Build Back Better & Healthcare for the Homeless

This week, we’re teaming up with the Poverty Policy Podcast and the National Healthcare for the Homeless Council for a crossover episode! We discuss the Build Back Better bill and weigh its potential impact on individuals experiencing poverty and houselessness.

Show Notes

The National Health Care for the Homeless Council is a membership organization uniting thousands of health care professionals, people with lived experience of homelessness, and advocates working towards the goal of improving health care and ending homelessness. Their podcast, Poverty Policy Podcast, explores the connection between structural and social policy issues and poverty.

Our special guests are Courtney Pladsen, DNP, FNP-BC, RN: Director of Clinical and Quality Improvement, and Barbara DiPietro, PhD: Senior Director of Policy.

We discuss some of the common misconceptions about people experiencing homelessness and healthcare. Homelessness isn’t a moral failing, and people experiencing homelessness do make healthcare a priority despite the barriers to care they face.

To access healthcare, people experiencing homelessness have to overcome things like access to transportation, lack of cell phones or internet, making time while trying to get all your needs met, and of course lack of insurance. Poor and homeless people also face a lot of stigma and racism in the healthcare system.

Getting insurance coverage is a hassle under the best circumstances; for people experiencing homelessness it’s even more difficult, with barriers including eligibility requirements, complicated enrollment processes, steps that require an address, and automatic unenrollment because you missed a phone call or a letter.

NHCHC’s membership spans health care providers as well as people who have experienced homelessness. NCHCH engages the people they serve in the work they do because the people who are most affected by the problem should be at the forefront of the solution.

In Build Back Better news, the BBB bill has some potential to improve social determinants of health by including the Medicare Expansion measures we’ve been advocating for. The bill has now passed the House… AGAIN… under a greatly reduced budget, and the bill’s fate now rests with the Senate. The version of the bill that passed the House will add sorely-needed hearing coverage to Medicare, but will NOT include dental or vision coverage.

The most recent version of the BBB bill also includes drug price “compromise” provision that will do three things:

  • Limit the amount that Medicare patients will pay out of pocket for drug coverage.
  • Restrict how much drug manufacturers can increase prices each year.
  • Will allow Medicare to negotiate prices with drug manufacturers of some drugs– of no more than 10 (in 2025), 15 (in 2026 and 2027), and 20 (in 2028 and later years), excluding any and all new drugs. For reference, the FDA approved 53 new drugs last year alone.

In addition, the BBB bill will cap out-of-pocket insulin prices at $35/monthfor individuals who already have insurance. In other words, it’s a cap on co-pays, not on the actual cost of insulin.

Other Build Back Better pieces that will improve healthcare and impact social determinants of health:

  • In-home healthcare: The bill includes $150 billion for a Medicaid program that supports in-home healthcare
  • Expanding existing programs and institutionalizing COVID protections:
    • Expands eligibility for health insurance marketplace subsidies to include anyone for whom the cost of benchmark coverage would exceed 8.5% of their income. 
      • There are some other similar measures intended to decrease ACA premiums. Individuals living in states that refused to expand Medicaid will be eligible for $0 premiums. CBO estimates premiums will drop by average of $600/year for ACA enrolees.
    • Federal Childrens Health Insurance Program (CHIP) funding will be made permanent
    • Maternal health care – Medicaid and CHIP must provide 12 months of postpartum coverage (increase from current 60 day max); employers will be required to provide up to 4 weeks of paid maternity/paternity leave.
  • Affordable Housing
    • Includes funding for rental and downpayment assistance 
    • Includes funding to help address longstanding maintenance issues that public housing units have faced.
    • Biden administration claims that the framework would help contribute to the construction or improvement of 1 million affordable homes. However current estimated need is 3.8 million new homes. Does not address housing supply problem
  • Climate Change response: increases in natural disasters are driving increased homeless; measures to address climate change will also support the health of Americans by preventing homelessness. BBB includes funding for public transportation, access to clean water and upgrading public housing.

What it costs: Health care provisions will cost $330 billion over the next decade and come with compensating health savings of $325 billion according to the CBO.

What’s not in the BBB:

  • Dental coverage in Medicare (thanks to the dentists’ lobby, who fought tooth and nail – pun intenteded – to keep seniors from getting the dental care they desperately need)
  • Vision coverage in Medicare
  • Out of pocket caps for Medicare beneficieries

The BBB would do some good things, and we’re pleased to see some progress, but until we realize that the for-profit health insurance model is more expensive and terrible for our health, we’ll keep fighting for Medicare for All.

While deficit hawks complain about the cost of the BBB they don’t seem bothered by the cost of tax cuts to the rich and decades of war. In fact they are so opposed to the idea of equitable care, they spend a lot on making sure people don’t get care, in the form of things like work requirements and prior authorizations. The US spends more on care than any other country, and an easy place to reduce that cost would be getting rid of the administrative burdens for patients and providers and just providing care to everyone. But too many decision-makers are more motivated by preventing someone “undeserving” from receiving the same quality of care they get.

Like Healthcare-NOW, NHCHC balances working to improve the system we have now now (like improving Medicaid coverage, eligibility and services) with working toward the system we need (Medicare for All). There’s no reason our policy-makers shouldn’t be able to do both too.

Call to Action: to get BBB done, we need to get it past the obstructionist GOP in the Senate. Call your Senators, show up at events, make sure they get this done now. Especially if you have a Republican Senator.

Priority Senators for Medicare expansion: on the Finance Committee –  Senator Menendez (NJ), Senator Carper (DE), and Senator Cortez Masto (NV). Also Senators Sinema (AZ) and Manchin (WV). To find your U.S. Senators’ contact information visit

Background Links

Build Back Better Act Would Patch Holes in Health Coverage 

House Passes Build Back Better Act with Significant Health Care Provisions | AHA 

The House Just Passed Biden’s Build Back Better Bill. Here’s What’s In It 

Build Back Better’s Insulin Pricing Benefit Isn’t Enough 

Biden and Democrats’ Build Back Better plan in summary: Paid leave, climate funding, and other priorities 

NHCHC: Health Insurance Enrollment Brief

NHCHC: Build Back Better Bill Summary 

NHCHC: Letter to Congressional Leadership on BBB Health Provisions

NHCHC: Medicare For All & The HCH CommunityNHCHC: COVID-19 Response in Countries with Single-Payer & Implications for Impoverished Populations

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