C-TAC Update: President Biden Releases Budget of the U.S. Government – Fiscal Year 2023

CTAC + Mar 30, 2022

Background

On March 28, 2022, the Biden-Harris Administration’s Budget of the U.S. Government Fiscal Year 2023 was released and sent to Congress for consideration.  As described by the progressive Center on Budget and Policy Priorities, “President Biden’s 2023 budget calls for a range of policies that would boost opportunity and reduce poverty, improve health and well-being, and advance widely shared prosperity, funded by proposals to make the nation’s tax system stronger and fairer.”  

Since Congress is still considering last year’s Build Back Better Act (budget reconciliation), the FY 2023 budget forgoes providing many of those specific proposals and costs again.  It includes a “deficit neutral reserve fund” to cover future legislation.  The budget does call on Congress to address economic security for families, reduce energy costs and combat climate change, cut prescription drug costs, fund free community college, continuing the enhanced child tax credit and high-quality preschool.  It is expected that a BBB package would still address expanding health coverage including for states that have not expanded Medicaid, childcare, HCBS for older and disabled individuals, housing, providing an expanded Earned Income Tax Credit and Child Tax Credit.  Of course, the fate of BBB is unknown, including whether it will include major funding for HCBS, additional funds for the Older Americans Act supports and services, palliative care, hospice education and training, and many other proposals.

The FY 2023 Budget Proposal

The Biden-Harris budget does include additional spending and support for Ukraine, additional defense spending, police on the streets and community violence intervention programs, a “historic increase” in funding for the education system, investments in transit systems and housing, hiring IRS staff, and much more.  Many of the new programs and increases in the budget are paid for with a “billionaire minimum income tax,” and an increase in the corporate tax rate on profits.

A Wide Range of Social Spending Increases

The budget includes a $26.8 billion increase for the Department of Health and Human Services (HHS) for a total of $127.3 billion.  Here are some of the programs the budget would fund and some of the legislative changes they propose.  Note that much of this document is taken directly from the Biden-Harris budget documents.

  • Accelerates Innovation through the Advanced Research Projects Agency for Health (ARPA-H). The Budget proposes a major investment of $5 billion for ARPA-H, significantly increasing direct Federal R&D spending in health to improve the health of all Americans. With an initial focus on cancer and other diseases such as diabetes and dementia, this major investment would drive transformational innovation in health technologies and speed the application and implementation of health breakthroughs. Funding for ARPA-H, along with additional funding for the National Institutes of Health, total a $49 billion request (an increase of $7.5 billion) to continue to support research that enhances health, lengthens life, reduces illness and disability, and spurs new biotechnology productions and innovation.  This does not include additional mandatory spending of more than $12 billion for pandemic preparedness.
  • Advances the Cancer Moonshot Initiative. The Budget proposes investments in ARPA-H, the National Cancer Institute, CDC, and the Food and Drug Administration to accelerate the rate of progress against cancer by working toward reducing the cancer death rate by at least 50 percent over the next 25 years and improving the experience of people who are living with or who have survived cancer.
  • Transforms Mental Healthcare (summarized). Mental health is essential to overall health, and the United States faces a mental health crisis that has been exacerbated by the COVID-19 pandemic. To address this crisis, the Budget proposes reforms to health coverage and major investments in the mental health workforce. For people with private health insurance, the Budget requires all health plans to cover mental health benefits and ensures that plans have an adequate network of behavioral health providers. The President’s 2023 Budget for HHS invests in: mental healthcare and suicide prevention; healthcare access and outcomes for vulnerable populations; requires parity in coverage between behavioral health and medical benefits and expands coverage for behavioral health providers under Medicare. The Budget invests in increasing the number of mental health providers serving Medicaid beneficiaries, as well as in mental health workforce development and service expansion, including at primary care clinics and non-traditional sites. The Budget also provides sustained and increased funding for community-based centers and clinics.
  • Add Medicare Coverage of Services Furnished by Community Health Workers. Under HHS Legislative Proposals, the budget includes targeted Medicare proposals that support the Administration’s priorities, including: Under current law, services provided by community health workers are not paid under Medicare. This proposal would provide coverage and reimbursement to community health workers acting within the scope of their license or certification under Medicare’s Physician Fee Schedule for select, evidence-based preventive, chronic, and behavioral care management services, as well as certain social determinants of health evaluation and navigation services, effective CY 2024. Such services would be exempt from Medicare cost-sharing. Services must be furnished under the direction of—and billed by—a Medicare-enrolled supplier or provider in accordance with a comprehensive community needs assessment and engagement plan. In addition to existing Medicare providers, the Secretary would be permitted to enroll community-based organizations (e.g., non-profits, public health departments, etc.) as community health worker suppliers to broaden access to services, subject to program integrity and patient safety guardrails. This proposal has positive equity implications, as it would increase access to the healthcare system for underserved Medicare beneficiaries and allow communities to better target resources to address local public health challenges. [Not Scorable]. 
  • Center for Medicare and Medicaid Innovation Programs Description: Beginning on Page 109-112 of the FY 2023 HHS Budget in Brief see a description of priorities: “Beyond formal certification, the Innovation Center will prioritize impacts on health equity, person-centered care, and health system transformation – efforts which are aligned with CMS-wide goals…”

https://www.hhs.gov/sites/default/files/fy-2023-budget-in-brief.pdf

  • Prescription Drug Costs. The budget states the President “supports legislation that cuts costs for prescription drugs.” The budget includes a “reserve fund to account for future legislation, preserving the revenue from proposed tax and prescription drug reforms for the investments needed to bring down costs for American families.”
  • Social Security. The FY 2023 spending proposal includes $14.8 billion (an increase of 14% above the 2021 enacted level) for SSA operations, to address long wait times on hold when calling the 800 number and excessive waiting periods for disability hearings and benefit determinations, and to reopen field offices.
  • Centers for Disease Control and Prevention and state and local health departments. Additional support for work to protect public health by alleviating shortfalls in staffing and capacity for laboratory analysis, data collection and dissemination, and epidemiology.  The Fiscal Year 2023 President’s Budget includes $47.5 billion in total mandatory and discretionary funding for CDC and the Agency for Toxic Substances and Disease Registry (ATSDR).
  • Money Follows the Person MFP Demonstration. The budget includes $456 million – increased by $191 million, the MFP demonstration supports state efforts for rebalancing their long-term services and supports system so that individuals have a choice of where they live and receive services
  • Medicare Survey and Certification. The budget includes $494 million for survey and certification activities – an increase of $97 million. Surveys can include mandated federal inspections of long-term care facilities (i.e., nursing homes), home health agencies, and hospices, as well as federal inspections of hospitals and other key facilities that occur on a non-mandated frequency interval.  All facilities participating in the Medicare and Medicaid programs must undergo certification when entering the program and on a regular basis thereafter.
  • Telehealth. The Health Resources and Services Administration (HRSA) supports telehealth services to increase health care quality and access, expand provider access to specialized expertise, and improve health outcomes in rural and underserved areas. The budget includes $45 million for telehealth programs at HRSA, which is a $9 million increase…to promote direct-to-consumer telehealth services, provider-to-provider telementoring, and a telehealth data collection infrastructure to track telehealth services across HRSA.  The Agency for Healthcare Research and Quality (AHRQ) budget includes an increase in FY 2023 to support the establishment of two Centers of Excellence in Telehealth Implementation.  These centers will play a role in evaluating the effects of telehealth on healthcare delivery and health outcomes to ensure the promise of telehealth is delivered through evidence-based practice and policy.  It is important to understand telehealth’s effect on key health policy priorities and thoroughly evaluate the effect of telehealth on healthcare quality, safety, equity, access, utilization, and value.  Medicaid. CMS released a robust toolkit and checklist for states seeking to expand or newly-offer telehealth services under Medicaid and CHIP. Telehealth, specifically audio-only telehealth, can greatly increase access to services for individuals who may not have sufficient bandwidth or technology to support 2-way audio-video, particularly in underserved areas and among older populations.  CMMI telehealth – in FY 2021, the Innovation Center added a telehealth benefit enhancement to this model, waiving the geographic originating site requirement for the furnishing and billing of telehealth services. This waiver enables the continuation of specific primary care telehealth services after flexibilities provided in the current Public Health Emergency expire.
  • Funding for other Community Supports. The budget provided additional funds for home and community-based supports and services to help older Americans and those living with disabilities, including American Indian, Alaska Native, and Native Hawaiian elders, to live independently and with dignity.
  • $3.108 billion for Older Americans Act (OAA) programs and Disability Programs under the Administration for Community Living (ACL) – an increase of $751.696 million.  Including:
    • $500m to support home-and community-based supportive services- $107 m increase;
    • $1.272 billion to support nutrition programs for older Americans – $306 million increase;
    • $50m for services, including nutrition, for Native American older adults;
    • $73 million for adult protective services – $59 million increase;
  • $36,885,000 for the Long-Term Care Ombudsman Program (LTCOP), an increase of $18,000,000 above the FY 2022 annualized CR level.  As a result of the pandemic, COVID-19 supplemental funding was used to extend monitoring by the LTCOP to assisted living facilities and other residential care communities.  Higher funding is requested so that LTCOP can continue to expand its efforts on behalf of individuals living in assisted living facilities. Fueled in part by the Administration’s efforts to expand home and community-based services, more people are increasingly choosing to live in community-based residential settings instead of in nursing homes, making the expansion of ombudsman services to these settings increasingly important.
  • $4,400,000 for Elder Rights Support Activities (ERSA), an increase of $526,000 above the FY 2022 annualized CR level.  The additional funding will go to the National Long-term Care Ombudsman Resource Center (NORC), which will support the increased request for the Long-Term Care Ombudsman program and coverage in residential care facilities.  Elder Rights Support Activities provide information, training, technical assistance, and resources to states and communities to promote the rights of older Americans to live where they wish, whether in their own homes or in long-term congregate housing.  These activities assist individuals to obtain necessary and appropriate health care, especially including care and services in their own homes; and to live free from abuse, neglect, and exploitation. 
  •   Families are the nation’s primary providers of long-term care, but several factors — including financial constraints, work and family demands, and the many challenges of providing care — place intense pressure on family caregivers. The Biden-Harris Administration identified strengthening the care economy as a key priority and one that is crucial to our country’s continued economic recovery from COVID-19.  ACL’s budget reflects this Administration’s priority in its request for funds to support family and other informal caregivers.
  • To address caregivers’ needs, for FY 2023 ACL is requesting a total of $310,022,000 for caregiver support programs, an increase of $75,670,000.
  • $249,936,000 for Family Caregiver Support Services, an increase of $61,000,000
  • $15,806,000 for Native American Caregiver Support Services, an increase of $5,000,000.
  • $30,060,000 for the Alzheimer’s Disease Program Initiative, an increase of $2,560,000.
  • $14,220,000 for Lifespan Respite Care, an increase of $7,110,000.

Resources

Written by Brian Lindberg – C-TAC Senior Public Policy Advisor

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