Dec 1, 2021

7 policies in Biden’s spending plan aimed at health equity Anna Moneymaker/Getty Images WASHINGTON — Democrats have made big promises to tackle racial inequities across society, including in health care, since protests for racial justice swept the nation in 2020. Until recently, it wasn’t clear how either lawmakers or the Biden administration would deliver on those goals — but some of the first concrete steps are now taking shape in the new spending plan Democrats are moving. Embedded in the nearly $2 trillion plan are billions of dollars to help make health care services more accessible and affordable for Americans who slipped through the cracks of existing safety-net policies. advertisement The health equity programs span the beginning of life, aiming to make birth safer for Black mothers, to the end, offering incentives to boost pay for home care services disproportionately provided by Black and Hispanic women. The package would also provide cheaper coverage options for low-income adults in states that haven’t expanded Medicaid under the Affordable Care Act — a population that is 60% people of color — and provide stable funding for coverage programs for children and people in the U.S. territories. The package, dubbed the Build Back Better Act, has passed the House, but still has to clear the Senate without a single Democratic defection, and then will likely have to go to another vote in the House before proceeding to the president’s desk. advertisement “This is historic legislation, and an incredible investment in health equity. There’s a lot of important provisions, and we need to get this across the finish line,” said Frederick Isasi, executive director of the consumer advocacy group Families USA. Maternal health After years of advocacy, led by Black women in Congress, Democrats are poised to make a substantial investment in services to promote maternal health. Mothers are much more likely to die within a year of childbirth in the United States compared with other high-income countries, and Black women in the U.S. are 2.5 times more at risk than Hispanic women, and 3.5 times more at risk than white women, according to recent data from the Centers for Disease Control and Prevention. The centerpiece of the maternal health provisions is a policy that would force states to cover mothers on Medicaid for a year after giving birth instead of the current 60 days. A federal Covid-19 relief bill passed this spring included an optional path for states to expand that coverage, but only about half of states have adopted the policy. In 2019, Medicaid paid for 65% of all births to Black mothers, and 59% of births to Hispanic mothers. “This is a huge advancement, if we can get everything that is in the bill right now. It would be a really promising investment, and certainly the beginning of our work on health equity,” said Rachel Kingery, the communications director for Rep. Robin Kelly (D-Ill.), who has led the push for the change. Other investments championed by Reps. Lauren Underwood (D-Ill.) and Alma Adams (D-N.C.) include funding to address social factors that affect mothers’ health, to promote research at minority-serving institutions , to diversify the perinatal health workforce, to increase data collection, and to conduct bias trainings for health professionals. A Democratic aide involved in the talks said there was never any substantial pushback to including the maternal health provisions in the spending bill, though advocates sent a letter to President Biden and congressional leaders in October to make sure the policies didn’t fall to the wayside when Democrats scaled back the bill to appease moderates concerned about the legislation’s overall price tag. Spending on maternal health totals more than $3 billion, according to congressional budget analysts. Joia Crear-Perry, founder and president of the National Birth Equity Collaborative, said she was proud that the lawmakers pushing the bill had collaborated with community-based organizations to build the policy based on the needs voiced by people working with mothers on a day-to-day basis. “The mere fact that it was something that was created by Black women really shows our leadership, and that the people closest to the problem have a solution,” Crear-Perry said. Medicaid coverage gap Democrats’ effort to extend health care coverage to low-income people in states that refused to expand Medicaid coverage, on the other hand, was highly controversial. Two of the policy’s champions were Sen. Raphael Warnock (D-Ga.) and House Majority Whip James Clyburn (D-S.C.), who both hail from states that haven’t expanded Medicaid under the Affordable Care Act. Clyburn explicitly framed the expansion as promoting racial equity to a greater degree than other policies Democrats were eyeing. “What is the life expectancy of Black people compared to white people? I could make the argument all day that expanding Medicare at the expense of Medicaid is a racial issue, because Black people do not live as long as white people,” Clyburn told Axios . The compromise Democrats reached was to allow low-income people in expansion states to receive premium-free insurance through Affordable Care Act exchanges, funded for four years. The expansion will cost $43.8 billion, congressional analysts estimate. While people of color comprise about 40% of the adult population in non-expansion states , they make up 60% of the people who fall into the Medicaid coverage gap. While the expansion will increase eligibility, outreach is still important to make sure people actually finish the enrollment process and know how to use their coverage, said Jennifer Sullivan, director of housing and health integration at the Center on Budget and Policy Priorities. Making CHIP permanent The Children’s Health Insurance Program that provides health coverage for more than 9 million children per year is popular — perhaps a little too popular for its own good. Until now, CHIP has been funded on a short-term basis, which has made it a tantalizing bargaining tool in fraught congressional negotiations time and time again. The Build Back Better Act would make the program permanent. It is currently funded through September 2027. Former HHS Secretary Donna Shalala, who worked with Congress to create CHIP during her tenure, said making the program permanent would provide protection from politicization. “Kids should not be used as a political football, but it has been in the past with the reauthorizations,” Shalala told STAT in an interview. Another policy would require states to cover children for a year if they qualify for CHIP, even if their family’s income fluctuates above the threshold for coverage. Black and Hispanic children are disproportionately likely to be covered by Medicaid or CHIP. Medicaid in the U.S. territories While people in non-expansion states face disadvantages accessing Medicaid coverage, low-income people in American Samoa, the Commonwealth of the Northern Mariana Islands, Guam, Puerto Rico, and the U.S. Virgin Islands are worse off because they technically don’t live in states at all. Congress has chosen to treat U.S. territories differently in the Medicaid program, capping the amount of funding territorial governments can receive regardless of how their needs change, and baking in lower matching funding rates than they would get if they were states. Lawmakers boost funding sometimes, but it leads to unpredictable levels of support, and crisis situations where territories face funding cliffs when extra money runs out. For example, next fiscal year Puerto Rico’s Medicaid funding would be cut from $2.8 billion to $393 million if Congress doesn’t do anything. Biden’s plan would permanently increase federal matching funds from 55% of territories’ Medicaid costs to 83%. Federal support would still be capped, but the caps would be higher. The disparities in support for health care services is one facet of many ways in which residents of U.S. territories are denied the rights afforded U.S. citizens. The Supreme Court in a series of cases in the 1900s determined that territorial residents wouldn’t be necessarily guaranteed constitutional rights and privileges enjoyed by citizens; this term, it will take up the issue anew . Medicaid coverage for incarcerated people When incarcerated people are released from prison or jail, they face a host of urgent, competing priorities, including finding housing and employment. One proposal in Biden’s spending plan would allow incarcerated people to transition their health insurance more easily by enrolling in Medicaid coverage 30 days before their release. The policy has been pushed by Reps. Paul Tonko (D-N.Y.) and Michael Turner (R-Ohio) and Sens. Tammy Baldwin (D-Wis.), Sheldon Whitehouse (D-R.I.), Mike Braun (R-Ind. ), and Sherrod Brown (D-Ohio) to help address the dramatically heightened risk of overdose that incarcerated people face shortly after release. While the majority of people who die due to drug overdoses are white , according to data compiled by the Kaiser Family Foundation, the share of Black, Hispanic, and American Indian people who are dying of overdoses compared with the overall population has increased in recent years. Coverage would also extend beyond behavioral health to other health care services, which would promote health equity because communities of color have been disproportionately impacted by mass incarceration and a resulting lack of access to health care, said Anna Bailey, a senior policy analyst at the Center on Budget and Policy Priorities. Home- and community-based services Though the investment is less than advocates originally hoped, lawmakers decided to pour $150 billion into promoting home- and community-based services for elderly and disabled people. States can qualify for extra Medicaid money if they develop and submit a plan about how they plan to expand services. The funding could help increase pay rates to providers to help support the home health workforce, who are disproportionately women, particularly Black and Hispanic women, according to an analysis by the Center for Economic and Policy Research . Women of color in the home health industry are also more likely to have household income below the poverty line. Keeping patients out of institutionalized care may be most meaningful for patients from communities of color, as nursing homes that serve largely Black and Hispanic patients are more likely to provide lower quality care . Promoting diversity in the health care workforce The Build Back Better Act also invests in diversifying the workforce for nurses, doctors, and health care professionals who work with mothers. A recent study showed that Black newborns may be more likely to survive following birth if they are cared for by Black doctors. The maternal health provisions of Biden’s plan include $295 million for the perinatal health workforce, including nurses, midwives, physicians, doulas, and maternal mental health professionals. Additional $500 million investments would go to medical schools and nursing schools, with priority given to minority-serving institutions and those in underserved areas. About the Author Reprints