in place during the public health emergency. This section also permanently extends the state option to simplify children’s enrollment in Medicaid and CHIP. Finally, it authorizes a new option for states to provide coordinated care for pregnant and postpartum women through a health home.

Requiring Medicaid and the Children's Health Insurance Program (CHIP) to cover pregnant/postpartum people for a full 12 months after they give birth would be hugely important.

As an aside, yes, I'm starting to refer to "pregnant people" instead of "pregnant women" as a nod to the transgender community...I admit it'll take some getting used to, but I'm working on it. It looks like those who wrote the BBB bill are still getting used to this as well; some of the references in the both the legislative text itself as well as the summary above refer to "pregnant / postpartum individuals" while others refer to "pregnant / postpartum women."

The basic problem is that some states require the enrollees to prove their eligibility as often as each month whether the enrollees income status has changed or not, which can be a royal hassle and often leads to coverage gaps. It's also an administrative mess for the states. By mandating a full year of coverage, it reduces the headaches for both enrollees and administrators.

There's also an interesting section here about the increased FMAP match (of 6.2%) during the COVID pandemic. It looks like this would wind that down gradually throughout 2022 instead of cutting it off entirely all at once.

There's another section which would require prison inmates to be eligible for Medicaid for the month prior to them being released from prison, which is an interesting item (I find the "justice-involved individuals" wording kind of amusing).

Section 30722. Investments to Expand Access to Behavioral Health.

This section makes important investments to strengthen and expand access to behavioral health. It provides all states with incentives to cover Certified Community Behavioral Health Care Clinics. It also permanently extends the option for states to cover Community-Based Mobile Crisis Intervention Services to help individuals experiencing a crisis quickly get the treatment they need.

Looks like $40 million.

Section 30723. Extension of 100 Percent Federal Medical Assistance Percentage for Urban Indian Health Organizations and Native Hawaiian Health Care Systems.

This section extends for an additional two years the 100 percent FMAP for urban Indian organizations and Native Hawaiian Health Centers that was first authorized in the American Rescue Plan.

The federal government would pay 100% of the cost of Medicaid for these organizations/systems through March 31, 2025.

Section 30731. Increasing Medicaid Cap Amounts and the Federal Medical Assistance Percentage for the Territories.

This section permanently increases federal Medicaid funding for the territories and corrects a long-standing historical injustice by permanently increasing each territory’s FMAP to 83 percent.

This is HUGE for residents of Puerto Rico, US Virgin Islands, Guam, American Samoa, and the Northern Mariana Islands.

Section 30741. Encouraging Continued Access After the End of the Public Health Emergency.

This section encourages states to maintain Medicaid eligibility standards that were in place prior to the public health emergency.

Last year, the emergency COVID-19 legislation enacted by Congress made a lot of changes to how the Medicaid & CHIP programs work, including making it much easier for people to enroll and a whole lot harder for states to disenroll them. In return, the FMAP level was increased significantly. However, as soon as the public health emergency officially ends, so do a lot of those requirements....which means that without further legislation, millions of enrollees will be kicked off the state Medicaid roles all at once.

Here's most of the actual wording of this section (it's short):

‘‘(1) IN GENERAL.—Subject to paragraph (2), if, between September 1, 2022 and December 31, 2025, a State puts into effect for any calendar quarter occurring during such period eligibility standards for individuals (except individuals described in subparagraph (D) of section 1902(e)(14)) who are applying for or receiving medical assistance, methodologies, or procedures under the State plan of such State under title XIX of the Social Security Act (42 U.S.C. 1396 through 1396w-6) (including any waiver under such title or section 1115 of such Act (42 U.S.C. 1315)) that are more restrictive than the eligibility standards, methodologies, or procedures, respectively, under the State plan (or waiver of such plan) that are in effect on October 1, 2021, the Federal medical assistance percentage otherwise determined under section 1905(b) of the Social Security Act (42 U.S.C. 1396d(b)) for that State shall be reduced by 3.1 percentage points for such calendar quarter.

In other words, any state which decides to start being a strict hard-ass about Medicaid/CHIP eligibility/applications the moment the pandemic ends will see their FMAP drop by 3.1 points, which could amount to tens or even hundreds of millions of dollars in lost federal funding.

Section 30742. Ensuring Accurate Payments to Pharmacies Under Medicaid.

This section ensures Medicaid accurately reimburses for prescription drugs.

It looks like this would be accomplished by requiring the HHS Secretary to "conduct a survey of retail community pharmacy drug prices to determine the national average drug acquisition cost" with harsh penalties for pharmacys which don't respond to the survey. Presumably this information will be used to make sure that Medicaid programs aren't overpaying pharmacies for drugs.

Section 30801. Investments to Strengthen CHIP.

This section makes comprehensive improvements to the Children’s Health Insurance Program (CHIP) for low-income children. It authorizes permanent funding for CHIP. It provides permanent funding for several programs related to CHIP, including the pediatric quality measures program and the child enrollment contingency fund to provide states with additional funding in the event its CHIP allotment is insufficient. It also closes a longstanding loophole and ensures that all CHIP programs are able to receive low-cost prescription drugs. Finally, this section provides states with the option to increase CHIP income eligibility levels above the existing statutory ceiling.

At any given moment, there's somewhere between 6 - 7 million children enrolled in the CHIP program nationally. CHIP funding has historically been renewed every 5 years or so without too much fuss, but under the Trump Administration, Congressional Republicans decided to use hold CHIP funding hostage. The issue was eventually resolved and funding was bumped out by several more years, but the BBB would take this off the table in the figure by permanently funding the program, which would be huge for those millions of children and their parents.


Section 30901. Providing Coverage for Hearing Care under the Medicare Program.

This section allows for qualified audiologists, beginning January 1, 2024, to deliver aural rehabilitation and treatment services in addition to the hearing and balance assessment services provided under current law. It also allows for qualified hearing aid professionals to deliver hearing assessment services, beginning January 1, 2024. This section defines qualified hearing aid professionals as state licensed hearing aid dispensers, hearing aid specialists, hearing instrument dispensers, or related professionals who meet other requirements, as determined appropriate by the Secretary.

This section also provides for coverage of hearing aids under Medicare Part B for individuals with severe or profound hearing loss in one or both ears, once every five years, and if furnished through a written order by a physician, qualified audiologist, hearing aid professional, physician assistant, nurse practitioner, or clinical nurse specialist, qualified to write such order by the state.

The earlier version of the BBB bill would have expanded traditional Medicare benefits to include dental, vision and hearing aid coverage, along with placing a cap on out of pocket expenses for prescription drugs under Medicare Part D.

Of the four, dental coverage is considered by far to be the most expensive (in 2019, the CBO estimated that it would cost around $238 billion to add dental coverage alone to Medicare, and that was only for a 5-year period, vs. just $89 billion for hearing aid coverage over 7 years). Interestingly, the White House budget projection estimates the hearing aid benefit will only cost $35 billion over 8 years. A big part of the projected savings will apparently come from President Biden's executive order over the summer instructing the FDA to finally allow hearing aids to be sold over the counter without a prescription, leading to dramatically lower prices.

Section 31001. Funding to Support Core Public Health Infrastructure for State, Territorial, Local, and Tribal Health Departments at the Centers for Disease Control and Prevention.

This section provides $7 billion in funding to support core public health infrastructure activities to strengthen the public health system through grants to state, territorial, local, or Tribal health departments, and expanding and improving activities of the Centers for Disease Control and Prevention (CDC).

Such activities include: health equity activities; workforce capacity and competency; all hazards public health and preparedness; testing capacity, including test platforms, mobile testing units, and personnel; health information, health information systems, and health information analysis; epidemiology and disease surveillance; contact tracing; policy and communications; financing; community partnership development; and relevant components of organizational capacity.

Needless to say, this is desperately needed at the moment.

Section 31002. Funding for Health Center Capital Grants.

This section provides $1 billion in funding to award grants and enter into cooperative agreements for capital projects to health centers and federally qualified health center look-alikes. Funds can be used for health center facility alteration, renovation, remodeling, expansion, construction, and other capital improvement costs.

Here's info about Federally Qualified Health Centers (FQHCs):

Federally Qualified Health Centers are community-based health care providers that receive funds from the HRSA Health Center Program to provide primary care services in underserved areas. They must meet a stringent set of requirements, including providing care on a sliding fee scale based on ability to pay and operating under a governing board that includes patients.

Federally Qualified Health Centers may be Community Health Centers, Migrant Health Centers, Health Care for the Homeless, and Health Centers for Residents of Public Housing.

The defining legislation for Federally Qualified Health Centers (under the Consolidated Health Center Program) is Section 1905(l)(2)(B) of the Social Security Act.

I admit I was scratching my head about the "look-alikes" part, but apparently that's a real thing as well; huh:

Federally Qualified Health Center Look-Alikes are community-based health care providers that meet the requirements of the HRSA Health Center Program, but do not receive Health Center Program funding. They provide primary care services in underserved areas, provide care on a sliding fee scale based on ability to pay and operate under a governing board that includes patients.

The defining legislation for Federally Qualified Health Center Look-Alikes (under the Consolidated Health Center Program) is Section 1905(l)(2)(B) of the Social Security Act.

The next five sections provide funding for various palliative & hospice training programs.

Sadly, there's a growing need in these areas as the Baby Boomer generation enters their 80's and older.

Palliative & Hospice Care:

Palliative care is specialized medical care for people living with a serious illness, such as cancer or heart failure. Patients in palliative care may receive medical care for their symptoms, or palliative care, along with treatment intended to cure their serious illness. Palliative care is meant to enhance a person's current care by focusing on quality of life for them and their family.

...Hospice care focuses on the care, comfort, and quality of life of a person with a serious illness who is approaching the end of life.

At some point, it may not be possible to cure a serious illness, or a patient may choose not to undergo certain treatments. Hospice is designed for this situation. The patient beginning hospice care understands that his or her illness is not responding to medical attempts to cure it or to slow the disease's progress.

Like palliative care, hospice provides comprehensive comfort care as well as support for the family, but, in hospice, attempts to cure the person's illness are stopped. Hospice is provided for a person with a terminal illness whose doctor believes he or she has six months or less to live if the illness runs its natural course.

Section 31007. Funding for Palliative Care and Hospice Education and Training.

This section provides $30 million in funding to support training of health professionals in palliative and hospice care, foster patient and family engagement, integration of palliative and hospice care with primary care and other appropriate specialties, and collaboration with community partners to address gaps in health care for individuals in need of palliative or hospice care.

Section 31008. Funding for Palliative Medicine Physician Training.

This section provides $20 million in funding for accredited schools of medicine, teaching hospitals, and graduate medical education programs to train physicians (including residents, trainees, and fellows) or specialists who plan to teach or practice palliative medicine.

Section 31009. Funding for Palliative Care and Hospice Academic Career Awards.

This section provides $20 million in funding for programs to promote the career development of individuals who are board certified or board eligible in hospice and palliative medicine and have a junior (non-tenured) faculty appointment at an accredited health professions school.

Section 31010. Funding for Hospice Palliative Care Nursing.

This section provides $20 million in funding to accredited nursing schools, health care facilities, programs leading to certification, partnerships of such schools and facilities, and programs and initiatives to develop and implement programs to train and educate individuals in palliative care in educational, hospital, hospice, home, or long-term care settings.

Section 31011. Funding for Dissemination of Palliative Care Information.

This section provides $10 million in funding for an awareness campaign to inform patients, families, caregivers, direct care workers, and health professionals about the benefits of palliative care and the services that are available to support patients with serious or life-threatening illnesses.

The next three sections deal with helping to prevent and/or mitigate the inevitable NEXT pandemic threat coming down the pike...

Section 31021. Funding for Laboratory Activities at the Centers for Disease Control and Prevention.

This section provides $1.4 billion in funding to support renovation, improvement, expansion, and modernization of state and local public health laboratory infrastructure; enhance the capacity of the laboratories at CDC; and enhance the ability of CDC to monitor and exercise oversight over the biosafety and biosecurity of state and local public health laboratories.

Needless to say, this is vitally important at the moment.

Section 31022. Funding for Public Health and Preparedness Research, Development, and Countermeasure Capacity.

This section provides $1.3 billion in funding to the Assistant Secretary for Preparedness and Response to prepare for, and respond to, public health emergencies, including supporting surge capacity; supporting expanded global and domestic vaccine production capacity; supporting activities to mitigate supply chain risks and enhance supply chain elasticity and resilience; supporting activities conducted by the Biomedical Advanced Research and Development Authority; and supporting increased biosafety and biosecurity in research on infectious diseases.

Needless to say, this is vitally important at the moment.

Section 31023. Funding for Infrastructure Modernization and Innovation at the Food and Drug Administration.

Section 31023 provides $300 million for improving infrastructure at the Food and Drug Administration (FDA), including technological infrastructure (including through the development of integrated systems and interoperability of IT systems) and laboratory and related facilities infrastructure.

Needless to say, this is vitally important at the moment.

There's a whopping 18 sections devoted to funding for various prenatal, perinatal, maternity & postpartum health programs, with many of them devoted to studying & reducing racial bias in maternity care. I think most of these are part of Rep. Lauren Underwood's "Momnibus Act":

Section 31031. Funding for Local Entities Addressing Social Determinants of Maternal Health.

This section provides $100 million in funding to award grants to address social determinants of maternal health for pregnant and postpartum individuals.

Section 31032. Funding for the Office of Minority Health.

This section provides $75 million in funding to the HHS Office of Minority Health to award grants to address social determinants of maternal health for pregnant and postpartum individuals.

Section 31033. Funding to Grow and Diversify the Nursing Workforce in Maternal and Perinatal Health.

This section provides $170 million in funding to award grants to accredited schools of nursing to grow and diversify the perinatal nursing workforce.

Section 31034. Funding for Perinatal Quality Collaboratives.

This section provides $50 million to carry out a program to establish or support perinatal quality collaboratives to improve perinatal care and perinatal health outcomes for pregnant and postpartum individuals and their infants.

Section 31035. Funding to Grow and Diversify the Doula Workforce. This section provides $50 million in funding to award grants to establish or expand programs to grow and diversify the doula workforce.

I've heard the term "doula" before but wasn't that familiar with it, so here you go:

A doula is a trained companion who is not a healthcare professional and who supports another individual (the doula's client) through a significant health-related experience, such as childbirth, miscarriage, induced abortion or stillbirth, or non-reproductive experiences such as dying. A doula may also provide support to the client's partner, family, and friends.

Section 31036. Funding to Grow and Diversify the Maternal Mental Health and Substance Use Disorder Treatment Workforce.

This section provides $75 million in funding to award grants to establish or expand programs to grow and diversify the maternal mental health and substance use disorder treatment workforce.

Section 31037. Funding for Maternal Mental Health Equity Grant Programs.

This section provides $100 million in funding to award grants to address maternal mental health conditions and substance use disorders with respect to pregnant, lactating, and postpartum individuals, including in areas with significant racial or ethnic disparities in maternal health outcomes.

Section 31038. Funding for Education and Training at Health Professions Schools to Identify and Address Health Risks Associated with Climate Change.

This section provides $85 million in funding to award grants to support the development and integration of education and training programs for identifying and addressing risks associated with climate change for pregnant, lactating, or postpartum individuals.

Section 31039. Funding for Minority-Serving Institutions to Study Maternal Mortality, Severe Maternal Morbidity, and Adverse Maternal Health Outcomes.

This section provides $50 million in funding to award grants to minority-serving institutions to study maternal mortality, severe maternal morbidity, and averse maternal health outcomes.

Section 31040. Funding for Identification of Maternity Care Health Professional Target Areas.

This section provides $25 million in funding for identification of maternity care health professional target areas, as defined under section 332(k) of the Public Health Service Act.

Section 31041. Funding for Maternal Mortality Review Committees to Promote Representative Community Engagement.

This section provides $50 million in funding to promote community engagement in maternal mortality review committees (MMRCs).

Section 31042. Funding for the Surveillance for Emerging Threats to Mothers and Babies.

This section provides $100 million for the National Center on Birth Defects and Developmental Disabilities with respect to conducting surveillance for emerging threats to mothers and babies.

Section 31043. Funding for the Enhancing Reviews and Surveillance to Eliminate Maternal Mortality Program.

This section provides $30 million to carry out the Enhancing Reviews and Surveillance to Eliminate Maternal Mortality program, including expanding the program and partnerships with state, territorial, and Tribal organizations to support MMRCs, as well as to provide technical assistance to existing MMRCs.

Section 31044. Funding for the Pregnancy Risk Assessment Monitoring System.

This section provides $15 million to support the Pregnancy Risk Assessment Monitoring System, including supporting COVID-19 assessments and transitioning to an electronic system.

Section 31045. Funding for the National Institute of Child Health and Human Development.

This section provides $15 million to support the activities of the Eunice Kennedy Shriver National Institute of Child Health and Human Development, including to conduct or support research for interventions to mitigate the effects of COVID-19 on pregnant and postpartum individuals.

Section 31046. Funding for Expanding the Use of Technology-Enabled Collaborative Learning and Capacity Building Models for Pregnant and Postpartum Individuals.

This section provides $30 million in funding to award grants to expand the use of technology-enabled collaborative learning and capacity building models for pregnant and postpartum individuals.

Section 31047. Funding for Promoting Equity in Maternal Health Outcomes through Digital Tools.

This section provides $30 million in funding to award grants to reduce racial and ethnic disparities in maternal health outcomes by increasing access to digital tools related to maternal health care.

Section 31048. Funding for Antidiscrimination and Bias Training.

This section provides $50 million in funding to award grants to develop, disseminate, review, research, and evaluate training for health professionals, with a focus on maternal health providers, to reduce discrimination and bias in the provision of health care, with a focus on maternal health care.

Implicit bias is a HUGE problem in the U.S. healthcare system, especially when it comes to maternal healthcare services.

There's four sections devoted to funding for the SAMHSA (Substance Abuse & Mental Health Services Administration):

The Substance Abuse and Mental Health Services Administration (SAMHSA) is the agency within the U.S. Department of Health and Human Services that leads public health efforts to advance the behavioral health of the nation. SAMHSA's mission is to reduce the impact of substance abuse and mental illness on America's communities.

Section 31051. Funding for Mental Health and Substance Use Disorder Professionals.

This section provides $50 million in funding for the Minority Fellowship Program at the Substance Abuse and Mental Health Services Administration (SAMHSA). The Minority Fellowship Programs seeks to improve behavioral health outcomes for communities of color by awarding scholarships to educate practitioners on mental health and substance use issues that commonly affect racial and ethnic minority populations; provide training to enhance the availability of culturally competent care; and improve the quality of behavioral health services provided to people of color.

Section 31052. Funding to Support Peer Recovery Specialists.

This section provides $25 million to support SAMHSA’s Recovery Community Services Program Statewide Network program, which seeks to strengthen recovery community organizations and their statewide network of recovery stakeholders. The program works to embed recovery stakeholders, including peers, into traditional substance use disorder treatment services; encourages states to allow for the reimbursement of peer billable recovery services; facilitates financial solvency for recovery services; and otherwise strengthens the delivery of peer recovery services nationwide.

Section 31053. Funding for Project AWARE.

This section provides $15 million in funding to support SAMHSA’s Project AWARE program, which helps build or expand coordination among state and local governments to increase awareness of mental health issues among school-aged youths, train school personnel to detect and respond to mental health issues, and connect school-aged youth who may have behavioral health issues to needed services.

Section 31056. Funding for the National Child Traumatic Stress Network.

This section provides $5 million to support the National Child Traumatic Stress Network at SAMHSA, which seeks to improve mental health and trauma support services for youth.

There's a bunch of sections funding various other health programs:

Section 31054. National Suicide Prevention Lifeline.

This section provides $75 million in funding to support the infrastructure of the National Suicide Prevention Lifeline, the 24/7, free, and confidential national suicide prevention hotline. This funding will help support the Lifeline and its network of local crisis centers in advance of the implementation of the new “988” Lifeline number in 2022.

Section 31055. Funding for Community Violence and Trauma Interventions.

This section provides $2.5 billion in funding to support public health approaches to reduce community violence and trauma.

Section 31057. Funding for HIV Health Care Services Programs.

This section provides $75 million in funding to support the Ryan White HIV/AIDS program to provide primary care, support services, and medications to communities disproportionally affected by HIV/AIDS.

Here's info on the Ryan White Program:

The Health Resources and Services Administration’s (HRSA) Ryan White HIV/AIDS Program provides a comprehensive system of HIV primary medical care, essential support services, and medications for low-income people with HIV. The program funds grants to states, cities, counties, and local community-based organizations to provide care and treatment services to people with HIV to improve health outcomes and reduce HIV transmission among hard-to-reach populations.

More than half of people with diagnosed HIV in the United States receive services through the Ryan White HIV/AIDS Program each year. That means more than half a million people received services through the program.

Section 31058. Funding for Clinical Services Programs.

This section provides $100 million in funding to support grants and contracts to public and private nonprofit clinics to carry out demonstration projects for the prevention and control of sexually transmitted infections.

Section 31059. Funding to Support the Lifespan Respite Care Program.

This section provides $5 million in funding to support the Lifespan Respite Care program, which provides accessible, community-based assistance to family caregivers of children and adults with special needs.

Section 31060. Funding to Increase Research Capacity at Certain Institutions.

This section provides $75 million in funding for the National Institutes of Health to increase research capacity at minority serving institutions, including Historically Black Colleges and Universities. The funding can also be used to expand the recruitment and retention of individuals underrepresented in biomedical research.

Section. 31061. Funding for Research Related to Developmental Delays.

This section provides $10 million in funding to the National Institutes of Health to support research, including longitudinal studies, of speech and language developmental delays in children.

Section. 31062. Supplemental Funding for World Trade Center Health Program.

This section provides $2.86 billion to the World Trade Center Health Program through the establishment of a Supplemental Fund for the program.

The World Trade Center Health Program...

...is a limited federal health program administered by the National Institute for Occupational Safety and Health, part of the Centers for Disease Control and Prevention in the U.S. Department of Health and Human Services and is authorized through 2090. The Program provides no-cost medical monitoring and treatment for certified WTC-related health conditions to those directly affected by the 9/11 attacks in New York, the Pentagon, and in Shanksville, Pennsylvania.

The Program also funds medical research into physical and mental health conditions related to 9/11 exposures.

The next three sections provide funding and protections specific to Native Hawaiians:

Section 31071. Native Hawaiian Health Care Systems.

This section provides $50 million in funding to support grants to Papa Ola Lokahi, including for distribution to Native Hawaiian Health Care Systems that receive grants or enter into contracts under the Native Hawaiian Health Care Improvement Act (NHHCIA), for construction projects, health information technology projects, and medical equipment acquisition.

Apparently Papa Ola Lokahi is the Native Hawaiian Health Board.

Section 31072. Native Hawaiian Health Improvement Grants.

This section provides $224 million in funding to award grants to Native Hawaiian entities to improve the health status of Native Hawaiians, including by providing comprehensive health promotion services, disease prevention services, and primary health services.

Section 31073. Native Hawaiian Health Care Systems Liability Coverage.

This section extends federal liability protections to Native Hawaiian health care systems that receive grants or enter into contracts under NHHCIA and their employees to the same extent and manner as Indian Tribes, Tribal organizations, or Indian contractors.

Finally, we have eight sections which help address the massive shortage of healthcare professionals in the United States, especially in rural & other underserved areas of the country:

Section 31003. Funding for Teaching Health Center Graduate Medical Education.

This section provides $3.37 billion in funding for payments to teaching health centers that operate graduate medical education programs and for the awarding of teaching health center development grants. In making such grants, the Secretary of Health and Human Services (HHS) shall make payments and awards that take into account states or territories in which there is no existing qualified teaching health center.

Section 31004. Funding for Children’s Hospitals that Operate Graduate Medical Education Programs.

This section provides $150 million in funding for the Children’s Hospital Graduate Medical Education program, which supports the training of pediatric primary care, specialty, and dental residents.

It's my understanding that there's a huge shortage of pediatric primary care physicians (partly because it's an underpaid specialty compared to many other medical specialties).

Section 31005. Funding for the National Health Service Corps.

This section provides $650 million in funding for the National Health Service Corps, which provides scholarships and loan repayment to qualified health care providers in exchange for their service in underserved areas across the country.

Section 31006. Funding for the Nurse Corps.

This section provides $200 million in funding for the Nurse Corps, which provides scholarships and loan repayment assistance to registered nurses (RNs) and advanced practice registered nurses (APRNs), in return for a commitment to work at eligible health care facilities with a critical shortage of nurses or serve as nurse faculty in eligible schools of nursing.

Section 137401. Administrative Funding of the Rural and Undeserved Pathway to Practice Training Programs for Post-Baccalaureate Students, Medical Students, and Medical Residents.

This section invests $6 million into implementation of the Pathway to Practice program.

I found this description:

We applaud the Ways and Means Committee for creating the Pathway to Practice Training Programs in its portion of the Build Back Better Act. Innovative initiatives such as this one would encourage students from communities that are underrepresented in higher education to attend medical school. The programs are also integral to efforts to ensure that all patients – particularly those in rural and other underserved areas – have access to the care they need.

The final three sections looks like they would dramatically expand the "Pathway to Practice" system further:

Section 137402. Establishing Rural and Underserved Pathway to Practice Training Programs for Post-Baccalaureate Students and Medical Students.

This section establishes Section 1899C of the Social Security Act for the Rural and Underserved Pathway to Practice Training Program for Post-Baccalaureate and Medical Students. This section incentivizes those from rural and underserved communities to become physicians and to practice in those communities through a scholarship and stipend for qualifying medical students to attend medical school or post-baccalaureate and medical school.

Students eligible for this program include first generation college or professional students; Pell Grant recipients; those who lived in a medically underserved, rural, or health professional shortage areas. Beginning in 2023, the Secretary shall award 1,000 scholarships per year, which includes tuition, academic fees, textbooks, equipment, and a monthly stipend tied to the amount in for the Armed Forces Health Professions Scholarship Program, which for 2021 is $2,540. The Secretary shall prioritize those students who participated in the Health Careers Opportunity Program, were Area Health Education Scholars, are disadvantaged students as defined by the National Health Service Corps, or attended a Historically Black College or University or minority serving institution.

Upon scholarship acceptance, the student agrees to complete medical school (and postbaccalaureate program as applicable), residency, and practice for at least one year per scholarship year in a health professional shortage area, a medically underserved area, or a rural area. If the student is not compliant with the terms of the scholarship, the student must repay the amounts and the Secretary will collect these repayments with interest, except for the case of hardship.

Section 137403. Funding for the Rural and Underserved Pathway to Practice Training Programs for Post-Baccalaureate Students and Medical Students.

The provision creates a new refundable Pathway to Practice medical scholarship voucher credit under section 36G of the Internal Revenue Code for qualified educational institutions. The credit amount for a taxable year is equal to the aggregate amount paid or incurred by a qualified educational institution during the taxable year pursuant to an annual award of a Pathway to Practice medical scholarship voucher to a qualifying student.

Section 137404. Establishing Rural and Underserved Pathway to Practice Training Programs for Medical Residents.

This section amends Section 1886 of the Social Security Act to incentivize additional residency training by, beginning on October 1, 2026, excluding from the residency slot cap those residents who participated in Rural and Underserved Pathway to Practice Training Programs at certain applicable hospitals that are recognized by the Accreditation Council for Graduate Medical Education (ACGME) for committing to train physicians with additional requirements, such as increased mentorship, structural and cultural competency training, and training in the community.

UPDATE: I've moved my update with the latest additions & twists to the House version of the bill to a separate post.