What’s in the Build Back Better bill to address ACEs and adverse community environments

PHOTO OF AN EXCERPT FROM THE
NOVEMBER 3, 2021
RULES COMMITTEE PRINT 117–18
TEXT OF H.R. 5376, BUILD BACK BETTER ACT
[Showing the text of H.R. 5376, as reported by the Committee
on the Budget, with modifications.]

With President Biden signing the $1.2 trillion Infrastructure Investment and Jobs Act (bridges, roads, internet access, etc.) November 15, it’s a good time to focus on the substance—not the legislative sausage-making—of the Build Back Better bill. The House of Representatives could vote as early as this week on the bill that includes approximately $2 trillion to fund the child tax credit, childcare subsidies, expansion of the Affordable Care Act, paid family leave and more. While the total cost of the bill is far less than the original proposals, the size and shape of the investments promise to be transformational, reducing inequality and supporting the nation’s families. The benefits could impact every person in communities around the country.

Tucked in the 2,000-page text of the Build Back Better bill is a $2.5 billion provision to fund:

• “Community Violence and Trauma Interventions” (Section 31055, page 704) “to support public health-based interventions to reduce community violence and trauma, taking into consideration the needs of communities with high rates of, and prevalence of risk factor associated with, violence-related injuries and deaths…” The funding is authorized for fiscal year 2022 and remains available until expended.
• Support for interventions to reduce community violence and trauma include grants and contracts “to support evidence-informed, culturally competent, and developmentally appropriate strategies to reduce community violence” and support for “training, technical assistance, research, evaluation, public health surveillance systems, data collection, and coordination among relevant stakeholders, to facilitate support for strategies to reduce community violence and ensure safe and healthy communities.”
• The grants or contracts to support a variety of strategies including services that “prevent or mitigate the impact of trauma, build appropriate skills, or promote resilience.” Eligible applicants include local government entities, states, territories and tribes, healthcare organizations, nonprofit community-based organizations, and others. Strategies to reduce community violence include outreach and conflict mediation, violence interruption, and services for “victims, and individuals and communities at risk for experiencing violence, such as trauma-informed mental health care and counseling, social-emotional learning and school-based mental health services, workforce development services, and other services that prevent or mitigate the impact of trauma, build appropriate skills, or promote resilience…”

The inclusion of this provision in the Build Back Better bill demonstrates the growing awareness in Congress of the importance of addressing trauma at the individual and community levels. The education and advocacy around bills first spearheaded by Senator Heidi Heitkamp (representing North Dakota from 2013-19) and Senator Dick Durbin (D-IL) were foundational in the ever-expanding awareness of trauma and strategies to prevent trauma and mitigate its impact. The current iteration of this bipartisan legislation, the “RISE from Trauma Act (S. 2086)", especially the section establishing “Trauma and Resilience-Related Coordinating Bodies,” embodies the central role of communities in addressing trauma. The bill provides $600 million for each of fiscal years 2022 through 2029 for these coordinating bodies. (For background on the RISE bill, see this story in PACEs Connection).

Building support for the RISE legislation will continue to be a priority for the Campaign for Trauma-Informed Policy and Practice (CTIPP) and the many organizations that are members of the Childhood Trauma and ACEs Policy Workgroup (CTAP) such as Futures Without Violence, the YMCA, and the American Academy of Pediatrics.

How Build Back Better Addresses Big P policy issues—Poverty and Inequality

Among the key provisions in the bill that address issues that impact trauma broadly such as reducing poverty and violence—characteristics in adverse community environments (click here for information on the Building Community Resilience Collaborative)—include the child tax credit, paid family leave, universal pre-K, child care subsidies as well as housing investments and health insurance expansion, etc. Below are selected sections from the summary (attached) released by the House leadership:

Extending the Child Tax Credit for One Year

• The Build Back Better Act extends the enhanced Child Tax Credit that was included in the American Rescue Plan for one year, through the end of 2022. However, in 2022, unlike 2021, only taxpayers with income below $150,000 (in the case of joint filers), $112,500 (in the case of a head of household), and $75,000 (in the case of other filers) will receive the tax credit as an advance monthly payment deposited in their bank account. It is estimated that the enhanced Child Tax Credit will cut the rate of child poverty in half.*  The amount of the monthly enhanced child tax credit is $250 per child and $300 per child under age 6, amounting to $3000 per child per year or $3,600 per child under age 6 per year. Under current law, the credit would have expired at the end of 2021.
• The bill also makes the refundability of the Child Tax Credit permanent, ensuring that Americans who are most in need can benefit from the credit in the same way that all other families do.

*This is a finding of a Columbia University study.

Establishing Paid Family and Medical Leave

• The United States lags behind the rest of the industrialized world when it comes to guaranteeing paid family and medical leave.  Only 21 percent of American workers have access to employer-provided paid family leave, and just 42 percent of American workers have access to paid medical leave through an employer-provided plan.
• The Build Back Better Act establishes a universal and permanent family and medical leave program. The program provides four weeks of paid parental, family caregiving, and medical leave.
• The benefits of paid family and medical leave are substantial, including improving business productivity, boosting employee morale, reducing turnover, and making it easier for employers to attract skilled workers.  The benefits also include strengthening the labor force, providing income security to families who might otherwise need public assistance to make ends meet, and helping women stay in the workforce.

Ensuring Universal Preschool for 3-and 4-Year-Olds

• Early childhood education provides children and families the strong foundation they deserve.  Yet, currently, many families do not have access to participate in preschool programs, and often communities do not have the resources to support universal preschool programs.
• The Build Back Better Act invests in securing universal preschool for three- and four-year-olds so that children can go on to live happier, healthier, and more productive lives. The bill invests $390  billion for the child care initiative and the universal preschool initiative.
• Under this bill, there will be free, high-quality preschool for three- and four-year olds, and communities will have resources to help them provide safe and healthy environments for preschool programs.
  
  

Dramatically Lowering the Cost of Child Care for Working Families

• Working families across the country are facing a child care crisis.  The high cost of child care is straining family budgets and pushing millions of Americans out of the workforce – a majority of whom are women.  The lack of affordable child care is also hurting our economy.  As workers are forced to stay home, employers are struggling to fill job openings to meet demand and grow their businesses.
• The Build Back Better Act will dramatically lower the cost of child care for many families.  Under the bill, the vast majority of families would not pay more than seven percent of their income on child care, representing an enormous savings from what they pay now.  The bill invests a total $390 billion for the child care initiative and the universal preschool initiative.
• Under the bill, child care providers would also have resources to raise wages for child care workers and expand available supply to serve more children and families.

Helping Prevent Child Hunger

• Even before the pandemic, more than five million children lived in homes that did not have reliable access to nutritious food. This has a lasting impact on children’s physical health, mental health, and their education. Every child should have the basic nutrition they need for a healthy and happy childhood.
• The Build Back Better Act invests $10 billion in proven child nutrition programs that will bolster the fight against child hunger, including making free school meals newly available to nearly nine million children and investing in food assistance for children during the summer.

Expanding ACA to Close the Coverage Gap (Reported by Energy and Commerce and Ways and Means Committees)

• Currently, 12 states still have not expanded Medicaid:  Alabama, Florida, Georgia, Kansas, Mississippi, North Carolina, South Carolina, South Dakota, Tennessee, Texas, Wisconsin, and Wyoming.
• The Build Back Better Act would provide access to affordable coverage through 2025 to the millions of Americans who currently fall within the coverage gap because they live in a state that did not expand Medicaid.  Closing the coverage gap will allow up to four million uninsured Americans to gain access to coverage.
• The bill expands the ACA to close the coverage gap by providing that, from 2022 through 2025, those in the coverage gap will have access to quality affordable coverage through the ACA Marketplaces, with eligibility for premium tax credits expanded below the federal poverty line. Due to the very low incomes of these individuals, they will qualify for coverage with $0 premiums. (These provisions are within the Ways and Means Committee jurisdiction.)
• The bill also provides for enhanced cost sharing assistance to ensure that these individuals can get the health care they need with minimal cost-sharing. (This provision is within the Energy and Commerce Committee jurisdiction.)
• In addition, the bill also provides a bump in the Federal Medical Assistance Percentage (FMAP) for 2023 through 2025 for those states that have already expanded Medicaid, which they can only receive if they maintain their expansion.  (This provision is within the Energy and Commerce Committee jurisdiction.)
  
  

Expanding Affordable Health Care Coverage

• The Build Back Better Act includes several provisions to expand affordable health care coverage and lower the cost of health care, including the following:

• Provides temporary enhanced ACA Marketplace cost-sharing reduction assistance to individuals in the Marketplaces with household incomes below 138 percent of the federal poverty level for calendar years 2022 through 2025.  (This provision relates to the provisions in the bill closing the Medicaid Coverage Gap (see above.)
• Makes available $10 billion annually to states for calendar years 2023 through 2025, providing the option for states to establish a reinsurance program to help lower premiums or use the funds to provide financial assistance to reduce out-of-pocket costs.
• Provides $100 million for the ACA’s health insurance consumer information grants for calendar years 2022 through 2025 to help consumers learn about their coverage options and to better assist consumers experiencing problems with their health coverage.
• Provides ACA cost-sharing reduction assistance to individuals receiving unemployment compensation for calendar years 2022 through 2025.
• Improves transparency in the pharmacy benefit manager (PBM) market, giving health plan sponsors a tool to be smarter shoppers for PBM services in order to reduce costs. The bill requires that group health plan sponsors receive a semi-annual report on the costs, fees, and rebate information associated with their pharmacy benefit manager (PBM) contracts.
• Ensures coverage of at least one of each type and dosage form of insulin under private insurance and ensures coverage of these insulin products before the application of any deductible and limits other cost sharing to no more than $35.

To view the entire bill text, click here and for the section-by-section summary (179 pages), click here.

Many factors including the razor-thin majorities in the House and Senate and the deep polarization in the public and in Congress make the passage Build Back Better far from certain. As the first year of President Biden’s term comes to an end, many fear that the passage of time will deplete the sense of urgency that is needed to get the bill through Congress. As the 2022 mid-term election season heats up, the few legislative days left in 2021 hold the best promise for passage of the transformative provisions of Build Back Better.