When Congress went on its winter break before Christmas, it left much of its healthcare business—along with most of it other responsibilities for 2023—unfinished, and now faces an intense scramble to get it all done in just weeks.
At the top of the healthcare list is funding programs that depend on annual appropriations for the Health and Human Services Department, which like the rest of the government is running on the latest stopgap funding bill enacted since fiscal 2023 ended Sept. 30. In addition, numerous health-related programs and initiatives expired and are also operating on a short-term lifeline.
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Asked before the break about the enormous amount of legislating a deeply divided Congress must do in a short time when it comes back in 2024, Senate Minority Leader Mitch McConnell (R-Ky.) acknowledged it would be daunting. "It's not going to be easy, and we've got plenty of work to do in January," he said.
That may be an understatement. The Senate is scheduled to return Jan. 8, leaving just nine days in session before funding expires for the Food and Drug Administration, the Community Health Center Fund, the Teaching Health Center Graduate Medical Education Program and the National Health Services Corps, as well as veterans, transportation, housing and energy programs. The House doesn't come back until Jan. 9, leaving itself just eight days.
Hospitals also face the start of $16 billion in cuts to Medicaid disproportionate share payments over the next two years.
“January is not going to be an enjoyable month. Let me just say that," said Sen. Susan Collins (Maine), the lead Republican negotiator in the budget talks. "So, Happy New Year to all of you.”
Then, on Feb. 2, funding for the rest of the government expires, including for HHS. The House is only scheduled to be in for four days between the two deadlines, while the Senate is in for five days.
Still, lawmakers expressed optimism that they would be able to get the work done.
Senate Health, Education, Labor and Pensions Committee Chair Bernie Sanders (I-Vt.) said he was particularly concerned about the deadline to fund and reauthorize community health centers. His committee passed a bill to do that and boost federally qualified health center funding to $5.8 billion a year, but it has not reached the floor.
"Given the enormous crisis of the primary healthcare system, which is virtually collapsing, we are working very hard to get something in the end-of-the-year bill," Sanders said, referring to the funding that needs to pass by Jan. 19. "I'm cautiously optimistic."
Sen. Mike Crapo (Idaho), the top Republican on the Finance Committee, which oversees Medicare and Medicaid, was similarly hopeful, but pointed to numerous complications Congress will have to overcome, particularly in the Senate, where any single member is able to stall legislation.
The Finance Committee passed bipartisan legislation that focuses on pharmacy benefit managers and also includes delays to those DSH cuts and money to spare doctors from at least part of a looming 3.4% cut to Medicare reimbursements.
"The question is whether that itself can be a vehicle or whether another vehicle is available for us to move it. And we're looking for those vehicles now," Crapo said. "The problem with any legislation that moves is that it will become the target for amendments that take eight to 10 days on the floor."
"There will be momentum" to pass the expiring programs early in 2024, Crapo said.
A major complicating factor, though, is budget politics in the House. Speaker Mike Johnson (R-La.) was able to pass the temporary government funding bill in November only because Democrats supported it, while 93 conservative Republicans voted in opposition. Some of those GOP members have declared they will not support a new fiscal 2024 funding bill unless it includes cuts that go deeper than what Republicans and President Joe Biden negotiated in the spring, when Rep. Kevin McCarthy (R-Calif.) was Speaker.
Johnson has floated the idea of simply setting 2024 funding at 2023 levels in what has been called a "date change" continuing resolution, or CR. Doing so would leave out expiring programs, and for domestic spending would amount to a 9% cut from the levels in the previous budget agreement. The Democratic-led Senate is adamantly opposed to the idea.
Normally, the full-year spending bill would be a framework onto which other pressing matters could be attached, such as the community health center reauthorization. But as Crapo suggested, that might not be the only option for healthcare legislating since both the House and Senate advanced bills to address most of the programs that are running out. The House has gone furthest, passing the Lower Costs More Transparency Act of 2023, which delays DSH cuts and funds community health centers and other programs, even though it primarily targets PBM business practices.
Senate Majority Leader Chuck Schumer (D-N.Y.) could pick that bill or any of the measures the Finance and HELP committees passed to use as a vehicle, Crapo said.
"Whether it is that piece of legislation or some other piece of legislation, whether this legislation [the Senate's PBM bill] becomes a vehicle, with Sen. Schumer putting it on the floor, I believe that there will be an opportunity to move it," Crapo said.
Congress will certainly miss at least one deadline. The 3.4% cut to physician payments the Centers for Medicare and Medicaid Services announced in November kicks in on Jan. 1, and Congress has not addressed that cut in stopgap bills, leaving doctors disappointed and hoping for future redress.
"In any given budget cycle, they're just maybe looking to save a buck here or there, but it honestly doesn't make sense to me," said Dr. David Eagle, a Patchogue, New York-based hematologist-oncologist and vice president of the recently created American Independent Medical Practice Association.
The Finance Committee's PBM bill would roll the Medicare physician pay cut back to a bit to 2.15%. Eagle said physicians are still hoping Congress can do better, and make it retroactive. He's likely going to have to wait until at least Jan. 19 to find out.
Here are some of the key expired or expiring programs Congress may address:
- Reauthorizing and funding community health centers
- Cancelling or delaying Medicaid disproportionate share payment cuts
- Reauthorizing and funding the National Health Service Corps
- Restoring some or all of Medicare physician reimbursement cuts
- Reauthorizing and funding Teaching Health Centers
- Reauthorizing the Pandemic All-Hazards Preparedness Act
- Reauthorizing the Support for Patients and Communities Reauthorization Act
- Reauthorizing the President’s Emergency Plan for AIDS Relief
- Extend adjustments to the work geographic index in Medicare that boosts pay for rural doctors
- Extend funding for the Special Diabetes Program for Type 1 Diabetes
