Infighting among House Republicans leading to a government shutdown
House Republicans have for the last two weeks tried and failed to move forward any legislation related to funding the government, and after a historic failure to even start debating the typically popular defense bill on Thursday, Members left town for the weekend. The inability to even start debate on bills has led Speaker McCarthy to scrap any discussion of stopgap funding bills, dramatically increasing the likelihood of a government shutdown on October 1. Far-right hardliners in his caucus have demanded ever steeper cuts to get their support, after House Appropriators already announced that they were funding bills far below the deal they made for lifting the debt limit this summer. In a sign of pessimism that House Republicans will be able to pass funding bills in time, the Biden Administration on September 22 formally notified government agencies to prepare for the stoppage.
A government shutdown is a lapse in funding. Current discretionary funding goes until September 30, which is the last day of the fiscal year. If Congress does not pass appropriations, either as appropriations bills or a continuing resolution, by that date, the programs that are covered by appropriations will shut down immediately. Federal law prevents all but a small and specifically designated group of programs and officials from performing any actions without appropriations. The consequences of a government shutdown are complex and dependent on the fiscal situation at hand. Most programs will be fully halted without appropriations while others will continue as normal, with many somewhere in between. Programs with mandatory spending, like Medicare and Medicaid will not be affected, but patients in NIH studies may not be able to access treatment for example. Some programs have contingency funds that they are able to draw on until they are exhausted, which means that as a shutdown goes on, more programs shutdown and the pain increases.
HELP Senators move bipartisan legislation on primary care
HELP Committee Chairman Bernie Sanders (I-VT) and Sen. Roger Marshall (R-KS) reached a deal on legislation that would invest $26 billion in funding to expand primary care access and health care workforce shortages. The compromise bill would provide $5.8 billion a year in mandatory funding for community health centers, including funding earmarked for expanding hours of access. It also increases funding for workforce development pipelines for doctors, nurses, dentists, mental health providers, and other health care professionals. The Senate HELP Committee voted it out of Committee on a 14-7 vote with three Republicans joining all Democrats.
CMS announces transformative model to redesign health care delivery
The Centers for Medicare & Medicaid Services (CMS) unveiled a transformative step to test a state’s ability to improve the overall health care management of its state population. The States Advancing All-Payer Health Equity Approaches and Development Model (“States Advancing AHEAD” or “AHEAD Model”) aims to better address chronic disease, behavioral health, and other medical conditions. Under the AHEAD Model, participating states will be better equipped to promote health equity, increase access to primary care services, set health care expenditures on a more sustainable trajectory, and lower health care costs for patients. States participating in AHEAD will be accountable for quality and population health outcomes, while reducing all-payer avoidable health care spending to spur statewide and regional health care transformation.
Nationwide kindergarten vaccination exemptions rates have doubled in the last decade
The nationwide median rate of kindergartners with vaccine exemptions nearly doubled between the school years ending in 2012 and 2022, per CDC estimates. While COVID-19 vaccination is not required for young children attending public school anywhere in the U.S., it appears that concerns over that shot may be fueling broader vaccine skepticism among a relatively small but growing number of parents — though that trend certainly existed before the pandemic. While misinformation during the COVID-19 pandemic eroded trust in science and medicine, public health officials worry that the 2024 election may make it worse as multiple presidential candidates continue to demonize vaccines.
NIH established Maternal Health Research Centers of Excellence
The National Institutes of Health has awarded $24 million in first-year funding to establish Maternal Health Research Centers of Excellence. Part of NIH’s Implementing a Maternal Health and Pregnancy Outcomes Vision for Everyone (IMPROVE) initiative, the centers will develop and evaluate innovative approaches to reduce pregnancy-related complications and deaths and promote maternal health equity. The grants are expected to last seven years and total an estimated $168 million, pending the availability of funds.
Congress has growing interest in doula care
As the health system for pregnant patients face increasing strains, some patients and programs are investing more in doulas to support women, especially those of color, in having safer births. Many insurers do not cover doulas, making the out of pocket cost of the care out of the reach of many who would benefit the most. On September 20, Rep. Robin Kelly (D-Ill.) introduced legislation calling for $50 million in federal funding to build up the doula workforce through grants to schools and training programs.
New data illustrates the challenges immigrant populations have in accessing health care
The Survey of Immigrants, a partnership between KFF and The Los Angeles Times, takes an in-depth look at the experiences of immigrants, a diverse group that makes up 16% of the U.S. adult population. The 2023 released report find that while most immigrants are healthy and employed, many face challenges to accessing and using health care in the U.S. due to higher uninsured rates, affordability challenges, linguistic and cultural barriers, and immigration-related fears, which has negative implications for their health and financial security. These challenges are more pronounced for some immigrants, including those who are likely undocumented, who have lower incomes, who are Black and Hispanic, and who have limited English proficiency (LEP). The survey data also show the difficulties immigrants face in obtaining health coverage and underscore the major role that coverage plays in access to health care.
Bipartisan frustration in implementation of No Surprises Act
Lawmakers are expressing bipartisan frustration over the implementation of the No Surprises Act, a law meant to protect patients from unexpected medical bills after receiving care from out-of-network providers at in-network facilities. In a House Ways and Means Committee hearing Representatives grilled witnesses including payers, providers and arbitration services representatives about the implementation of the NSA, which went into effect in January 2022. Rep. Richard Neal, D-Mass., ranking minority member and the law’s author, called the implementation a “disappointment.” An overloaded and contentious dispute resolution process has strained relations between providers and payers and impeded access to quality care for other patients, particularly those in rural areas, according to testimony. Chairman Jason Smith, R-Mo., said implementation had strayed far from congressional intent and had “made the very problem it intended to fix worse.”
What I am reading…
The New York Times wrote about the interesting phenomenon that should be forcing a fundamental rethink in how we perceive the federal budget, which is that per capita Medicare spending has been nearly level for the last decade after a history of growth. Spending on Medicare has continued to grow as more Baby Boomers age into the program, but the cost for each patient has barely changed. As researchers seek to identify the causal mechanisms, it remains unclear how long this stability will last. The Congressional Budget Office has attributed the changes to “technical adjustments”, which is based on changes to public health and the practice of medicine itself. If Medicare per capita spending increased at the same rate as it did pre-2011, the federal debt would be $3.9 trillion higher than it is today.
Gun violence is the leading cause of death among American children and adolescents. A new study published in Pediatrics found that firearm deaths among children hit a new record high in 2021, with 4,752 pediatric firearm deaths. Between 2018 and 2021, the pediatric firearm death rate rose 41.5 percent. This public health crisis has sparked the Biden Administration to announce the first ever White House Office of Gun Violence Prevention, led by Vice President Kamala Harris. The healthcare workforce is a key player in identifying and mitigating risk factors for gun violence.
As we continue to reckon with the implications of institutional medical abuses against underserved populations, I found this story of California attempting to provide reparations to survivors of a policy of involuntary sterilization procedures against incarcerated people. The bulk were of the 20,000 victimes were survivors of a eugenics program in the early 20th century, but hundreds more, including Pulido, were forcibly sterilized in more recent decades, often a result of medical provider bias against incarcerated people. A state audit from 2013 identified 144 women inmates who underwent such procedures between 2006 and 2010 alone. Black women and Latinas made up a disproportionate share of those harmed. Under a state law passed in 2021, Californians who can prove they were sterilized without consent while incarcerated in the state’s women’s prisons are eligible for at least $15,000. Applications to the program opened at the beginning of 2022 and will close this December. Only approximately 100 people have gotten the reparation payment.
There are few topics more complex or uncertain that we are facing right now than what AI means for the future of medicine. An interesting anecdote that I saw was this story of a young boy who dealt with chronic pain for years that got a diagnosis from Chat GPT that he was unable to get after seeing 17 different specialists. His mother plugged in information from an MRI and details about his symptoms into the AI bot program, which suggested that he had tethered cord syndrome. With this direction in mind, he was able to see a neurosurgeon who confirmed the diagnosis and undertook a surgery to treat the condition.