Few people enjoy witnessing a dysfunctional Congress run up against one deadline after another just to avoid shutting down the government, but if you lead a community health center, you have little choice but to watch and hope.
Congress narrowly avoided a shutdown in September but at that time only extended funding until this Friday. At the same time, lawmakers failed to reauthorize multi-year funding for federally qualified health centers, granting them the same brief reprieve. They did the same again Wednesday by passing another stopgap bill that includes funding through Jan. 19 for community health centers and other healthcare programs.
For many healthcare organizations, delays or cuts in government funding present familiar problems. For the most part, they are able to cope. For community health centers, which can depend on federal grants for one-quarter or more of their budgets, the stakes are higher. And lately, the prospect of continued funding has become increasingly uncertain.
"It's agonizing," said Dr. Jackson Griggs, the CEO of Waco Family Medicine, which serves 62,000 people across a vast swathe of central Texas. "When we have these kinds of uncertainty in our budget, we have to consider what activities we're currently subsidizing and what service lines we're currently subsidizing within our organizations, and we have to consider cutting them."
Griggs believes his organization is large enough and its finances carefully managed enough that it could carry on without new funding for several months before encountering serious problems. But Congress has been so hard to predict that he has found himself following the follies on Capitol Hill with remarkable intensity for someone busy with a complicated day job. He's preparing for the worst because it makes him consider the sacrifices he might be forced to make.
"These are beautiful human beings, lives and health that we're so intimately tied to," Griggs said. "When I'm caring for individuals who I love, and have had long-standing relationships with, and think about them going without care, or others like them, and other Texas communities going without care because our elected officials are bickering, it's challenging. It's heart-rending."
This short-term uncertainty has longer-term consequences.
"There's a chilling effect on any kind of expansions, additions of services, hiring new staff," said Barbara DiPietro, senior director of policy at the National Health Care for the Homeless Council and its Baltimore location, which serves about 10,000 patients. "It's hard from just a business perspective to be able to plan."
And if funding is delayed, forcing community health centers to scale back and eliminate jobs, that would hamper their ability to attract employees when the money returns, said John Santistevan, president and CEO of Fort Lupton, Colorado-based Salud Family Health, which treats about 74,000 people in an area spanning the northern outskirts of Denver to the Nebraska and Wyoming borders. "The next time you go to recruit someone, they're going to be skeptical," he said.
The most recent round of political squabbling was resolved this week when Congress approved the short-term spending measure, known as a continuing resolution or CR. On Tuesday, the House passed a two-tiered continuing resolution that lasts until Jan. 19 and Feb. 2. Community health center funding is included in the former track. The Senate cleared the legislation Wednesday, preventing a government shutdown at the end of the week.
A brief shutdown wouldn't have had a dramatic financial impact on community health centers, but the threat intensifies uncertainty and casts more doubt on how Congress will proceed next year ahead of Election Day. For community health centers, which treat more than 31 million people, largely in underserved communities, it means months more of gnawing concern over the future.
"Yes, I actively worry about what Congress will do. It does not feel good, no," DiPietro said. "You want to have more confidence, but right now it is very hard to see what the next steps will be, and whether those next steps will be constructive ones for health centers."
An irony of the situation facing Griggs, DiPietro and their counterparts elsewhere is that the vast majority of lawmakers actually supports their goals.
The House Energy and Commerce Committee approved the Lower Costs, More Transparency Act of 2023 in September, which would boost mandatory funding for federally qualified health centers by about $400 million to $4.4 billion. A measure the Senate Health Education, Labor and Pensions Committee advanced in September, the Bipartisan Primary Care and Health Workforce Act of 2023, would provide $5.8 billion a year for three years on top of the discretionary funding Congress approves every year, which amounted to $1.7 billion in fiscal 2023.
While community health center advocates would like Congress to take inflation more into account when determining funding—especially rising labor costs—they at least are not in a position of having to convince one party or the other that they deserve to exist. Republican lawmakers with large rural districts back these clinics, as do Democrats representing low-income urban populations. Historically, support for community health center funding has run the political gamut from President George W. Bush to Sen. Bernie Sanders (I-Vt.).
This long track record of bipartisan alignment makes the current budget standoff even more confounding to community health center leaders. Failure to act would generate predictable, cascading consequences for federally qualified health centers.
Executives and employees at Salud Family Health are stressed enough by their work, and political uncertainty only makes matters worse, Santistevan said. "With my staff, there's a lot of nervousness out there," he said. "They're wondering will they have a job here in a few months. It puts a stress on the management because none of us want to have to lay off staff members that are very mission-oriented, just fantastic people."
Yet that is what they have to contemplate. Leaving aside the political morass, health centers face the same inflationary and staffing pressures as the rest of the healthcare industry.
The American Rescue Plan Act of 2021 alleviated significant pain through the height of the COVID-19 pandemic, but its funding ran dry in March. The ongoing Medicaid redeterminations process has resulted in millions losing benefits, which means community health centers lose Medicaid reimbursements when they treat those patients. By Santistevan's count, four federally qualified health centers in Colorado already have made cutbacks this year.
The plight of community health centers and other organizations that depend on federal funding gets lost in big-picture politics, and the end-of-year-rush to cram countless provisions into large legislative packages makes it harder for those affected to get attention and influence policymaking, Santistevan said.
"Can they get things together to even really seriously know the challenges we're facing out here?" Santistevan said.
Even though Congress avoided another funding cliff this week, community health centers still don't know what will happen after Jan. 19.
House Speaker Mike Johnson (R-La.) faces strenuous demands from within his own party to slash government spending and only got the short-term bill through because Democrats backed it. And the budget deal House Republicans struck with President Joe Biden earlier this year includes a provision that would cut federal spending 1% across the board if Congress hasn't approved fiscal 2024 appropriations for the entire government by Jan. 1.
"Given that some folks' agenda is to cut the budget anyway, they probably see that 1% as a down payment on further reductions," DiPetro said.