Build Back Better Act's Implications Significant for Behavioral Health

Early Nov. 19, the US House passed landmark legislation primarily aimed at improving America’s social infrastructure—those fundamental features of our society that affect our health, wellbeing, families, and communities. This Build Back Better Act, estimated to cost about $1.8 trillion, now goes to the US Senate for approval through a reconciliation process, which will permit passage by a simple majority. A section-by-section summary of the Act can be accessed on the House website.

>> READ a section-by-section summary of the Build Back Better Act

Here, I would like to explore the key features of this bill, with reference to their implications for the behavioral healthcare field. Topics will be discussed in the order from largest to smallest expenditure in the legislation.

$555 billion to fight climate change. The bulk of the spending here will be in the form of tax credits to install solar panels, improve the energy efficiency of buildings, and purchase electric vehicles.

The behavioral healthcare field must be involved in the development of the programs for these initiatives. The field can help assure that some of the resources from these programs go directly to those with behavioral health conditions who are most needy. At the same time, it will be essential that behavioral healthcare also be represented on the national council to improve environmental quality, which was created by the Infrastructure Act passed 2 weeks ago. Global warming, storm severity, and population displacement all have direct effects on behavioral health and the effectiveness of care.

$400 billion for universal pre-kindergarten. All children ages 3 and 4 will be eligible for pre-K education at a school chosen by their parents.

This provision presents a wonderful opportunity for the behavioral healthcare field to improve the wellbeing of our youth. The field must develop and implement socio-emotional learning modules for these classrooms. Similarly, the field must develop early screening protocols for identifying behavioral health concerns.

$200 billion for child tax credits. Child tax credits will be extended for 1 year. Parents will receive $300 per month for children under age 6 and $250 per month for children from age 6 to 17.

Childhood poverty is a potent predictor of later behavioral health conditions. The behavioral healthcare field must assure that children living with parents or other family members who have behavioral health conditions actually can access and benefit from this program.

$200 billion for 4 weeks of paid family and medical leave. A permanent family and medical leave program will be created for all workers, with a 90% salary reimbursement for most workers. This leave can be used for care of a family member or for periods of personal illness.

The behavioral healthcare field must be engaged in the creation of this program. The field must assure that such leave can be used to care for a family member who has a behavioral health or intellectual/developmental disability (I/DD) condition; it also must assure that such leave is available for personal care by persons with these conditions. The field also will need to broaden the concept of respite to encompass such periods of leave.

$165 billion for healthcare spending. Health insurance premiums will be reduced for participants in the state health insurance exchanges operated under the Affordable Care Act, Medicaid coverage will be extended to those in non-expansion states who have been excluded, and drug price increases and out-of-pocket costs will be controlled. Further, Medicare will be expanded to cover hearing services, funds will be made available to support essential public health infrastructure, and training funds will be made available for healthcare personnel.

Provisions of specific interest to behavioral health and I/DD care include extension of Medicaid coverage to those who are incarcerated up to 30 days prior to release, additional support for comprehensive community behavioral healthcare clinics (CCBHCs), and additional state coverage for mobile crisis response teams.  

All these provisions offer huge opportunities for the behavioral healthcare field to expand insurance coverage for persons with behavioral health and I/DD conditions, improve access to care and in-community supports, and address major field problems, such as crisis response. A critical question the field will need to address is readiness to implement all these provisions effectively when the funds become available.

$150 billion for affordable home care. The Medicaid Home and Community Based Services Program will be expanded through additional resources to the states to improve in-home care.

Like the healthcare program expansions discussed above, the home care provisions clearly offer essential support for persons with behavioral health and I/DD conditions. The field must incorporate this new support into care planning and coordination. 

$150 billion for affordable housing. Funds will be made available to build more than 1 million new rental and single-family homes. Rental and down-payment assistance will be provided through an expanded voucher program.

One of the worst problems faced by the behavioral healthcare field is lack of affordable or even any housing for persons with behavioral health conditions. Like actions required for the other programs noted above, the behavioral healthcare field will need to be represented during the design of these programs so that they are made available to persons with behavioral health and I/DD conditions.

The US Senate is likely to change some of the provisions in this act, yet it is unlikely to take no action or to defeat the bill entirely. Hence, the behavioral healthcare field should engage in strenuous advocacy to preserve those pieces of the legislation that are particularly relevant to care and support of persons with behavioral health and I/DD conditions, as well as those that enhance the infrastructure of the field. Further, the field should plan for how it will be represented in the federal settings where these programs will be designed and implemented. Each of these actions is a must.

Ron Manderscheid, PhD, is the former president and CEO of NACBHDD and NARMH, as well as an adjunct professor at the Johns Hopkins Bloomberg School of Public Health and the USC School of Social Work.

The views expressed in Perspectives are solely those of the author and do not necessarily reflect the views of Behavioral Healthcare Executive, the Psychiatry & Behavioral Health Learning Network, or other Network authors. Perspectives entries are not medical advice.