Congress talks a big game about supporting healthcare providers and workers, but the messy, unpredictable way lawmakers go about enacting budgets has some in the field feeling like Capitol Hill just makes things worse.
"It's infuriating," said Dr. Omer Deen, a Los Angeles County-based clinical nutrition specialist. "It's infuriating for so many reasons."
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Congress is supposed to complete the annual appropriations process before the end of the fiscal year every Sept. 30, after methodically moving a dozen separate bills through regular order in the House and Senate. But it almost never works that way. The last time Congress passed a year's worth of spending measures on time was 1996.
The performance for fiscal 2024 appropriations was even worse than usual: Congress resorted to four stopgap bills before finally passing all the annual spending measures in two tranches in March, nearly six months late.
While the medical community has grown accustomed to a certain level of frustration about this recurring phenomenon, the increasing frequency and scope of the chaos is exacting a meaningful toll across the sector, providers and their representatives said in interviews.
When Congress fails to operate predictably, that exacerbates the underlying financial problems already causing burnout and staffing shortages and limiting access to healthcare, particularly in rural and underserved urban areas, they said.
This year's epic delays came at an especially bad time. In addition to the normal annual discretionary spending Congress had on its plate, it was also supposed to renew longer-term funding for important healthcare programs such as federally qualified health centers, graduate medical education, the National Health Service Corps and opioid reduction initiatives.
On top of that was the now-annual guessing game over whether Congress would delay looming reductions in Medicaid disproportionate share hospital payments or restore the Medicare cuts to physician pay.
Those priorities, which are not politically controversial themselves, got caught up in broader power struggles and legislative tactics that meted out funding in short bursts. The result, from providers' perspective, is a Congress that heaps hardship and stress onto already beleaguered segments of the medical community.
Rural healthcare threatened
"It's pretty tough," said Dr. Steven Furr, a family medicine clinician in Jackson, Alabama, and president of the American Academy of Family Physicians.
Furr's practice employs a handful of nurses and doctors. The local hospital he works with has 32 beds, and already struggles under a 2% across-the-board cut Congress imposed on Medicare in 2013. This year, the Centers for Medicare and Medicaid Services also trimmed 3.4% from the conversion factor it uses to determine physician reimbursements, leading to a modest overall decrease that took effect Jan. 1. Congressional leaders had intended to restore some of that cut, but failed to do so until March 22, when they put back a little more than half.
"For January and February, we lost 3.4% of all of our Medicare charges. We're thankful that they did reverse some of that, but we're still losing 1.7%," Furr said. "When you add on to the fact that we've not had an inflationary update in 21 years, it's hard to keep a business — and a medical practice is a business, we have to survive and have to make a profit — it's hard to keep a business survivable."
Leaving budgets dangling has pile-on effects, Furr said. Graduate medical programs and the National Health Service Corps are significant boosters for community health centers and rural hospitals, for instance, he said.
"I went through the National Health Service Corps. I was funded, I went out and served in a rural area, and I've been here for 39 years. That's exactly what you want," Furr said. "But with that uncertainty of funding, it really is penalizing our rural and underserved and minority patients tremendously because it's cutting those services where they're most needed."
Congressional budget math
Lawmakers are aware of the challenges that rural and underserved urban communities face, and of the difficulty such areas have attracting providers and sustaining healthcare facilities. It is why Congress has created so many initiatives to help.
But because congressional budgeting uses 10-year cost windows, lawmakers often keep the estimates down by only authorizing programs for a couple of years or less, even when a program is essentially permanent. If they only authorize one year, they can spread out the spending over the entire 10-year period to make the books appear balanced.
Community health centers, for instance, are getting $1.9 billion in this year's belated discretionary budget. But 2023 was also the year that health centers' long-term mandatory funding ran out. If Congress functioned under regular order, that money would have renewed for three to five years, creating the certainty needed to plan ahead.
Instead, Congress kept community health centers alive with the four short-term measures before finally settling on $4.3 billion in mandatory funding. That runs out at the end of December — only three months longer than the annual allocation — thereby sacrificing the stability mandatory spending allotments are supposed to offer.
Republicans and Democrats broadly agree federally qualified health centers need longer-lasting funding. If they try to add more years at once, however, they run up the price that has to be balanced on the 10-year budget scorecard. That means tougher negotiations over how to get a larger pot of money. It was easier in this especially dysfunctional year to go for less.
Community health centers suffer
To community health centers, this meant that when their mandatory and discretionary budgets were expiring, they had no idea what would get through Congress. On Sept. 30, Congress passed a stopgap. It did so again Nov. 15, Jan. 18 and Feb. 29, before finally passing mandatory community health center funding March 8 and the discretionary portion March 22.
The people who run those clinics could not make solid commitments to employees, contractors or patients for half a year, and had to rely on goodwill and promises from lawmakers who repeatedly came to the brink of a government shutdown. And they are in the same position for next year's budget, again facing two legislative deadlines.
"It's kind of disgraceful, honestly, at this point, and irresponsible," said Amanda Pears Kelly, the CEO of Advocates for Community Health, which represents federally qualified health centers. "How do you operate a small business — or a large business for that matter, it doesn't really matter the size — when you don't have financial solvency for more than six to nine months at a time?"
The consequences for community health centers and many other healthcare providers that depend on federal payments can include shutting down. Small rural hospitals are especially at risk when payments are delayed or shrink unexpectedly.
"Some of them haven't coped with it and they've gone out of business," said Harold Miller, president and CEO of the Center for Healthcare Quality and Payment Reform, a research institution.
Indeed, nine small rural hospitals closed last year and more than 600 are at risk of shuttering, the Center for Healthcare Quality and Payment Reform estimates.
Physicians struggle
Independent physicians are in an analogous circumstance. They tend to be more focused on Medicare reimbursement reductions and whether Congress will reverse them, but the frustration is similar. Doctors burn out, retire or take jobs with hospitals where they can find stability, said Deen, who chairs the Physician Association of California board of directors.
"There's a looming cut coming? Well, how much is it this time? And when does it take effect? And what do I have to do to compensate?" Deen said. "I've already packed my schedule full of patients."
Pears Kelly had a message for lawmakers who congratulated themselves for managing to keep government funded this year.
"Four or five stopgaps is like, okay, well, thank you so much. We're very grateful that we didn't go over the cliff. And that's something," Pears Kelly said. "But it's also just like, what are you doing?"
It's a question providers and advocates will likely be posing anew in six months. Not only does Congress have to appropriate money for fiscal 2025, but because of the tight time frames, community health centers still need new mandatory funding by the end of the calendar year, and those other programs need to be reauthorized. This being an election year further complicates matters.
To make it more daunting, Congress is also supposed to address programs that boost payments for Medicare-dependent hospitals and low-volume hospitals. Here, too, there are no guarantees.
"There's never any assurance there's going to be reauthorizing," Miller said. "Every year or two or three or whatever the length of time for the reauthorization is, there's a dance in Congress to say, 'Are we willing to do that? Is there enough money to pay for that?'"
Lately, it seems as though the dance may never end.
