Congressional Democrats unveiled updated text of the Build Back Better Act (H.R. 5376) on Oct. 28. The $1.75 trillion social spending package is a scaled-back version of the budget reconciliation legislation originally advanced by several House committees of jurisdiction in September [refer to Washington Highlights, Sept. 17].
Prior to the release of the updated text, President Joe Biden announced the new Build Back Better Act framework reflecting the administration’s monthslong negotiations with Sens. Joe Manchin (D-W.Va.) and Kyrsten Sinema (D-Ariz.), Congressional Democratic leadership, and moderate and progressive House Democrats to determine a path forward for this spending package and separate Senate-passed infrastructure legislation [refer to Washington Highlights, Oct. 1]. Several key policy priorities remain undecided as negotiations among Democrats continue, with Republicans opposed to the exercise. The legislative text released on Oct. 28 is not final and will be subject to alterations and ultimately approval by the House Rules Committee before it is considered and voted on by the full House of Representatives.
The revised legislation maintains many provisions from the bills passed by committees of jurisdiction. Key provisions that impact the missions of academic medicine are detailed below.
Health Care Workforce
The updated legislation maintains a provision that would create a new Pathway to Practice Training Program, which would provide scholarships for tuition and other fees to underrepresented and economically disadvantaged students planning to attend medical school, or students participating in postbaccalaureate programs with the intention of applying to medical school. As terms of participating in the scholarship program, a student would be required to practice a year in a medically underserved area after residency for each year they receive the scholarship. Scholarship recipients who complete their residency at teaching hospitals with recognition by the Accreditation Council for Graduate Medical Education for certain training activities related to health equity would be exempt from the teaching hospital’s graduate medical education (GME) cap.
As a complement to the scholarship program, the AAMC and other health care stakeholders are continuing to advocate for the inclusion of the Resident Physician Shortage Reduction Act of 2021 (H.R. 2256/S. 834) in the Build Back Better Act [refer to Washington Highlights Sept. 10]. The 14,000 slot Medicare GME expansion legislation does not appear in the released draft text, but additionally GME positions could still be included in the forthcoming manager’s amendment.
Other provisions impacting the health care workforce in the legislation include: $3.37 billion in supplemental Teaching Health Center GME, $150 million for Children’s Hospital GME, $650 million for the National Health Service Corps, $30 million for training physicians in palliative care, $85 million for health professions schools to identify and address health risks associated with climate change, and 500 new health professions residency positions at Veterans Affairs Medical Centers.
Health Care Coverage
The legislation contains a modified proposal to cover the estimated 4 million people in the Medicaid coverage gap. Instead of offering Medicaid coverage for individuals in the 12 states that have not expanded Medicaid, the new legislation would offer subsidized private insurance to low-income, uninsured people in those states. The legislation would also extend until 2025 the increased Affordable Care Act tax credit subsidies that are set to expire in 2022.
Additionally, the legislation would permanently extend funding for the Children’s Health Insurance Program, which is currently set to expire at the end of fiscal year 2023. It would also provide 12 months of continuous Medicaid eligibility to postpartum individuals, building on the existing state plan option included in the American Rescue Plan Act (P.L. 117-2) [refer to Washington Highlights, March 12].
The legislation contains a number of investments in programs to reduce maternal morbidity and mortality that remain unchanged from the Energy and Commerce Committee-passed legislation. Among these investments are $100 million in funding for maternal mental health equity grants, $75 million to the Office of Minority Health to address social determinants of health impacting pregnant and postpartum individuals, $75 million to grow and diversify the maternal mental health and substance use disorder treatment workforce, $50 million for minority-serving institutions to study maternal mortality, $30 million to expand the use of technology enabled collaborative learning for pregnant and postpartum individuals, and $30 million to promote equity in maternal health outcomes through digital tools.
Public Health and Preparedness
The updated text maintains a $7 billion investment for core public health infrastructure activities for state, territorial, local, and tribal health departments as well as for the Centers for Disease Control and Prevention (CDC). The bill also includes $1.4 billion to support public health laboratory infrastructure and a $2.5 billion investment in the CDC to support public health approaches to reducing community violence, including through hospital-based violence intervention programs.
The bill also provides $1.3 billion for the assistant secretary for preparedness and response to address public health emergencies, including funds to support surge capacity, vaccine production, supply chain resiliency, and increased biosafety and biosecurity in infectious disease research.
The legislation does not include the $10 billion for hospital infrastructure that was included in the committee-passed legislation.
The higher education portion of the legislation would allow for Deferred Action for Childhood Arrival recipients to receive Title IV federal student aid through award year 2029-2030, increase the minimum Pell Grant award by $550 dollars, and would modify the endowment excise tax for private institutions based on the amount of undergraduate institutional aid they award.
The higher education allocation also includes $6 billion in institutional support and need-based student financial assistance at historically black colleges and universities (HBCUs), tribal colleges and Universities (TCUs), and other minority-serving Institutions (MSIs). Additionally, the legislation would provide $3 billion to HBCUs, TCUs, and MSIs over seven years to improve their research infrastructure at institutions that are not classified as “very high research activity” institutions by the Carnegie Classification of Institutions of Higher Education.
Federal Research Agencies and Infrastructure
The updated bill includes $100 million in new funding for the National Institutes of Health (NIH), with $75 million to expand research capacity at MSIs and diversify the scientific workforce. The bill also includes $10 million for the NIH to support research related to developmental delays in children as well as $15 million for the NIH’s Eunice Kennedy Shriver National Institute of Child Health and Human Development to fund research on interventions to mitigate COVID-19 impacts on pregnant, lactating, and postpartum individuals. Unlike the committee-passed legislation, the revised bill does not include investments to establish the president’s proposed Advanced Research Projects Agency for Health, though separate legislation is expected to address the initiative.
For the National Science Foundation (NSF), the legislation would provide a total of $3.5 billion, including $700 million to fund research and training awards and efforts to increase workforce diversity, well as $700 million for infrastructure and equipment improvements, including at academic research facilities. The bill would also include $1.5 billion for the NSF to establish a new Directorate for Technology, Innovation, and Partnerships.