With all eyes on a possible government shutdown at the end of the month, Congress is also on the brink of plunging large swathes of the healthcare system into limbo.
Numerous pieces of legislation meant to fund or reauthorize a slew of major programs affecting hospitals, federally qualified health centers, medical education programs, opioid and HIV/AIDS treatment programs and even pandemic preparedness expire on Sept. 30.
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While bipartisan majorities believe most of that legislation needs to pass, lawmakers and outside observers said the best case scenario as of now is a stopgap measure—and that remains a long shot, with odds rising that programs could be left hanging into December, or even next year.
"We know that traditionally these issues have come down to the last minute and the like, and we're doing our best to try to avoid that," Senate Finance Committee Chair Ron Wyden (D-Ore.) said. But he offered no predictions of when lingering legislation would pass. "This is just starting. Obviously, this is a challenging time," he said.
"I'm frustrated, and I'm very aware that these reauthorizations are running out," said Sen. Dr. Bill Cassidy (R-La.), ranking member of the Health, Education, Labor and Pensions Committee. "We never had a lot of time. We've got like almost no time left now."
The programs at stake are worth billions of dollars and affect millions of people, both in the U.S. and abroad. Here are some of the key initiatives on the congressional agenda:
- The Medicaid Disproportionate Share Hospital program, which provides funding to hospitals that treat large numbers of people who can't pay for care, faces an $8 billion cut this year and each of the next three years.
- Legislation to reauthorize and fund community health centers, the National Health Service Corps and teaching hospitals that run graduate medical education programs, which all need to be renewed.
- The Pandemic and All-Hazards Preparedness Act of 2006, which aims to help the U.S. detect and counter infectious disease outbreaks such as COVID-19 or biological attacks.
- The SUPPORT for Patients and Communities Act of 2018, which funds treatment and education programs to combat the opioid epidemic.
- The President’s Emergency Plan for AIDS Relief, or PEPFAR, which debuted under President George W. Bush and is credited with saving 25 million lives.
Cassidy is hardly the only frustrated lawmaker. Even though most of these programs enjoy strong bipartisan support, unrelated issues are complicating prospects for collaborative action.
The most significant snags are emerging from the House, where many of the more conservative Republicans have signaled they will not pass government funding—which also expires on Sept. 30—even though many voted for the spending levels that House Speaker Kevin McCarthy (R-Calif.) agreed to last spring when Congress raised the debt limit. Then there's McCarthy's announcement Tuesday that House is launching an impeachment investigation against President Joe Biden.
"If these crazy House Republicans weren't fighting with themselves over who cares about impeachment more, and instead were focused on keeping health clinics open, maybe we would be in less of a crisis," said Sen. Chris Murphy (D-Conn.), who sits on both the Appropriations and HELP committees.
The House's focus on matters outside of legislating threatens to cause harm in their own communities if the lower chamber doesn't act on key programs, Murphy said. "My guess is that more than half of House Republicans have no idea what DSH is," he said. "I don't even think it's on their radar screen."
In this and other ways, healthcare is hostage to larger political forces and the partisan split between the GOP-led House and majority-Democratic Senate, which contribute to the 11th-hour crush to keep the government from shutting down and to maintain continuity for federal programs.
Cassidy pointed to failures in the HELP Committee, where Chair Sen. Bernie Sanders (D-Vt.) has advanced labor measures, which Cassidy said will never pass Congress, at the expense of moving the popular community health centers reauthorization.
"We've got limited legislative days, and in July we didn't use it on committee hearings addressing this issue," Cassidy said. "We had hearings scheduled, and they're canceled at the last minute."
Congress commonly attaches uncontroversial measures to larger bills considered "must pass," such as spending legislation, either because lawmakers didn't take time to consider them sooner or to entice lawmakers to support bills that might include provisions they oppose.
This year, however, evident rancor and a sudden opposition to long-running bipartisan initiatives such as PEPFAR are disturbing even optimistic observers.
"The tenor of this time is very different," said Shana Christrup, director of public health at the Bipartisan Policy Center's health program. In the past, looming spending and reauthorization deadlines tended to force Congress' hand even when it appeared politics would prevent action, she said.
But this year, even the PEPFAR reauthorization has attracted adamant opposition from outside groups raising new objections to abortion, which PEPFAR does not finance. Throw in a possible presidential impeachment and many House Republicans trying to renege on the debt and spending deal, and it becomes impossible to foresee how standoffs will get resolved or if some key program will simply drop off the table during the food fight, Christrup said.
"There's just a different environment, and when that happens, when it gets that charged, it means it's less predictable," Christrup said. "We on the outside looking in. You know—get your popcorn ready and figure out just how many times you're going to deal with things you just didn't expect, or the processes you didn't think were going to happen before."
While lawmakers did not offer specifics or ironclad promises of success, many did profess confidence. "I'm just going to be working with all concerned. We obviously will be looking for a way to find some common ground," Wyden said.
Wyden said he had a "good meeting" with Sanders on Monday discussing how to proceed from their side. "He and I feel very strongly about these programs ... and ensuring that vulnerable people don't get the short end of the stick, and the billionaires just keep winning out," he said.
In the meantime hospitals, teaching centers, opioid treatment programs, community clinics and others will have wait while Congress fights it out.
Cassidy predicted lawmakers would advance a short-term measure to keep programs such as community health centers running. "But that's exactly what I was hoping to avoid, the uncertainty associated with it. Instead, the way the process has worked, unfortunately, I think there will be uncertainty," he said.
