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President Joe Biden had to make numerous concessions to bridge the divide among congressional Democrats, but even the slimmed-down version of his Build Back Better agenda would expand health coverage and make new investments in the healthcare workforce.
The overall package shrank down to about $1.75 trillion in new spending from $3.5 trillion, in part by downsizing Biden’s healthcare goals.
The House could vote on the latest iteration of the proposal as soon as early November but the Senate has not yet released its version. Congressional Republicans uniformly oppose the legislation.
Here are the key healthcare provisions, including those that have changed, are new or have stayed the same.
Health coverage
The legislation would reduce the number of people who are uninsured by millions, offering financial assistance to cover health insurance premiums.
Changed: People making more than 400% of the federal poverty level—about $52,000 per year for an individual—will be eligible for Affordable Care Act subsidies through 2025. Congress created these enhanced subsidies this year and they are due to expire in 2023.
Subsidies will also be more generous for people making below 400% of poverty, also in keeping with the current policy. An earlier version of the bill made these changes permanent.
Changed: More than 2 million residents of states that haven’t expanded Medicaid to cover low-income adults will also be eligible for large subsidies they can use to buy private health insurance on the exchanges through 2025. The ACA originally intended for all states to expand Medicaid to people with incomes below 138% of poverty—about $13,000 per year for an individual—but the Supreme Court ruled in 2012 that it was optional for states. Twelve states have not adopted the expansion. Under current law, people living in non-expansion states aren’t eligible for Medicaid or for ACA subsidies.
Changed: House committees advanced an earlier version of the legislation that would’ve created a fully federal, Medicaid-like plan for this population. Like many other provisions, this one fell by the wayside after conservative Democratic Sen. Joe Manchin (W.Va.) objected to the introduction of new government programs.
Same: The package retains $30 billion for state reinsurance programs, which help reduce premiums for health insurance exchange customers.
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Medicaid, Medicare and CHIP
Biden’s revised plan would make significant changes to Medicaid and Medicare that Democrats say would improve coverage for older people, low-income adults and children, and would narrow health disparities.
Changed: The bill includes $150 billion to expand home- and-community-based services in Medicaid, short of the $400 billion that Biden initially requested. This would still mark the biggest investment in home- and community-based services in decades. The additional funding is intended to raise wages for home careworkers and shorten waiting lists for services.
Same: States would have to maintain Medicaid coverage for beneficiaries 12 months after childbirth. Many states currently cut off Medicaid coverage 60 days postpartum, even though most pregnancy-related fatalities occur within the first year of giving birth. This policy would likely have an outsize impact on Black women, who are three times more likely to die from pregnancy complications than white women.
Same: States would be required to offer Medicaid to incarcerated people 30 days before their release.
Changed: Medicare would cover hearing aids for fee-for-service beneficiaries beginning in 2024. The original package also included coverage for dental and vision care, but this was dropped to reduce the bill’s cost.
Same: The package would permanently fund the Children’s Health Insurance Program, which periodically needs to be reauthorized under current law. The plan also would require states to cover children for a full 12 months even if their households’ incomes rise above the CHIP eligibility threshold during that period.
Public health infrastructure, workforce and education
New: The new plan includes $100 million to build up the palliative care and hospice workforce.
Changed: The bill would establish a $1 billion grants program hospitals can tap for capital projects, $9 billion less than originally proposed.
Changed: $10 billion in hospital infrastructure spending from an earlier version of the plan is gone.
Changed: Medical schools located in underserved communities were due to get $1 billion under a previous iteration of the plan, but it’s left out of the revised package.
Changed: Biden’s proposal for a new agency to accelerate research on cancer, Alzheimer’s disease and other ailments has been eliminated.
Same: The Centers for Disease Control and Prevention and state and local health departments would get $7 billion to shore up public health infrastructure.
Changed: The Health and Human Services Department would get $1.3 billion for public health preparedness and research, down from $8 billion included in the original bill.
Changed: The CDC would get about $1.4 billion to modernize public health laboratories, less than the $5 billion initially proposed.
Changed: Academic medical centers would get $3.37 billion to operate graduate medical education programs, about half of what was included in the original bill.
Changed: Children’s hospitals would get $150 million for graduate medical education, a 40% decrease compared to the original bill.
New: The National Health Service Corps, which provides scholarships and loan repayments to providers in underserved areas, would get $650 million.
Changed: The Nurse Corps, which provides scholarships and loan repayments to registered nurses to help alleviate workforce shortages, would get $200 million under the updated package, a decrease of about $100 million from the previous bill.
Same: The package includes about $1 billion in grants aimed at reducing maternal mortality, including programs that address social determinants of health, diversify the workforce and tackle mental health and substance use disorder.
Same: The bill keeps $6 billion for a new program designed to enlarge the physician workforce in rural and urban areas with shortages. Residents of those regions would be eligible for scholarships if they and practice in underserved locales after completing medical school.
Drug pricing
Changed: Democrats dropped language that would have allowed Medicare to negotiate prices with pharmaceutical companies because a handful of lawmakers objected, but party leaders on Congress continue to press the issue.
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