Beltway Update is an occasional column keeping you up to date on timely Congressional and administrative action on mental and behavioral health bills and policy in Washington, DC.

With the possible exception of the Affordable Care Act, major health care legislation has passed on Capitol Hill, for decades, with little or no additional mental health care and substance use financing. We appear to have left that era in the past. The latest example is the now $1.75 trillion Build Back Better Act (BBBA), which carries most of President Biden’s domestic agenda.

Below are mental health-related items that remain in the narrowed version:

  • Extends the certified community behavioral health clinic (CCBHC) Medicaid demonstration program by two years, makes CCBHC demonstration an option for every state
  • Extends Medicaid eligibility to individuals 30 days prior to release from incarceration – also known as the Medicaid Reentry Act
  • Makes the CAHOOTS-inspired financing bump for mobile crisis response efforts in the Medicaid program permanent
  • Allocates $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
  • Funds grants for maternal health, including services for maternal mental health and substance use disorders for pregnant, lactating, and postpartum people and another to diversify the workforce.
  • Extends Medicaid coverage to one year postpartum and makes CHIP a permanent program
  • Provide $500 million to support construction/modernization of health care facilities, including behavioral health centers and community health centers.
  • Enforces existing mental health parity laws through civil monetary penalties for violations by plan sponsors or administrators for group health plans
  • Invest $150 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
  • Closes the Medicaid coverage gap for the 12 states that have not expanded Medicaid

Due to hesitation on the projected cost and savings from the package, several House and Senate Democrats pledged to withhold support until they could review the full Congressional Budget Office (CBO) report on the bill. The CBO is a nonpartisan agency within Congress that is responsible for “scoring” legislation on how much it saves or costs the federal government over the next 10 years. After a two-week delay, they released a report that determined the bill does offset new spending through prescription drug pricing reform, new taxes and other various savings provisions.

Now that the CBO has released its report, enough centrist House Democrats voted in favor to pass the bill out of the House. The Senate now plans to take up its consideration during the week of December 13. Democratic leadership must now hammer out the remaining policy differences between the bill and Senator Manchin and Senator Sinema, two centrist Democrats in the Senate. 

Remaining procedural obstacles in the Senate includes a “vote-a-rama,” where Senators can offer amendments to the bill. Often lasting all night, they are time-limited for debate and cannot allow the procedure to be dragged out indefinitely. The Senate parliamentarian – the procedural judge – will also review and rule on potential “Byrd Rule” violations, which allows Senators to object to specific lines in the text of the bill, arguing that they are not germane to the reconciliation process requirements.

There will likely be no Republican support for the bill, which makes getting all 50 Democratic Senators on board imperative. Once there is a final bill, the Democrats need 51 votes in the Senate – all 50 Democrat Senators plus the Vice President breaking the tie – to pass it. The Administration and Congressional Democrats hope to schedule votes in the Senate shortly before holiday recess to pressure Republicans to expedite the vote-a-rama in order to get home for the holidays. Since it will have been amended during these processes, the House will need to pass it again before it can go to the President for signature. This could push a final vote in the House to early January.

While there still is a long road ahead before Build Back Better could become law, it seems now that they may be closer than before. With several other high-priority items on the congressional agenda to complete before the end of the year, it’s unclear if there’s enough time to pass Build Back Better and make a dent in the rest of the growing list. This suggests a difficult December — but Congress tends to be motivated by deadlines, especially when faced with the prospect of working into the holiday recess. 

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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