Courtesy of the National Association for Home Care & Hospice (NAHC)

The Build Back Better (BBB) Act, a signature legislative priority for the Biden administration and its allies in Congress, passed the U.S. House of Representatives on Friday, November 19, on a party-line vote of 220-213. The legislation now heads to the Senate for consideration.

The 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. Click here to read the framework of President Biden's plan to rebuild the middle class.

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."

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 a 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.

NAHC has analyzed the legislation to see how it will impact the home health and hospice provider community. Below is background information on some of those most consequential policies included in the House BBB legislation. Additionally, a section-by-section overview of the bill's provisions can be found here.

Medicaid HCBS Investment (“Better Care Better Jobs Act”)

The House BBB legislation includes a $150 billion investment to bolster Medicaid home- and community-based services (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 updates 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; and
• 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 and an overview here.

Direct Care Worker Training and Support Investments

The House BBB legislation includes:

• $400 million per year for fiscal years 2023 through 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 licensed practical nurses and licensed clinical social workers, are eligible to receive support under these grants. See the legislative language for this provision here and an overview here.
• $1 billion over 10 years for a separate program to support the direct care workforce through renewable three-year grants administered by the U.S. Department of Labor (DOL). 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 and an overview here.
• $20,000,000 to fund a national technical assistance center through the Department of Health and Human Services (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 and an overview here.

Additional Health Workforce Investments

The House BBB legislation invests $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 and an overview 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

The House BBB legislation amends the Occupational Safety and Health Act of 1970 to increase Occupational Safety and Health Administration (OSHA) fines as follows:

• 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 is $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 Affordable Care Act (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; and
• 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 and new Medicare dental and vision benefits.

As negotiations over the legislation move to the Senate, NAHC and industry groups, including HCAF, will continue to push for the inclusion of policies that will benefit patients, families, and the home-based providers that care for them.

Stay tuned for developments and opportunities to make your voice heard to Florida Senators Marco Rubio and Rick Scott.