Inside the Beltway August 2021

Viewing the Bipartisan Infrastructure Bill as a Public Health Investment

Contributed by Health Policy Committee member Kristin Gigli, PhD, RN, CPNP-AC, CCRN

After months of negotiation, last week, the Senate introduced a bipartisan infrastructure bill, the Infrastructure Investment and Jobs Act.1 While this bill is a mechanism to build new roads and bridges across the country it should also be considered a significant investment in public health and the health of children in America. Social determinants of health (SDOH) are “the conditions in which people are born, grow, live, work and age” and 10 percent of health outcomes are attributed to the physical environment including air and water quality, housing and transit.2,3 There are three areas of proposed infrastructure investment that address the physical environment which contribute to the SODH that pediatric-focused advanced practice registered nurses (APRN) can advocate for as this bill moves through the legislative process. These areas focus on clean water, public transit with increased reliance on low emission vehicles and broadband access.

The Flint Michigan water crisis may be the most infamous incident of lead exposure from water in the United States.4 However, the Environmental Protection Agency reports 6 to 10 million homes, schools and businesses across the country have lead pipes.5 Exposure to lead increases risks of adverse health outcomes in children, including slowed growth and development, learning and behavior problems, and hearing and speech delays. The new legislation proposes $55 billion to replace lead pipes across the country, including on tribal lands. This is an important commitment to address the invisible problem of lead exposure from our water.

Increased use of public transit is associated with improved air quality, greater levels of physical activity and health equity.3 In the United States, transportation is the single largest source of greenhouse gas emissions.6 A shift towards public transit and zero emission vehicles for use in public transit has the potential to mitigate the effects of our current driving and transit patterns. The infrastructure bill proposes $39.2 billion dollars of spending to improve public transit and $15 billion on zero emission vehicles for public transit along with investments in electric vehicles and building associated infrastructure. Making public transit more accessible in high-pollution corridors, home to 45 million Americans, and moving towards electric vehicles can improve health outcomes.7

We learned during the COVID-19 pandemic the importance of broadband internet access to work, attend school, maintain social connections and receive health care. Lack of broadband access is not just in poor and rural communities. Estimates suggest more than 30 million households lack access to broadband access.8 A recent survey of pediatric-focused APRN faculty found one third of faculty and more than half of the students had inadequate internet access to support their ongoing course work.9  Internet access is essential in these times and viewing it as a public good supports the health and well-being of the country. As such, the legislation allots $65 billion to build the broadband infrastructure in the United States.

With nearly $175 billion of spending proposed to address the physical environment SDOH in the Infrastructure Investment and Jobs Act, I hope you will consider this more than a roads and bridges bill. Consider contacting your representatives in Washington, D. C., to ask them to support the Infrastructure Investment and Jobs Act (also known as “Infrastructure Investment & Jobs Act” (H.R. 3684)), an investment in the health and future of America’s children.

References
1. Morgan, D. & Brice, M. (2021, August 3). What’s in the U.S. Senate bipartisan $1 trillion infrastructure bill? Reuters. https://www.reuters.com/world/us/whats-us-senates-bipartisan-1-trillion-infrastructure-bill-2021-08-03/
2. World Health Organization. (2020). Social determinates of health. https://www.who.int/gender-equity-rights/understanding/sdh-definition/en/
3. “Public transportation in the US: A driver of health and equity,” Health Affairs Health Policy Brief, July 29, 2021. DOI: 10.1377/ hpb20210630.810356
4. Hanna-Attisha, M., LaChance, J., Sadler, R. C., & Champney Schnepp, A. (2016). Elevated blood lead levels in children associated with the Flint drinking water crisis: A spatial analysis of risk and public health response. American Journal of Public Health, 106(2), 283–290.
5. Environmental Protection Agency. (2020, September 24). Lead Service Line Replacement. https://www.epa.gov/ground-water-and-drinking-water/lead-service-line-replacement
6. Environmental Protection Agency. (2021, July 27). Sources of Greenhouse Gas Emissions. https://www.epa.gov/ghgemissions/sources-greenhouse-gas-emissions
7. Environmental Protection Agency. (2014, August). Near Roadway Air Pollution and Health: Frequently Asked Questions. https://www.epa.gov/sites/default/files/2015-11/documents/420f14044_0.pdf
8. “Podcast: The Bipartisan Infrastructure Bill – What’s in it for Health Care, ” Health Affairs Podcast, August 6, 2021. DOI: 10.1377/hp20210805.209202
9. Peck, J. L., & Sonney, J. (2021). Exhausted and burned out: COVID-19 emerging impacts threaten the health of the pediatric advanced practice registered nursing workforce. Journal of Pediatric Health35(4), 414–424. https://doi.org/10.1016/j.pedhc.2021.04.012


 

House Prepares to Vote on Infrastructure, Budget Framework

Members of the House of Representatives will interrupt their month-long August recess to return to Capitol Hill next week for critical votes on President Biden’s key policy priorities including a bipartisan $1.2 trillion infrastructure enhancement bill and a fiscal 2022 budget resolution that provides the framework for a $3.5 trillion package of health, education, and social welfare initiatives. House leaders called lawmakers back to Washington after the Senate passed the “Infrastructure Investment & Jobs Act” (H.R. 3684) August 10, followed by the resolution (S. Con. Res. 14) providing instructions for drafting of a budget reconciliation bill this fall on Aug. 11.

Senate passage of the infrastructure bill, which includes $550 billion in new funding for roads and bridges, public transportation, water systems, and broadband access, came after months of negotiations and days of slow-moving Senate debate. Nineteen Republicans including Minority Leader Mitch McConnell joined with all 50 senators in the Democrats caucus to support the bill, which still faces hurdles in the House. Speaker Nancy Pelosi is under pressure from progressives who want their priorities addressed in the bill, while moderate Democrats are pushing for quick action on the measure.


Budget Outlines Sweeping Health Care Expansions

The fiscal 2022 budget resolution (S. Con. Res. 14) passed by the Senate Aug. 11 on a 50 to 49 vote seeks to encompass health care priorities promised by President Biden and congressional Democrats, although the plan’s $3.5 trillion in funding might not be enough to achieve them all. However, Democratic lawmakers and staff have acknowledged that they will likely be forced to scale back their plans and make some programs temporary, while dropping other efforts altogether to fit within the budget resolution’s allocations.

Materials released by Senate Budget Committee Democrats outline plans for a fall reconciliation bill to include provisions that expand Medicare to include dental, vision and hearing benefits, close the health care coverage gap in states that haven’t expanded Medicaid programs, extend enhanced premium subsidies for Affordable Care Act marketplace policies, make home and community-based care available to more people, and lowers prescription drug prices. The outline calls for the Health, Education, Labor, and Pensions Committee to address investments in primary care including the National Health Service Corps and the Nurse Corps, as well as workforce development, health equity, and pandemic preparedness.

The House will consider the Senate-passed resolution the week of Aug. 23. Committee staffers will be drafting specifics on various policies while lawmakers are back home during the August congressional recess, facing a Sept. 15 deadline for committees to submit their legislative proposals to be combined into the reconciliation package.


House Provides $50 Million Increase for Nursing Education Programs

House Democrats passed a $617 billion seven-bill “minibus” fiscal 2022 appropriations bill (H.R. 4502) July 29 on a mostly party-line vote of  219 to 208 vote, including an increase of $50 million for nursing workforce programs under Title VIII of the Public Health Service Act to a total of $314.47 million, along with a $25.8 million increase for the National Institute of Nursing Research to a total of $200.78 million.

The bill also eliminates a ban on federal funding for abortions – a promise championed by Appropriations Committee Chair Rosa DeLauro (D-CT) that almost certainly won’t survive in the Senate. The bill also includes a total of $120 billion for the Department of Health and Human Services, with $10.6 billion allocated to the Centers for Disease Control and Prevention. Earmarks in the bill would direct billions of dollars toward education and training programs, higher education, medical facilities and more. The “minibus” would also fund the departments of Energy, Interior, Veterans Affairs, Treasury, and Housing and Urban Development, as well as the EPA, military construction projects, the FDA, water infrastructure and the IRS.

Senate appropriators have started to advance their fiscal 2022 spending bills but haven’t yet released their version of a bill to fund HHS programs. And Congress is no closer to a bipartisan funding deal that would stave off a government shutdown in six weeks, meaning that lawmakers will have to pass a stopgap measure in September to extend current agency funding until later this year to give them more time to reach agreement on fiscal 2022 appropriations.


Public Health Expulsion of Migrants Extended

The Biden administration announced Aug. 2 that it would leave in place for now a controversial public health rule that allows the government to turn away hundreds of thousands of migrants at the southern border as their numbers increase amid the resurging COVID-19 pandemic. The decision by the Centers for Disease Control and Prevention was a shift in the administration’s position after working on plans to begin lifting the rule, known as Title 42, this summer, more than a year after it was imposed by the previous administration. The CDC said allowing noncitizens to come over the border from either Mexico or Canada “creates a serious danger” of further spread of the coronavirus leading to even more overcrowded and unsafe conditions in border facilities where more migrants and border patrol officers have been testing positive for the coronavirus.

The American Civil Liberties Union responded by saying it would move ahead with a lawsuit seeking to force the administration to lift the public health order for migrant families after months of negotiations with the “ultimate goal” of ending the policy, declaring “It is now clear that there is no immediate plan to do that.”


In Other News

Administration Proposes Clean Energy Rules

President Biden unveiled a far-reaching, multipronged plan Aug. 5 to make U.S. cars and light trucks more fuel-efficient and to begin a shift to electric vehicles over the coming decade – the administration’s most consequential pushes so far to combat climate change and tackle greenhouse gas emissions. The President signed an executive order calling for half of new passenger car sales to be of electric vehicles powered by batteries and fuel cells or plug-in electric hybrids by the end of the decade. In addition, the Environmental Protection Agency and the Transportation Department proposed new requirements on greenhouse gas emissions and fuel efficiency for cars, SUVs and pickup trucks through model year 2026.

The new policies were released days before a United Nations committee published a major report Aug. 9 concluding that countries have put off curtailing their fossil-fuel emissions for so long that they can no longer stop global warming from intensifying over the next 30 years, though there is still a narrow window to prevent the bleakest future. Humans have already heated the planet by roughly 2 degrees Fahrenheit since the 19th century, largely by burning coal, oil and gas for energy, the Intergovernmental Panel on Climate Change said. Even if nations started sharply cutting emissions today, total global warming is likely to rise around 1.5 degrees Celsius within the next two decades, a hotter future that is now essentially locked in, causing more frequent life-threatening heat waves, severe droughts, extinction of animal and plant species, and loss of coral reefs.

Administration Extends Moratorium on Student Loan Payments

The Education Department announced August 6 that it would continue a moratorium on federal student loan payments through Jan. 31, extending emergency relief for millions of borrowers that had been set to expire next month. The department said that this would be the “final extension” of the pause, which the previous administration instituted in March 2020 at the outset of the coronavirus pandemic, and that the additional time would allow the agency to transition borrowers back into repayment and reduce the risk of default and delinquency. More than 40 million borrowers have federally held loans, and during the moratorium, they have been interest-free and not subject to repayment or penalties for nonpayment.

Democrats in Congress pressed the Biden administration over the summer to continue the student loan pause, saying that the fast-approaching expiration was ill timed considering that millions were still suffering financial hardship from the pandemic. Many lawmakers are also calling on the administration to take executive action to cancel up to $50,000 a person in student loan debt.

Biden Administration Revokes Medicaid Work Rules in Three States

Federal health officials rolled back work requirements for Medicaid enrollment in Ohio, South Carolina, and Utah Aug. 10, continuing to reserve one of the Trump administration’s central policies to reduce federal spending on the program. Centers for Medicare and Medicaid Services (CMS) Administrator Chiquita Brooks-LaSure informed state health officials that the administration was withdrawing federal approval of policies mandating that Medicaid enrollees work or volunteer in order to get coverage, concluding that the requirements “are not likely to promote the objectives of the Medicaid statute.”

Separately, CMS also told Tennessee health officials Aug. 10 that it would seek public comments on the state’s plan to implement its version of a Medicaid block grant, though the agency said doing so won’t delay implementing the controversial waiver that advocates are fighting in court. In a letter to the state, federal officials said those suing the administration agreed to put the lawsuit on hold if the agency opened a new, monthlong public comment period on the waiver, which CMS doesn’t believe constitutes an actual block grant. A group of 13 Medicaid beneficiaries and health law groups filed suit in April to overturn the plan, arguing it allows the state to restrict coverage of prescription drugs and permits other “troublesome” policies.

FDA Cracking Down on ENDS Manufacturers

From January through July 2021, FDA has issued a total of 140 warning letters to firms selling or distributing more than 16,800,000 unauthorized electronic nicotine delivery systems (ENDS) that did not submit premarket applications by the Sept. 9, 2020 deadline. On FDA’s Warning Letters page, you can find these warning letters by entering “Center for Tobacco Products” in the “Issuing Office” box in the “Filter by” section of the search tool.

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