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What Might Build Back Better Mean for Patients?

The reconciliation package has been in negotiations for weeks at this point. It’s been whittled down from its original $3.5 trillion sum, but what’s still in it? What’s been cut out? And what is still unclear? We’ve got you covered!

Great, there’s finally a bill. What’s in it?

Glad you asked. We still don’t have the text of the bill, just statements from senior legislators like Speaker Pelosi or Majority Leader Schumer and from the White House, so it’s a bit of guesswork. There’s also the issue of certain senators making angry, uncertain noises about the bill–but not saying if they oppose it or not. That said, we have some leads. You can split the health portions of the bill into a few big categories: 

  1. Making coverage better
  2. Getting coverage to more people
  3. Making healthcare cheaper

So how would the bill make coverage better? And how does it compare to the original proposal?

Making coverage better is a big, broad goal–but the bill has some big, broad changes. The two biggest ones are changes to Medicare and changes to in-home care. For the first time, Medicare would start covering hearing. For budgetary reasons, this coverage would start in 2023, but when it happens, it’ll be a big deal: Millions of older Americans would be able to get their hearing needs covered without paying significant extra costs. In-home care would also receive a permanent funding boost of $150 billion. This money would go towards reducing the 800,000 strong waitlist for in-home health care and towards paying the essential workers the wages they deserve.

These both represent compromises with more conservative senators. Initially, the reconciliation package would’ve had Medicare cover dental, vision, and hearing, and it included $400 billion for in-home care. It’s a significant cutback, but at the same time, these are the biggest boosts in support in generations.

Ok, so what about getting coverage to more people?

This is perhaps the strongest part of the bill. Right now, millions of low-income Americans live in states that deny them Medicaid coverage, but if they moved over state lines, they would be eligible for coverage. It makes no sense, and it harms low-income Americans for no reason–especially Black Americans and Southerners, since most Southern states refused to expand Medicaid when the Affordable Care Act gave them the choice. The reconciliation package would move about 4 million people in the states that didn’t expand Medicaid onto subsidized insurance like Medicaid.

Again, this is a compromise, but also a huge step forward. Getting millions of people access to care is genuinely life-changing. Medicaid coverage saves lives, and finally getting Medicaid to some of the most vulnerable Americans would help right a horrible wrong.

That last one, cheaper healthcare–what’s that about?

This one is hard, since it’s still a little murky. There are two components: Tax credits to subsidize plans on Affordable Care Act marketplaces, which are fairly straightforward, and controls on drug costs. Right now, there are significant subsidies for insurance plans bought on the ACA marketplace, and the reconciliation package would extend them through 2025–making access to care much cheaper for millions of Americans. The drug cost controls would let the government negotiate for some of Medicare’s most expensive medications, starting with 10 in 2025 and increasing to 20 by 2028. These medications wouldn’t be allowed to increase in cost faster than inflation, and no one would pay more than $35 of their own money a month for insulin.

Both of these proposals are historic. While the tax credits were initially planned to be permanent, these were negotiated down to just a few years. The drug cost controls were also initially much more sweeping, planned to cover hundreds of medications and control the cost of insulin even more tightly, but even this is a step forward.

Got it. So how do we feel about the whole thing?

We feel pretty good. It’s not what the original package included, and it’s not as ambitious– but compared to what we’re dealing with now, it’s a huge upgrade. At the end of the day, the choice is stark. The reconciliation bill offers us a significant step forward, even if it isn’t as big as the step we wanted to take–or as big as the step we need to take. But any step forward is better than a step back.