#BuildBackBetter: The Sausage-making continues.

Last Friday I took an in-the-weeds look at the healthcare provisions of the pared-down (but still hugely significant) Build Back Better Act.

Well, as the long-gestating legislation finally heads into the endgame this week, there's been a last-minute rush to add to & change some provisions of the bill before it actually gets voted on, and earlier today, the House Rules Committee released a revised/updated version of the bill, including a handy comparison version which shows exactly what legislative language has changed since the prior version.

Many of these changes are either simple grammatical or wording tweaks to make sure it all passes legal muster, while others simply provide clarification. Other changes involve simply increasing or decreasing the amount of federal money which would be allocated to one program or another.

Some changes are pretty significant, however...and within the healthcare field, that includes a few of the big-ticket items previously jettisoned from the bill:

Congressional Democrats on Tuesday announced they had agreed to a broad plan to overhaul the way America pays for prescription medicines.

Under the deal, Medicare would be allowed to negotiate drug prices for both drugs dispensed at the pharmacy counter and those administered in doctors’ offices for drugs older than 9 years or 12 years, depending on the type of drug. Drug makers would have to pay penalties if they hike prices faster than inflation, including for employer-sponsored insurance plans. Seniors’ out-of-pocket costs would be capped at $2,000 per year. Insulin prices per dose will also be capped.

The Medicare drug negotiation provision is still stripped down from the original vision of the Elijah Cummings Lower Drug Costs Now Act, but it'd still be a huge step up from the status quo.

Assuming it actually passes the House, of course, there's still no guarantee about the bills fate in the Senate as long as Senators Joe Manchin & Kyrsten Sinema continue to jerk the rest of the Dem caucus around...and even if they give it their stamp of approval, there's likely to be some provisions which have to be cut out anyway due to the so-called "Byrd Bath" required for bills to pass the Senate via the reconciliation process.

Having said that, let's take a look at the healthcare-related changes made in this version of the bill. I'm sure I've left out some, but these are the ones I've been able to find so far:

Section 30713. Funding for Federal Activities.

This section requires the Secretary of Health and Human Services (HHS) to report on the implementation and outcomes of state HCBS improvement programs, and to provide states with technical assistance to implement HCBS improvement programs.

Funding has been bumped up from $15 million to $40 million.

Section 30901. Providing Coverage for Hearing Care under the Medicare Program.

This section allows for qualified audiologists, beginning January 1, 2024, to deliver aural rehabilitation and treatment services in addition to the hearing and balance assessment services provided under current law. It also allows for qualified hearing aid professionals to deliver hearing assessment services, beginning January 1, 2024. This section defines qualified hearing aid professionals as state licensed hearing aid dispensers, hearing aid specialists, hearing instrument dispensers, or related professionals who meet other requirements, as determined appropriate by the Secretary.

This section also provides for coverage of hearing aids under Medicare Part B for individuals with severe or profound hearing loss in one or both ears, once every five years, and if furnished through a written order by a physician, qualified audiologist, hearing aid professional, physician assistant, nurse practitioner, or clinical nurse specialist, qualified to write such order by the state.

Hearing aid coverage would begin in 2023 instead of 2024!

Section 31002. Funding for Health Center Capital Grants.

This section provides $1 billion in funding to award grants and enter into cooperative agreements for capital projects to health centers and federally qualified health center look-alikes. Funds can be used for health center facility alteration, renovation, remodeling, expansion, construction, and other capital improvement costs.

Looks like the funding has been doubled to $2 billion!

Section 31007. Funding for Palliative Care and Hospice Education and Training.

This section provides $30 million in funding to support training of health professionals in palliative and hospice care, foster patient and family engagement, integration of palliative and hospice care with primary care and other appropriate specialties, and collaboration with community partners to address gaps in health care for individuals in need of palliative or hospice care.

Knocked down to $25 million? Really? Weird.

Section 31011. Funding for Dissemination of Palliative Care Information.

This section provides $10 million in funding for an awareness campaign to inform patients, families, caregivers, direct care workers, and health professionals about the benefits of palliative care and the services that are available to support patients with serious or life-threatening illnesses.

Knocked down to $5 million.

Section 31005. Funding for the National Health Service Corps.

This section provides $650 million in funding for the National Health Service Corps, which provides scholarships and loan repayment to qualified health care providers in exchange for their service in underserved areas across the country.

Funding has been tripled to $2 billion.

Section 31006. Funding for the Nurse Corps.

This section provides $200 million in funding for the Nurse Corps, which provides scholarships and loan repayment assistance to registered nurses (RNs) and advanced practice registered nurses (APRNs), in return for a commitment to work at eligible health care facilities with a critical shortage of nurses or serve as nurse faculty in eligible schools of nursing.

Funding increased to $500 million.

Section 137301. Improve Affordability and Reduce Premium Costs of Health Insurance for Consumers.

Extends the American Rescue Plan section 9661 affordability percentages used for 36 (B) premium tax credits through 2025 to increase generosity for individuals eligible for assistance with household incomes below 400 percent of the federal poverty level (FPL) and provides 36 (B) credits for taxpayers with household incomes above 400 percent of the FPL. Specifies that the applicable percentages are not indexed after 2025.

The prior version would have permanently eliminated the Premium Adjustment Percentage Index (PAPI) for both the ACA subsidy table as well as the employer-sponsored insurance affordability test (which would also be dropped from 9.5% of household income to 8.5% through 2025).

It looks like at least the affordability test would go back to PAPI indexing starting in 2027, which would be irritating as hell. I assume this is, once again, to try and shave a few bucks off the overall cost, but it seems like a silly way to do it as opposed to simply making the non-indexed caps slightly higher in the first place.

Section 137305. Special Rule for Individuals Receiving Unemployment Compensation.

Extends section 9663 of the American Rescue Plan through 2025, provides that a taxpayer can receive 36 (B) premium tax credits as if the taxpayer’s household income was no higher than 150 percent of the FPL for individuals receiving unemployment compensation as defined in section 85(B) of the Internal Revenue Code.

It looks like the ARP's Unemployment Benefit would only be bumped out for one year (the end of 2022) instead of four years (through 2025).

The CBO estimated that extending this benefit for 4 years would cost around $10.6 billion, so I assume this would save roughly $8 billion or so.

Section 137307. Exclusion of Certain Dependent Income for Purposes of Premium Tax Credit.

Excludes certain dependent income from the calculation of household income for purposes of determining 36 (B) premium tax credit amounts.

I think this was supposed to be permanent; it looks like the new version would sunset this exclusion after 2026.

Section 30713. Funding for Federal Activities.

This section requires the Secretary of Health and Human Services (HHS) to report on the implementation and outcomes of state HCBS improvement programs, and to provide states with technical assistance to implement HCBS improvement programs.

Funding increased from $15 million to $40 million.

Section 30716. Permanent Extension of Money Follows the Person Rebalancing Demonstration.

This section provides permanent funding for the Money Follows the Person Rebalancing Demonstration to help states transition folks out of institutions and into HCBS.

Funding for this program was apparently supposed to be changed to $450 million per year starting in 2022, but that's been delayed until 2023. I don't know if that means it would save $450 million or what, however, since I don't know if this is simply a change from some previous yearly amount.

Section 31058. Funding for Clinical Services Programs.

This section provides $100 million in funding to support grants and contracts to public and private nonprofit clinics to carry out demonstration projects for the prevention and control of sexually transmitted infections.

Funding reduced from $100 million to $60 million.

Here's the brand-new sections:

Section 30604: Requirement with Respect to Cost-Sharing for Certain Insulin Products.

“(a) In General.—For plan years beginning on or after January 1, 2023, a group health plan or health insurance issuer offering group or individual health insurance coverage shall provide coverage of selected insulin products, and with respect to such products, shall not—

“(1) apply any deductible; or

“(2) impose any cost-sharing in excess of the lesser of, per 30-day supply—

“(A) $35; or

“(B) the amount equal to 25 percent of the negotiated price of the selected insulin product net of all price concessions received by or on behalf of the plan or coverage, including price concessions received by or on behalf of third-party entities providing services to the plan or coverage, such as pharmacy benefit management services.

Section 30606: Oversight of Pharmacy Benefit Manager Services

“(a) In General.—For plan years beginning on or after January 1, 2023, a group health plan or health insurance issuer offering group health insurance coverage or an entity or subsidiary providing pharmacy benefits management services on behalf of such a plan or issuer shall not enter into a contract with a drug manufacturer, distributor, wholesaler, subcontractor, rebate aggregator, or any associated third party that limits the disclosure of information to plan sponsors in such a manner that prevents the plan or issuer, or an entity or subsidiary providing pharmacy benefits management services on behalf of a plan or issuer, from making the reports described in subsection (b).

I don't know much about PBMs, actually, but I know this is considered a major reason why a lot of drugs are so expensive.

Section 30607: Funding to Support State Applications for Section 1332 Waivers & Administration

“(1) APPROPRIATION.—In addition to any other amounts made available, there is appropriated to the Secretary of Health and Human Services for fiscal year 2022, out of any amounts in the Treasury not otherwise appropriated, $50,000,000, to remain available until expended, for purposes of implementing the grant program under paragraph (2) and awarding grants under such paragraph.

"(2) GRANTS.—From the amount appropriated under paragraph (1), the Secretary of Health and Human Services shall award grants to States for purposes of developing a new waiver application, preparing an application for a waiver extension or amendment, or implementing a State plan under this section. The amount of a grant awarded to a State under this subsection shall remain available until expended.

“(3) LIMITATION.—Each grant awarded to a State under this subsection shall be in 23 an amount not to exceed $5,000,000.”.

I explain what "Section 1332 Waivers" are here; it basically amounts to ways in which individual states can modify certain aspects of the ACA to better suit their needs. These changes have some flexibility, but the rules are that they have to cover at least as many residents at least as comprehensively as would otherwise happen without the waiver, and (this is the big one) they hae to be able to prove that they can do so without increasing federal spending.

Reinsurance waivers are the most common type of 1332 waiver under the ACA, with well over a dozen states having implemented one type of reinsurance waiver or another. 1332 waivers can get complicated and wonky to compose and publish, so it sounds like this would provide the states with $50 million to help develop and administer them.

Section 30717: Funding to improve the Accuracy and Reliability of Certain Skilled Nursing Facility Data

$50 million for this.

Section 30718: Ensuring Accurate Information on Cost Reports

$250 million for this...it again relates to nursing facilities.

Section 30719: Survey Improvements

$325 million.

Section 30720: Nurse Staffing Requirements

Not later than 3 years after the date of the enactment of this 15 paragraph, and not less frequently than once every 5 years thereafter, the 16 Secretary shall, out of funds appropriated under subparagraph (A), conduct a 17 study and submit to Congress a report on the appropriateness of establishing 18 minimum staff to resident ratios for nursing staff for skilled nursing facilities.

$50 million.

Section 30722: State Option to provide coordinated care through a maternal health home for pregnant and postpartum individuals.

...beginning 24 months after the date of enactment of this section, a State, at its option as a State plan amendment, may provide for medical assistance under this title to eligible individuals who choose to enroll in a maternal health home under this section and receive maternal health home services from a designated provider, a team of health professionals operating with such a provider, or a health team.

Section 31007: Funding for Schools of Medicine in Underserved Areas

—In addition to amounts otherwise available, there is appropriated to the Secretary for fiscal year 2022, out of any money in the Treasury not otherwise appropriated, $500,000,000, to remain available until expended, for purposes of making awards to eligible entities for the establishment, improvement, or expansion of an allopathic or osteopathic school of medicine, or a branch campus of an allopathic or osteopathic school of medicine, consistent with subsection (b).

$500 million.

Section 31008: Funding for Schools of Nursing in Underserved Areas

In addition to amounts otherwise available, there is appropriated to the 3 Secretary for fiscal year 2022, out of any money in the Treasury not otherwise 4 appropriated, $500,000,000, to remain available until expended, for purposes of making 5 awards to schools of nursing (as defined in section 801 of the Public Health Service Act (42 6 U.S.C. 296)) to enhance and modernize nursing education programs and increase the 7 number of faculty and students at such schools.

$500 million.

Then of course there's the Big One: Subtitle I, Drug Pricing:

SEC. 139001. PROVIDING FOR LOWER PRICES FOR CERTAIN HIGH-PRICED SINGLE SOURCE DRUGS.

“PART E—PRICE NEGOTIATION PROGRAM TO LOWER PRICES FOR CERTAIN HIGH-PRICED SINGLE SOURCE DRUGS

“SEC. 1191. ESTABLISHMENT OF PROGRAM

Needless to say, this gets pretty wonky and technical, but it looks like the first year that drug prices would actually have their prices negotiated is 2025:

“(a) In General.—Not later than the selected drug publication date with respect to an 21 initial price applicability year, in accordance with subsection (b), the Secretary shall select 22 and publish in the Federal Register a list of—

“(1)(A) with respect to the initial price applicability year 2025, not more than 10 negotiation-eligible drugs described in subparagraph (A)(i) of subsection (d)(1), but not subparagraph (B) of such subsection, with respect to such year;

“(B) with respect to the initial price applicability year 2026, not more than 15 negotiation-eligible drugs described in subparagraph (A)(i) of subsection (d)(1), but not subparagraph (B) of such subsection, with respect to such year;

“(C) with respect to the initial price applicability year 2027, not more than 15 negotiation-eligible drugs described in subparagraph (A) of subsection (d)(1), but not subparagraph (B) of such subsection, with respect to such year; and

“(D) with respect to the initial price applicability year 2028 or a subsequent year, not more than 20 negotiation-eligible drugs described in subparagraph (A) of subsection (d)(1), but not subparagraph (B) of such subsection, with respect to such year;

Finally, there's the Medicare Part D Prescription Drug Out-of-Pocket Cap:

SEC. 139201. MEDICARE PART D BENEFIT REDESIGN.

...which, again, gets pretty wonky but I think it would kick in starting in 2024.

I'm sure there's a bunch of other important changes that I've missed; feel free to bring them to my attention or correct me on any of my descriptions above.