What's missing from Biden's infrastructure bill

A larger commitment to public health, rural hospitals and fighting the social causes of disease

There’s much to praise in the Biden administration’s proposed infrastructure bill – dubbed the American Jobs Plan. But it could use some fine tuning when it comes to public health.

Its boldest health initiative is its proposed $400 billion investment in the nation’s underfunded system for providing community and home-based care for the elderly and people with disabilities. The plan pledges to structure that investment in ways that allow providers to give workers in the sector, whose average pay is just $12 an hour, long overdue raises, better benefits and protects their right to join unions.

On the health facility side, the plan earmarks $18 billion to modernize Veterans Administration hospitals and clinics, most of which were built in the first two decades after WWII and now have a median age of 58 years. The median age of non-government hospitals is roughly 11 years. Surveys and studies consistently show veterans over 65 who rely on the VA for healthcare do better health-wise and financially than those who rely on Medicare to access private facilities.

On the public health side, the plan calls on Congress to invest $45 billion to eliminate all lead pipes and service lines in the country, which continue to leach their intelligence-sapping ions into the drinking water of as many as 10 million homes across America – many of them in older cities. The bill invests another $66 billion in improving drinking water and wastewater treatment facilities with special attention given to rural areas and smaller communities.

The plan also calls for investing $30 billion in stockpiling personal protective equipment and other supplies for pandemic preparedness and biosecurity, and for investing in technologies for rapidly developing and manufacturing vaccines and drugs. This is on top of the $10 billion earmarked for such efforts in the $1.9 trillion COVID-19 relief bill (the American Rescue Plan), which was just signed into law.

What’s missing

Unfortunately, the infrastructure outline released by the White House is silent on a number of key health-related measures that ought to be high on its agenda. The VA isn’t the only institutions badly in need of new investment. The bill’s architects should consider including the following provisions in the final bill.

About 120 rural hospitals have closed in the past decade. Many of the remaining 1,844 are teetering on the brink of bankruptcy since they were built as full-service hospitals in areas that can no longer support such facilities, especially if they are located in economically distressed regions.

The federal government should invest $20-$30 billion over the next decade into turning these hospitals into multi-purpose community health centers that, while preserving some critical hospital functions, also serve as community health clinics. They could provide the services that are most needed in any particular community but are currently missing, such as primary care, maternal and reproductive health, behavioral health, substance abuse treatment and specialized elder care. The government should also help pay for appropriate staffing at these reconfigured facilities.

The Biden plan calls for investing $100 billion in upgrading the nation’s internet infrastructure with a heavy emphasis on bringing broadband to every corner of the nation. But it is silent on maximizing the nearly $40 billion the nation has already invested in health information technology infrastructure.

It could start on that project by investing more money in the data collection and coordination systems run by the Centers for Disease Control and Prevention and the nation’s state and local public health departments. During the pandemic, the cacophony of conflicting reports coming from public and private data compilers on cases, deaths, hospitalizations has not served the public well.

Create a national All Payer Claims Database

The new infrastructure legislation should also create a nationally-run all-payer claims database (APCD), which would empower researchers and policymakers by giving them the latest data on how much the U.S. spends annually on each medical service and where; who bears those costs and their prices; and how changes in health system organization and ownership affects costs. The rationale is laid out in this recent posting from the Milbank Memorial Fund.

The No Surprises Act, which banned charging patients for the balance of bills not paid by insurers starting next year, allocated $125 million to states that have already begun setting up state-based APCDs. But a national system, which state officials and researchers could easily use, would be a far more elegant solution with the added benefit of simplifying compliance by insurers and government payers, most of whom operate across state lines.

Finally, the infrastructure bill should include a multi-year commitment to funding the grass roots public health corps that was kickstarted by the 2020 CURES Act and the American Rescue Plan, which earmarked $7.6 billion for states to hire workers to detect, diagnose and trace the spread of infections. That is enough to assure them of a few additional years of funding.

Long-term commitment needed

But what state and local health departments need most is a long-term commitment. Without it, many states will be reluctant to hire qualified workers capable of transforming themselves into a grass roots army of community health workers after the pandemic subsides.

“A lot of people will see this money as one-time and be very hesitant to make outlays that they think will obligate them in the out years,” said Dr. Georges Benjamin, the executive director of the American Public Health Association.

Once the COVID-19 pandemic is in the rearview mirror, this permanent community health workforce could switch roles and begin reaching out to individuals and families where poverty, inadequate housing, poor nutrition and social stressors are triggering disease. These outreach workers could then coordinate a comprehensive social service response by the appropriate government and private sector agencies.

Moreover, when the next pandemic pathogen reaches our shores – as it surely will – we will already have in place the track-and-trace workforce needed to keep it contained. That’s why long-term funding for that workforce should be in the infrastructure bill, too.