• Here is what it means for NAHC members and their patients

The Build Back Better Act, a signature legislative priority for the Biden administration and its allies in Congress, passed the House of Representatives this morning on a party line vote of 220-213. The legislation now heads to the Senate for consideration.

The Build Back Better Act (BBB) is a roughly $1.7 trillion social spending package that, among other things, creates new Medicare benefits for hearing services and enables the government to negotiate some prescription drug prices to lower the costs that seniors pay for lifesaving medicines such as insulin.

The legislation also contains substantial implications for the future of home and community-based services in the United States, as well as training and development of the direct care workforce.

“Today’s historic vote of support for home care comes at a time when the country needs it more than ever,” said NAHC President William A. Dombi, moments after the vote in the House. “Health care at home is widely recognized as high value, high quality, and highly preferred. From pediatric nursing care to home care aide services for those with multiple chronic illnesses as they age, this legislation will provide improved access to home care. We now look to the Senate to complete the work to protect our families and friends who need this essential care. “

NAHC has analyzed the legislation to see how it will impact our members and the wider home care and hospice community.

• Bill text can be found HERE
• A section-by-section overview of the bill’s provisions can be found HERE

The BBB bill is the cornerstone of President Biden’s and congressional Democrats’ domestic agenda. Initially proposed spending targets for the package were around $3.5 trillion, but lack of Democratic consensus on the topline figure and scope, as well as narrow margins for Democrats in both the House and Senate forced lawmakers to shrink the overall size and ambition of the bill. This legislation will impact nearly every sector of American society, and there are a number of policies with direct relevance for home health, home care, and hospice providers, some of which are NAHC advocacy priorities.

Below is background information on some of those most consequential policies included in the House BBB legislation:

Medicaid Home and Community-Based Services (HCBS) Investment (“Better Care Better Jobs Act”)

• $150 billion investment to bolster Medicaid HCBS, with the goal of increasing access to services, reducing waitlists, and better supporting the direct care workers that provide the bulk of HCBS. Specifically, the approved language would:
  • Provide a 6% FMAP increase for HCBS;
  • Require coverage of personal care services;
  • Require caregiver supports such as respite care;
  • Require updated of payment rates that “support the recruitment and retention of the direct care workforce”;
  • Require an update of HCBS payment rates at least every three years;
  • Make permanent the protections against spousal impoverishment for recipients of Medicaid HCBS;
  • Make permanent the Medicaid Money Follows the Person (MFP) demonstration that helps those in institutional facilities transition back to the community.
    • See the legislative language for this provision HERE
    • See an overview of the provision HERE

Direct Care Worker Training and Support Investments

• $400 million/yr for FY2023-2026 for a grant-based program that would bolster frontline caregivers’ access to economic and educational supports. These grants would go to states and territories, to be spent on things like worker wage subsidies, student loan repayment or tuition assistance for a degree or certification in a relevant field, childcare for eligible workers, and transportation assistance, amongst other approved activities that benefit direct care workers. The bill makes clear that aides working in home health, personal care, and hospice, as well as LPNs and LCSWs, are eligible to receive support under these grants.
  • See the legislative language for this provision HERE
  • See an overview of the provision HERE
• $1 billion over 10 years for a separate program to support the direct care workforce through renewable three-year grants administered by the Dept of Labor. Grants can be used to invest in strategies to recruit, retain, and advance the direct care workforce; implement models and strategies to make the field of direct care more attractive; and improve wages, including through training and registered apprenticeships, career pathways, or mentoring.
  • See the legislative language for this provision HERE
  • See an overview of the provision HERE
• $20,000,000 to fund a national technical assistance center through HHS’ Administration for Community Living which will develop and disseminate evidence-based strategies for recruitment, education and training, retention, and career advancement of direct care workers and provide recommendations for activities to further support paid and unpaid family caregivers.
  • See the legislative language for this provision HERE
  • See an overview of the provision HERE

Additional Health Workforce Investments

• $400 million for the Health Profession Opportunity Grant (HPOG) program, which awards grants to organizations to provide education and training to low-income individuals for occupations in the health care field that are expected to either experience labor shortages or be in high demand. Home care and home health aides are identified as being HPOG-eligible professions.
  • See the legislative language for this provision HERE
  • See an overview of the provision HERE

Paid Family and Medical Leave

• Starting in January 2024, all workers would be eligible for up to four weeks of paid leave for new parents, workers dealing with their own serious medical conditions, and workers who need leave to care for a loved one with a serious medical issue. Benefits would be progressive, with lower-income workers receiving higher levels of wage replacement. Wage replacement would be about two-thirds for the average worker.
  • See the legislative language for this provision HERE

Increases in OSHA Fine Amounts

• Amends the Occupational Safety and Health Act of 1970 to:
  • Increase the maximum penalty to $700,000 for willful and repeat violations (current penalty is $136,532);
  • Increase the minimum penalty to $50,000 for willful violations (current penalty if $9,753);
  • increase the maximum penalty for both serious and failure-to-abate violations to $70,000. (current penalties are $13,653);
• See the legislative language for these provisions HERE

The bill also includes a number of provisions that would:

• Expand Medicaid coverage;
• Lower prescription drug costs;
• Extend ACA marketplace health plan subsidies;
• Add hearing coverage to the Medicare program;
• Invest tens of billions of dollars in bolstering public health infrastructure and training;
• Boost funding by over $1 billion for Older Americans Act (OAA) programs that support older adults and family caregivers;
• Provide $40 million in funding for programs to support family caregivers’ mental health and well-being;
• Provide $500 million in new grant funding to support medical-legal partnerships (programs that integrate patient-centered legal services into health care settings to address their patient and families’ health-related social needs).

Major health and care-related provisions that were not incorporated into the House bill include:

• A separate tax credit for family caregivers (A NAHC policy priority issue);
• New Medicare dental and vision benefits.

As negotiations over the legislation move to the Senate, NAHC will continue to advocate for polices that will benefit patients, families and the home-based providers that care for them. We are closely tracking the movement on this massive bill, and will be updating members on relevant developments as they arise. Stay tuned to NAHC Report for updates.

The Build Back Better (BBB) plan is a $1.85 trillion social spending package released last week by the House of Representatives and NAHC has analyzed the legislation to see how it will impact our members and the wider home care and hospice community.

• Bill text can be found HERE
• A section-by-section overview of the bill’s provisions can be found HERE
• A summary post on the bill’s framework developed by the White House can be found HERE

The BBB bill is the cornerstone of President Biden’s and congressional Democrats’ domestic agenda. Initially proposed spending targets for the package were around $3.5 trillion, but lack of Democratic consensus on the topline figure and scope, as well as narrow margins for Democrats in both the House and Senate forced lawmakers to shrink the overall size and ambition of the bill. This legislation will impact nearly every sector of American society, and there are a number of policies with direct relevance for home health, home care, and hospice providers, some of which are NAHC advocacy priorities.

Agreement on the BBB framework was supposed to result in a House vote this week on the “hard infrastructure” package that passed the Senate months ago. However, that vote was delayed once more, as House progressives indicated they would withhold support for the infrastructure deal until it becomes clearer that the Senate is on-board with the BBB legislative details. More negotiations are expected in the coming days, but the release of the House bill this week provides the clearest signal yet of what will ultimately be in a final package.

Below is background information on some of those most consequential policies included in the House BBB legislation:

Medicaid Home and Community-Based Services (HCBS) Investment (“Better Care Better Jobs Act”)

• $150 billion investment to bolster Medicaid HCBS, with the goal of increasing access to services, reducing waitlists, and better supporting the direct care workers that provide the bulk of HCBS. Specifically, the approved language would:
  • Provide a 6% FMAP increase for HCBS
  • Require coverage of personal care services
  • Require caregiver supports such as respite care
  • Require updated of payment rates that “support the recruitment and retention of the direct care workforce.”
  • Require an update of HCBS payment rates at least every three years.
  • Make permanent the protections against spousal impoverishment for recipients of Medicaid HCBS.
  • Make permanent the Medicaid Money Follows the Person (MFP) demonstration that helps those in institutional facilities transition back to the community.
    • See the legislative language for this provision HERE
    • See an overview of the provision HERE

Direct Care Worker Training and Support Investments

• $400 million/yr for FY2023-2026 for a grant-based program that would bolster frontline caregivers’ access to economic and educational supports. These grants would go to states and territories, to be spent on things like worker wage subsidies, student loan repayment or tuition assistance for a degree or certification in a relevant field, childcare for eligible workers, and transportation assistance, amongst other approved activities that benefit direct care workers. The bill makes clear that aides working in home health, personal care, and hospice, as well as LPNs and LCSWs, are eligible to receive support under these grants.
  • See the legislative language for this provision HERE
  • See an overview of the provision HERE
• $1 billion over 10 years for a separate program to support the direct care workforce through renewable three-year grants administered by the Dept of Labor. Grants can be used to invest in strategies to recruit, retain, and advance the direct care workforce; implement models and strategies to make the field of direct care more attractive; and improve wages, including through training and registered apprenticeships, career pathways, or mentoring.
  • See the legislative language for this provision HERE
  • See an overview of the provision HERE
• $20,000,000 to fund a national technical assistance center through HHS’ Administration for Community Living which will develop and disseminate evidence-based strategies for recruitment, education and training, retention, and career advancement of direct care workers and provide recommendations for activities to further support paid and unpaid family caregivers.
  • See the legislative language for this provision HERE
  • See an overview of the provision HERE

Additional Health Workforce Investments

• $400 million for the Health Profession Opportunity Grant (HPOG) program, which awards grants to organizations to provide education and training to low-income individuals for occupations in the health care field that are expected to either experience labor shortages or be in high demand. Home care and home health aides are identified as being HPOG-eligible professions.
  • See the legislative language for this provision HERE
  • See an overview of the provision HERE

Major provisions that were not incorporated into the House bill include paid family and medical leave, a tax credit for family caregivers, Medicare drug price negotiation, and new Medicare dental and vision benefits.

As Congressional negotiations progress, NAHC will continue to advocate for the inclusion in the reconciliation package of additional polices that will benefit patients, families and the home-based providers that care for them. We are closely tracking the movement on this massive bill, and will be updating members on relevant developments as they arise.