House-Passed Build Back Better Would Bolster Public Health Infrastructure, Health Workforce
The Build Back Better Act (BBB) narrowly passed the House on November 19th, 2021. It next moves on to what is expected to be a tumultuous time in the Senate because of the major policy differences that remain, as well as the special procedures governing the Senate’s reconciliation process that would guide the debate. But as the BBB starts what hopefully will be its final journey to passage, it is well worth drawing attention to the historic investments in public health infrastructure and the health workforce that the BBH in its current form includes. These investments, like many of the BBB’s health insurance reforms, are time limited. But together, they would direct tens of billions of dollars to strengthen core public health and health workforce capabilities in ways that would build on proven successes, set in motion longstanding recommendations from experts, and ultimately position the nation to face 21st century health challenges from a position of greater strength.
The range of population health matters these amendments address is quite breathtaking: the long-term care needs of an aging nation; the nation’s maternal mortality crisis; mental illness; gun violence; medically underserved communities; and more. Collectively these important initiatives are grounded in the principle of health equity and will act jointly with the BBB’s strengthening of health insurance to support the health of the poorest and most vulnerable Americans.
This post examines a number of the key provisions in the November 3 version of House bill, the most current version available.
Workforce Provisions
Direct Care Workers And Apprenticeships
BBB includes $1 billion, to be made available through 2031, to strengthen the direct care workforce. As the United States population ages, the need for direct care workers (DCWs) is increasing. Over 1.1 million new home health and personal care aide jobs are projected over the next decade, outpacing any other occupation’s growth by over half a million jobs. DCWs—who are predominantly women of color and often immigrants—face low pay and high stress. Average hourly wages range from $12 to $14 an hour and COVID has placed incredible strain on these workers.
The BBB legislation would authorize a new grant program under the Department of Labor (DOL), in coordination with the Department of Health and Human Services’ (HHS) Administration for Community Living. Grants would fund competitive wages, benefits, and supports, including transportation, childcare, dependent care, and workplace health and safety protections, for direct care workers. The legislation would also support education and training for DCWs on workers’ rights around wages and hours, safe working conditions, and labor organizing, as well as career ladder programs that help DCWs acquire new skills and advance their careers.
BBB contains extensive complementary measures to address the quality of home and community-based services (HCBS) that could improve conditions for DCWs. The bill would provide enhanced federal Medicaid funding for HCBS expenditures while dedicating $130 million to state HCBS improvement planning grants that, in addition to other matters, would have to assess the relationship between payment rates and workforce shortages. States could use enhanced funding to improve DCW payment rates, to implement training programs, to develop processes to assign unique identifiers to DCWs, and to implement programs to connect beneficiaries to DCWs, such as a pilot proposed by New York.
Beyond the direct care workforce, BBB would increase funding for a number of additional DOL programs important to the health workforce more broadly. One example is Registered Apprenticeships. Apprenticeship programs in the health care sector have been growing over time and have been developed in over 40 health care occupations. One example is medical assistant, which, like direct care worker, is in the top-20 occupations projected to add the most new jobs over the next decade.
Meeting the need for medical assistants with expanded training is considered vital to new models of health care. Apprenticeship programs have both trained new medical assistants and upskilled existing workers for expanded roles. The DOL’s Apprenticeship Program, which was funded at $185 million in FY2021, would receive an additional $1 billion, available through 2026.
National Health Service Corps (NHSC)
Today more than 13,000 National Health Service Corps (NHSC) clinical professionals work in hundreds of the nation’s most medically underserved communities. From the program’s enactment in 1972, the NHSC has witnessed enormous growth, in tandem with the growth of the nation’s community health centers. Administered by the Health Resources and Services Administration (HRSA), the NHSC has provided loan repayment and scholar programs to 63,000 medical, dental, and behavioral health professionals to date in exchange for working in clinics located in federally designated Health Professional Shortage Areas (HPSAs). The NHSC is currently funded at $120 million per year. The BBB would provide an additional $2 billion for the NHSC, to remain available until expended.
Nurse Corps
BBB would provide an additional $500 million for the Nurse Corps, to remain available until expended. Like the NHSC, Nurse Corps is administered by HRSA and provides scholarships and loan repayment assistance, in this case for registered nurses (RNs) and advanced practice registered nurses (APRNs). Investment in these professionals is made in return for a commitment to either work at an eligible critical shortage facility located in a HPSA or to serve as faculty in eligible schools of nursing.
Funding for the program has stood at $89 million per year for the previous two years, suggesting the new funding will provide major growth for multiple years. Of current Nurse Corps funding, $5 million is set aside for Women’s Health applicants (e.g., Certified Nurse Midwives (CNM)), after which 50 percent is allocated to Nurse Practitioners (NPs), 10 percent to faculty, and the remainder to other RNs and APRNs.
Teaching Health Centers
The BBB includes $3.37 billion for the Teaching Health Center (THC) Graduate Medical Education Program, one of the Health Resources and Services Administration’s signature initiatives. Established by the Affordable Care Act as a complement to the expansion of community health centers and the NHSC, the THC program develops and supports a highly skilled workforce for underserved communities. THCs are residency training programs that expand the supply of primary care physicians working in rural and underserved communities. THC residents train in family medicine, geriatrics, internal medicine, obstetrics/gynecology, pediatrics, psychiatry, and dentistry in community health centers, rural health clinics, and other community-based settings.
In the decade since the program was created as part of the Affordable Care Act, more than 1,100 THC residents have been trained in primary care, with a recently published study showing that THC graduates are more likely to practice in rural and medically underserved settings compared to physicians overall. The BBB funding would provide a significant boost in terms of program expansion and strengthen THC long-term financial stability, since the use of the funding is not time-limited.
Schools Of Medicine And Nursing, Children’s Hospital GME, And Palliative Care Training
BBB would add $500 million in funding to support schools of medicine, with priority given to medical schools recognized as Minority-Serving Institutions, and an additional $500 million for nursing schools, prioritizing the provision of care in underserved areas. Both of these amounts would remain available until expended. Funding for schools of medicine could be used to recruit and retain students from disadvantaged backgrounds, to develop curricula that emphasize care for rural or underserved populations, or to open a new medical school or campus in an area without one. Funding for schools of nursing could be used to recruit students from disadvantaged backgrounds as well as to generally strengthen and expand nursing programs.
In addition, BBB includes an additional $200 million for Children’s Hospital Graduate Medical Education, which supports pediatric residency programs, and $90 million for palliative and hospice care workforce programs.
Rural And Underserved Pathways To Practice Training Program
Sections 137401 through 137405 would establish a new Rural and Underserved Pathways to Practice Training Program that would support medical education for students from underrepresented backgrounds, as well as supporting new Medicare GME positions for these trainees by excluding them from hospital residency caps and establishing 4,000 new Medicare GME positions. The program would offer 1,000 scholarships per year for students to attend medical school or a post-baccalaureate program leading to medical school; scholarship recipients would be first-generation students or former Pell grant recipients, or have a history of living in a medically underserved or rural area prior to college; certain students from disadvantaged backgrounds would be given priority.
New GME positions would be prioritized to primary care, psychiatry, hospitals in rural and underserved areas, and states with a new medical school or in the lowest resident-to-population quartile. Scholarship recipients must agree to practice after residency in an HPSA, medically underserved area, public hospital, or rural area for at least as many years as they received the scholarship.
Public Health And Health Care Infrastructure Provisions
Public Health Infrastructure
BBB would provide $7 billion over five years to support “core public health infrastructure” investments by state and local health departments and to enhance capacities at the Centers for Disease Control and Prevention. BBB represents an effort to end the boom-and-bust cycle of public health funding: During an emergency, Congress infuses vast funding into state and local health agencies, but then investment declines precipitously once the emergency recedes into the rear-view mirror, leaving agencies short of funds and the nation’s public health infrastructure unprepared for the next emergency. One recent study estimated that state and local public health agencies need another 80,000 positions to meet basic public health service needs.
BBB’s definition of infrastructure focuses on workforce-based foundational capabilities, such as epidemiology and surveillance, needed to address community health in general and emergency response as well. This would enhance the value of the public health workforce investments in the American Rescue Plan, of which $3 billion has been targeted by the Administration to support the effort to rebuild state and local public health in the post-pandemic period. Combined, these two funding streams would give stabilize public health response capabilities now and in the future.
The House BBB bill would also provide another $1.4 billion for Centers for Disease Control and Prevention (CDC) laboratories and state and local public health labs; $1.3 billion to support capacity building and research through the HHS Assistant Secretary for Preparedness and Response; and $300 million for Food and Drug Administration infrastructure, all of which would remain available until expended.
Gun Violence Prevention
The House BBB bill designates $2.5 billion in funding to address community violence, which would remain available until expended. This new pool of funding would be used to address violence through competitive grants for public health strategies to address violence, to be awarded to local, state, territorial, and tribal governments, non-profit organizations, and other entities.
While guns are not specifically mentioned in the bill text, advocates against gun violence had pushed for the inclusion of this public health approach. Rates of gun violence, already very high in the U.S., have risen during the Covid-19 pandemic. Example programs that would be eligible for funding include hospital-based violence interventions and school-based mental health services.
Mental Health
The bill would provide additional funding for public mental health care through four sections totaling $165 million; the money would remain available until expended. Of this sum, $75 million is designated to improve infrastructure at the National Suicide Prevention Line; $50 million is designated for a fellowship program to strengthen the skills and cultural competency of the mental health and substance abuse workforce in addressing the needs of communities of color; $25 million is designated for peer-based programs to support those recovering from substance abuse; and $15 million is designated for Project Aware, a program to educate school-aged youth about mental health issues. These funds would complement BBB Medicaid and marketplace expansions that expand and extend critical behavioral health services while also significantly improving access to insurance.
Sexually Transmitted Disease
The House Bill would provide $100 million, available until expended, to fund grants for the prevention and control of sexually transmitted diseases. CDC would award this funding to public and private non-profit clinics.
Maternal Mortality
BBB includes numerous provisions contained in Titles I through XII of the Black Maternal Health Momnibus Act of 2021, originally sponsored by Rep. Lauren Underwood (D-IL) and another 163 House Democratic co-sponsors and also separately moved as a series of stand-alone bills through one or both Houses.
The Momnibus Act represents a comprehensive effort to improve maternal health and reduce maternal mortality, especially among groups who are the most severely affected by adverse outcomes before, during, and after the delivery of a child. The most recent data from the CDC show that Black women are 2.5 times more likely to die in childbirth than white women and Indigenous women are at a 2.3 times greater risk. As embodied in BBB, the Momnibus Act would create a federal multi-agency, multi-pronged approach and provide major new investments in public health funding for maternity care. These changes would complement Medicaid reforms that would replace the American Rescue Plan state option to create a 12-month postpartum coverage period with a 12-month postpartum coverage requirement; states would also get the ability to undertake new “maternal health home” Medicaid initiatives with the potential to build on investments made over decades by state Title V Maternal and Child Health Services Block Grant programs.
While many states have pursued maternal health improvement initiatives under Title V over the years, maternal health has remained a relatively modest part of the Title V program. In FY 2019, states spent a total of $290.1 million on pregnant women, who represented 5 percent of the population served by the program. At that time, only 15 states had selected risk-appropriate perinatal care—one of 15 Title V national performance measures—as a Title V quality improvement area of focus.
BBB would invest over $1 billion in new maternal health funding. Much of this money would be used by HHS to grow and diversify the perinatal workforce: community perinatal health workers, doulas, NPs, clinical nurse specialists, CNMs, RNs, and the mental health/substance use disorder (MH/SUD) workforce in particular. The funding is also designed to improve training, with a special focus on trauma-informed care, health risks associated with climate change, and equity to reduce discrimination and bias in health and maternity care. BBB also would enable HHS to support on-the-ground evidence-based interventions that increase access to MH/SUD care and digital tools as basic elements of primary care and maternity care.
Finally, the Act would provide supplemental funding to the CDC and the National Institute of Child Health & Human Development to enhance maternal health surveillance and research. BBB’s text emphasizes engagement from communities of color and from pregnant and postpartum individuals themselves, as well as the use of perinatal health learning collaboratives aimed at improving the quality of care.
Native Hawaiian Health Care Systems
BBB includes $274 million in funding, to remain available until 2031, targeted to Native Hawaiian communities that experience significant health care access barriers. This sum includes $224 million for Native Hawaiian entities to improve access to preventive services, primary care, and comprehensive health promotion services, thus giving an additional boost to the Native Hawaiian Health Care Improvement Act. The remainder ($50 million) would be distributed to the five Native Hawaiian Health Care Systems (NHHCS) through Papa Ola Lokahi, which serves as the health board, to support construction projects, health information technology, and acquisition of medical equipment. The legislation would also extend federal liability protections to NHHCS entities and their employees.
Separately, BBB would also extend through March 2025 the special 100 percent federal medical assistance funding formula to support state Medicaid expenditures, first authorized under the American Rescue Plan, for health care services provided by Native Hawaiian Health Care Systems and Urban Indian Health Systems.
Community Health Center Capital Grants
The BBB would provide $2 billion dollars to community health centers for capital improvement projects, which will remain available until expended. This funding is critical to the development and expansion of health centers, which provide comprehensive primary health care in more than 13,000 of the nation’s most medically underserved communities, whose residents are disproportionately members of racial and ethnic minority groups. In 2020, nearly 1,400 health centers served approximately 29 million patients, of whom 91 percent were low-income and 62 percent were nonwhite.
Ryan White Funding
BBB would appropriate an additional $75 million to the Ryan White program, which provides HIV care, treatment, and support services through grants to states, hard-hit metropolitan areas, and service providers. The Trump administration had, prior to the COVID-19 pandemic, initiated a national Ending the HIV Epidemic initiative with the goal of reducing new infections in the U.S. by 75 percent by 2025 and 90 percent by 2030. By late 2020, a survey of Ryan White providers nationwide found that the COVID pandemic had created significant challenges, including an increase in clients, particularly clients with no health insurance. Even as nearly all program providers shifted to telehealth, moved to multi-month prescriptions, and took other steps to mitigate the impact on their clients, the pandemic has triggered major additional needs.
Supplemental Funding For World Trade Center Health Program.
BBB would provide $2.9 billion to establish a supplemental fund for the World Trade Center Health Program, which would be available through 2031.The World Trade Center Health Program provides no-cost screening and health care services, for conditions certified as related to the September 11, 2001 attacks, for responders and survivors. In 2020, slightly more than 100,000 individuals were enrolled and over 40,000 received treatment through the program.
The program was budgeted at $500 million in federal spending in 2021. However, as the cohort of those who served and were exposed on September 11 ages, the cost and complexity of their care will increase. The additional money is intended to address a projected funding shortfall.
Authors’ note
George Washington University faculty and staff are funded through a combination of school educational funding, gifts, and grants. Grants and gifts come from the Commonwealth Fund, the Robert Wood Johnson Foundation, the Episcopal Health Foundation, the Geiger Gibson Program, and the Mullan Institute.