September 15, 2021

Debate Begins on Build Back Better Act

This week, the House began debate on the Biden Administration-led spending proposal that makes historic investments in human infrastructure. Readers will recall that before Congress adjourned for summer recess, both chambers spent significant political capital reaching an agreement on a traditional infrastructure package that includes improvements to transportation and energy infrastructure. This separate ‘human infrastructure’ bill, the Build Back Better Act, includes huge investments in the public health infrastructure, including issues such as drug pricing reform, expansions to Medicare (vision, dental and hearing), a national paid family and medical leave plan, and an increase in funding for the national social safety net. There are some key provisions in the committee drafts that would be of interest to Academy members:


  • Drug Pricing Reform: This proposal is largely based on H.R. 3, the Elijah E. Cummings Lower Drug Costs Now Act, which allows the Secretary of Health and Human Services (HHS) to negotiate prices for certain medications. Specifically, this bill would require HHS to negotiate the maximum price for the top 125 drugs that comprise the greatest national spending or the greatest Medicare spending. The original bill largely pertains to Medicare, but the version included in the Build Back Better Act may also include some commercial markets, including those in the Affordable Care Act (ACA) marketplace. As of the drafting of this article, final language is not yet known. On the surface, this proposal seems like a welcome reform to a healthcare system in which households, particularly many that rely on Medicare, can spend huge amounts on prescription drug costs. However, an inadvertent consequence would be that the price of HIV drugs are capped and 340B savings evaporate, sending HIV providers scrambling. The Academy is working diligently to ensure that HIV medications are available to all who need them, while taking into consideration many providers’ reliance on 340B savings.


  • Medicaid Expansion: In a previous issue of the VOICE, we wrote about a proposal to extend Medicaid eligibility to those living in the 12 states that have not expanded Medicaid, as offered under the ACA. This ‘Medicaid-like’ program that is expected to be included in this larger legislative package, would provide care for an estimated two million low-income individuals who currently are not eligible for Medicaid or subsidies to purchase private insurance on the ACA marketplace. Academy members who provide care in these 12 states know firsthand how impactful it would be for folks with and at risk for HIV to be eligible for affordable, quality healthcare. As such, the Academy has joined the HIV community in sending a letter to Congress urging them to close this Medicaid “coverage gap.” Doing so would ensure health insurance coverage to the 20 percent of all people living with HIV who are uninsured in non-expansion states, thereby reducing transmissions. Additionally, this proposal offers a way to address racial disparities in healthcare that are exacerbated in non-expansion states, particularly among persons of color who in 2019 alone, accounted for 75 percent of people newly diagnosed with HIV. Closing this gap is imperative to fixing enduring injustices and ending the HIV epidemic.


  • Additional Funds for the Ryan White Program: The House Energy and Commerce Committee’s markup of this legislation includes an additional $150 million for the Ryan White HIV/AIDS Program in fiscal year 2022. The Academy signed a letter to Committee leadership applauding the addition of these funds. As readers know, the Ryan White program is an important safety net program that serves as the payer of last resort for more than half of the people living with HIV in the United States. This program provides medical care and prescription drugs along with other services critical to managing HIV, including: case management; mental health and substance use services; adult dental services; and transportation, legal, and nutritional support services. Because of the comprehensive care provided by the Ryan White program, the most recent data shows that over 88 percent of Ryan White clients have achieved viral suppression, which is significantly higher than the viral suppression rate of 69.4 percent of all people with HIV in the United States. While these funds are very much welcome, it’s not yet clear how they will be distributed amongst providers, clinics and services.


Committee markups are expected to conclude by today, though it is unclear if every committee will be able to meet that deadline. The full chamber will then vote on the complete bill after the House returns from the Yom Kippur holiday. The Senate will then take up the bill, but inter- and intra-party fighting has already begun around the bill’s large price tag and the use of the budget reconciliation process which only requires a majority vote, thereby avoiding filibuster.

Readers can view the full report HERE.

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