As everyone paying attention knows, Congress is locked in an epic battle over the scale and shape of the so-called “human infrastructure” bill that contains the bulk of President Biden’s “Build Back Better” agenda. You probably also know that in the meantime, House progressives have forced a delay in voting on the Bipartisan Infrastructure Framework (known around DC as “BIF”), a $1.2 trillion bill focused on physical infrastructure priorities such as transportation and climate change response that passed the Senate with bipartisan support in August. 

What you may not know is that there is potentially a lot of mental health money in the outlines of that human infrastructure package, which must pass both houses and requires a majority vote in the Senate. Democratic leaders from the House and Senate have worked with the White House and budget committees to give each committee working on the package a top-line funding number they can work with and non-binding recommendations on funding priorities.

The list of proposed policies includes changes in Medicare, Medicaid, and the Children’s Health Insurance Program (CHIP), as well as several mental health initiatives. So far, we’ve only seen text from the 13 House committees involved in crafting the bill.

The House’s version of the “human infrastructure” bill was crafted to spend a total of $3.5 trillion, though centrist Democrats are trying to slash that number. The original version would: 

• allocate $75 million to help prepare the National Suicide Prevention Lifeline for implementation of the new 9-8-8 mental health crisis and suicide prevention line

• close the Medicaid coverage gap for the 12 states that have not expanded Medicaid 

• allow people who are incarcerated to be enrolled in Medicaid 30 days before they are due to be released from prison or jail

• invest $190 billion into the Home and Community Based Services (HCBS) Medicaid program, which provides person-centered care for seniors and people with disabilities in home and community-based settings rather than institutional facilities like nursing homes or hospitals 

• provide $500 million to support construction/modernization of health care facilities, including behavioral health centers and community health centers. 

The bill also expands Medicare coverage for vision, dental and hearing benefits; establishes two weeks of universal paid family and medical leave for all U.S. workers; and better enforces existing mental health parity laws through civil monetary penalties for violations by plan sponsors or administrators for group health plans. While this doesn’t apply to every insurance plan, most private sector, employer-sponsored group plans are governed by the Employee Retirement Income Security Act (ERISA) and regulated by the Department of Labor. 

Additionally, changes to the Affordable Care Act (ACA) would reduce costs for people with incomes below 138 percent of the Federal Poverty Level (FPL) and expand the ACA tax credit to people with incomes below 100 percent of the FPL. Both of these measures aim to lower health care costs for those getting coverage through the ACA marketplace, which would in turn allow more people to afford these plans that include essential benefits like mental health services. 

Finally, the bill includes grant programs for maternal health, including one that would fund services for maternal mental health and substance use disorders for pregnant, lactating, and postpartum individuals and another that would help diversify the workforce. Additionally, the bill extends Medicaid coverage to one year postpartum and makes CHIP a permanent program. 

These items seem to reflect the House’s preferred approach to expand access to behavioral health services by increasing insurance benefits in the private market rather than providing direct funding to mental health and substance use providers or expanding other access to care.

A few weeks ago, the two health-focused House Committees – Energy and Commerce (with jurisdiction in mental health/substance use, Medicaid/Medicare, Public Health Service Act, among other areas) and Ways and Means (with jurisdiction in taxation, Medicare, Social Security, among other areas) – wrapped up their marathon markup sessions, which allow members of each committee to offer amendments. 

Notably, Energy and Commerce was not able to advance a key part of the Biden agenda on drug pricing as part of the reconciliation bill. The administration wants to give Medicare, a huge purchaser of drugs, the power to negotiate with pharma companies over drug prices; to penalize companies that increase prices faster than inflation; and to put an annual cap on the amount of money Medicare patients spend on medications.

Democrats need these measures, which would lower overall costs, to help pay for the spending in the rest of the package. Drug pricing has become an area of disagreement in the different wings of the Democratic party in Congress, along with the final price tag of the bill.

The Senate has finished drafting its reconciliation text, though it hasn’t been released and likely won’t go through public markups. The House and Senate will need to find agreement on a final list of priorities and funding levels before moving to the later stages of the reconciliation process. Which priorities make it in and how long they are funded for is anyone’s guess. With Democrats holding very thin margins in both chambers of Congress, there is little room for disagreement to get a bill over the finish line, which party leaders aim to do by the end of October. 

Democrats must use the complicated reconciliation process because it requires only a simple majority in the Senate and cannot be filibustered. When a single party holds the Presidency and a small majority in both chambers of Congress, they resort to this process to get things through the Senate. 

At this point, it’s too soon to tell which mental health initiatives will be included, how long this process will last, how deeply the $3.5 trillion price tag will be cut, or if the reconciliation bill will make it across the finish line. Mental health priorities may get a historic boost … or not. It’s going to be a long and messy autumn in Congress. 

Sarah Corcoran is vice president of government relations at Guide Consulting Services (GCS), a government relations consulting practice based in Washington, DC. GCS represents mental health providers, technology companies, patient advocacy organizations and state mental health agencies before Congress and the administration. A complete list of GCS clients can be found here.

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