How Shrinking Biden's Build Back Better Could Be Bad for Older Americans
What the BBB proposals would do and who they'd help
Halloween may be more trick-or-treat than usual in 2021. That's the proposed deadline set by Democratic leaders to complete work on President Joe Biden's Build Back Better Act (BBB), also known as the budget reconciliation act. And no constituency may have more at stake in this legislation than older adults.
The first goal is to emerge with a final topline number for this key part of the Biden agenda. As a longtime elder advocate and Washington observer, I can say with confidence that neither the $3.5 trillion proposed by the president nor the $1.5 trillion offered by Sen. Joe Manchin (D-W.Va.) will be the final number — think something in between.
Will we achieve the most historic changes to aging policy since 1965 as proposed or will we have missed a golden opportunity?
The topline number sets the table for what provisions remain, at what funding level and for how long. But as the overall size and cost of the bill continues to shrink, we must ask: Will we achieve the most historic changes to aging policy since 1965 as proposed or will we have missed a golden opportunity?
Build Back Better Proposals to Watch
Neither the House nor the Senate has passed a version of the BBB. The House is further along; its various committees have produced portions of the bill and a full House vote awaits. The Senate bill remains a mystery.
From what we've seen in both the president's original proposal and the House bill to date, these are some of the key items that could positively impact older adults and where they might be heading:
Broadening Medicare coverage and lowering prescription drug costs for people on Medicare. BBB would add dental, vision and hearing coverage under fee-for-service Medicare. It would also let the federal government negotiate the price of prescription drugs for Medicare Part D health plans for the first time.
Adding $400 billion for Home and Community-Based Services for people on Medicaid as well as improvements in wages and benefits for long-term care workers. The House bill presently contains $190 billion for these programs. The Senate figure remains in flux but seems to be closer to the House-proposed number than the president's.
Another $4 billion for federal elder justice programs. This is part of the House bill and would help with such things as Adult Protective Services, the long-term care ombudsman program, improved staffing in nursing homes and a new grant program to address social isolation. Sen. Ron Wyden (D-Ore.), chair of the Senate Finance Committee, has proposed a bill for this amount of funding, but this proposal was not included in the president's plan and will need White House backing to survive.
Creating a family caregiver tax credit. This is not a new idea, but one that has gained tremendous new urgency lately. Whether the tax credit idea becomes law may be decided on how much new revenue will come through tax increases to offset the revenue loss of the credit.
There are also important BBB provisions to expand housing for older adults, expand paid family leave (including for family caregivers for older relatives) and a boost in funding for the Older Americans Act.
Which of these aging policy ideas can survive as proposed?
The House bill already delays the start of the Medicare dental benefit until 2028. Further, there is no consensus yet among Democrats on how far prescription drug reform will go. One positive note: older adults may finally see a cap imposed on how much they could be forced to pay out-of-pocket for prescription drugs.
The Battles Ahead in Washington, D.C.
Add to all this: some powerful Democrats would prefer to make Affordable Care Act health insurance subsidies permanent rather than expanding Medicare.
I am concerned about the pitting of key provisions for children against those for older adults.
The Medicaid battle is also heated. Here, it is more about the need to make the policy and political case for ending waiting lists for home care and for making long-overdue investments in the health care workforce. Those who resist are opposed mostly because of the cost.
One possible BBB outcome would be scaling back its provisions to lower costs. Another is a shorter duration for new and expanded programs.
There seems to be an inherent intergenerational fairness to these approaches, but the details will be important. However, I am troubled by reports that means testing for programs (basing them on a person's income) may be adopted. Unfairness is built right into this approach.
I am also concerned about the pitting of key provisions for children against those for older adults. One prime example was in a recent New York Times article headlined, "Among the Family Benefits Proposed by the Democrats, Which Deserves Priority?" Of the four listed, only one — paid family leave —had any implications for older adults.
In order for the major aging-policy provisions in BBB to survive, advocates must successfully make the policy and political arguments. If they don't, or if the proposals are substantially weakened, aging advocates must become more politically aggressive.
How this all plays out will have enormous implications on the remainder of this session of Congress, the midterm elections in 2022 and the 2024 Presidential election. Let's hope that we emerge with legislation that is transformational in its reach and that improves the quality of life for persons of all ages.