In this edition of AcademyHealth's Situation Report, we explore the potential impact of a federal shutdown on health agencies, including significant furloughs at HHS, NIH, and CDC, and the resulting strain on public health infrastructure. We also break down the debate over Medicaid work requirements, where new exemptions based on local unemployment could protect millions, but only if states act. Finally, AHRQ’s recently released strategic plan marks a notable shift away from long-standing commitments to health equity and implementation science, raising questions about the future of patient-centered research. AcademyHealth remains committed to advancing evidence-based policy and urges health services researchers to engage with policymakers to protect access, equity, and scientific integrity. Read on to learn more and see how you can take action.
In today’s issue:
- Government Shutdown and Health Care Cuts Loom
- States, CMS Thresholds Key to Medicaid Work Rule Exemptions
- How Federal Cuts Strain State and Local Systems
- A Looming Trade-Off at AHRQ: What's at Stake for Health Services Research
- Medical Associations Advocate for Foreign Visa Exemption for Physicians
- Stay Informed: September Advocacy Update Available Only to AcademyHealth Members
Government Shutdown and Health Care Cuts Loom
Hakeem Jeffries (D-N.Y.), House Minority Leader, warned that Democrats will not accept a Republican spending bill that raises costs for working class Americans and noted looming health care cuts must be addressed to gain Democratic support. After canceling a meeting with top congressional leaders last week, claiming the spending bill required no further negotiations, Trump rescheduled the meeting for Monday with House Speaker Mike Johnson (R-La.), Senate Majority Leader John Thune (R-S.D.), Senate Minority Leader Chuck Schumer (D-N.Y.) and Jeffries.
While Republican leaders have been receptive to addressing the Affordable Care Act subsidies that are due to expire at the end of the year, they do not want to consider them as part of the current spending debate. Democratic leaders have rejected pushing off negotiations since the Affordable Care Act’s open enrollment begins November 1 and patients could opt out of coverage if the rates appear unaffordable. While Monday’s meeting offers some hope of reckoning, a government shutdown will take effect at the end of day today if Congress does not reach a deal.
The Department of Health and Human Services is planning on furloughing over 40 percent of staff in the event of the shutdown. Programs such as Medicare, Medicaid, the Affordable Care Act marketplace, and Food and Drug Administration drug approvals will continue as they rely on non-discretionary funds. NIH is expected to furlough 75 percent of its workforce and CDC will furlough 64 percent. These furloughs will be highly corrosive to public health efforts and the scientific enterprise. Of the remaining staff still at AHRQ, 90 percent will be furloughed.
Researchers should act proactively in case of a government shutdown. For researchers with federal contracts or grants, it may be wise to contact respective program officers or agencies for guidance on what to expect in the event of a shutdown.
States, CMS Thresholds Key to Medicaid Work Rule Exemptions
Individuals in counties with high unemployment may be protected from the impending Medicaid work reporting requirements calling for adult, nondisabled Medicaid enrollees in expansion states to work or volunteer 80 hours a month or go to school. States can apply for an exemption to reporting requirements for enrollees living in counties with 8 percent unemployment or unemployment 1.5 times the national unemployment rate. KFF’s latest analysis shows that this exemption could benefit millions, but the impact hinges on how CMS operationalizes the criteria.
Based on the latest unemployment data, if CMS exempts individuals in counties with an unemployment rate above the threshold for any month over a 12-month period, around 4.6 million Medicaid enrollees in 386 counties could qualify. This represents just under a quarter of all Medicaid enrollees subject to these work reporting requirements, indicating significant impact. However, if CMS adopts stricter thresholds, such as those based on average unemployment over a 12-month period, such as work reporting thresholds under SNAP, the impact would be curtailed – just 1.4 million Medicaid enrollees in 158 counties could be exempt.
Health advocates fear that some state policymakers will choose not to apply for such an exemption in order to keep their broader Medicaid enrollment down, as has happened with SNAP exemptions. Research shows that most coverage losses due to such work requirements occur among those who work or qualify for an exemption but lose coverage due to red tape. Health services researchers can continue to meet with their state policymakers and highlight both the evidence on the potential harms of work reporting requirements and opportunities to mitigate such harms, like applying for this exemption.
How Federal Cuts Strain State and Local Systems
As the nation edges toward a potential government shutdown, one in which health care funding is a pivotal topic of debate, stark examples have emerged depicting how federal policy decisions ripple down to strain local systems. A recent Politico story reported on the challenges Democratic- and Republican-leaning counties face in the wake of new requirements for federal assistance programs like Medicaid and SNAP. In at least nine states, Medicaid and SNAP have county-level administration rather than state-level administration. When accounting for the new complex eligibility requirements, more frequent enrollment renewals, and changes to the cost-sharing between the local and federal governments, local officials who are already overburdened are facing ballooning workloads. In some cases, localities may have to levy additional local taxes to support the administration of these essential programs, as evidenced by a recent report from the National Association of Counties that estimates counties may face up to $850 million in additional yearly administrative costs due to the budget reconciliation bill .
Nowhere is the tension between federal decisions and state policy clearer than in North Carolina, where their innovative Medicaid program has been halted due to funding cuts. Five years ago, the Healthy Opportunities Pilot endeavored to address the evidence-based determinants of health that have an impact on health outcomes and hospital stays. Equipping recipients with nutritious food, safe housing, and transportation to medical visits was the epitome of Medicaid innovation—and it worked, as evidenced by the annual $1000 savings for each of the 13,000 Medicaid recipients enrolled and the economic boost for local farmers who supplied fresh produce. After the passage of the budget reconciliation bill bill, State lawmakers declined to renew the pilot’s funding.
Taken together, these two developments illustrate the fragility of the U.S. health infrastructure at a moment of fiscal and political uncertainty. For health services researchers, this serves as a reminder that policy must be examined and developed with multiple levels of context in mind, ranging from federal to state to localities. Further, it underscores the need to translate evidence to inform policy debates and support the sustainability of evidence-based programs, clearly highlighting what is at risk of being lost in the face of these funding cuts.
How Federal Cuts Strain State and Local Systems A Looming Trade-Off at AHRQ: What's at Stake for Health Services Research
The Agency for Healthcare Research and Quality (AHRQ) has released a new strategy document signaling a major shift in its research priorities and moving away from foundational pillars of health services research (HSR). While the document emphasizes hallmarks of “gold-standard science,” it raises serious concerns about the future of patient-centered care, health disparities research, and dissemination & implementation (D&I) science.
Specifically, AHRQ’s guidance moves away from its historic commitment to equity, access, and including the patient voice, favoring more narrowly defined, quantifiable data. This pivot risks devaluing qualitative insights, dismissing structural causes of health disparities (such as systemic racism), and sidelining real-world implementation science. The agency’s new approach could limit the kinds of research that help translate evidence into equitable, patient-centered improvements in care. Read more on our blog here.
Our CEO Aaron Carroll said in a statement to Inside Health Policy that AHRQ has not funded a new grant since April and over 80 percent of AHRQ staff, including nearly all the staff who manage grants, have been let go.
“Some priorities, like long COVID, telehealth, and using real-world data, could produce really useful, high-quality research. But the strategy points toward a very narrow view of what counts as 'quality' research, explicitly dismissing whole areas of inquiry like equity, racism, and gender-affirming care, as 'ideological' or 'unmeasurable.' This runs counter to decades of progress in patient-centered care and implementation science,” Carroll said.
Medical Associations Advocate for Foreign Visa Exemption for Physicians
The American Medical Association (AMA), alongside 53 top medical societies, requested that the U.S. Department of Homeland Security (DHS) exempt physicians, residents, and fellows from the recently announced $100,000 H-1B visa fee. In an effort to protect patient access to care, the groups signed a letter to the DHS argued that the new fee threatened the sustainability of the U.S. health care workforce, raising concerns about increased labor costs and decreased access to skilled workers. The visas allowed employers from specialty fields such as medicine and academia to hire international workers and are commonly used in the health care sector, notably in the recruitment of health care workers and medical school graduates trained abroad.
More than half (64 percent) of physicians trained abroad work in health-professional shortage or medically underserved areas, with an additional 46 percent practicing in rural areas. The visa fee will increase wait times and worsen patient access to care, according to the groups, which is especially concerning in the context of an expected shortage of 86,000 doctors in the U.S. by 2036. In the letter, the groups asked the administration to “categorically consider H-1B physicians entry into the U.S. to be in the national interest of the country, and waive the application fee, so that H-1B physicians can continue to be a pipeline that provides health care to U.S. patients.”
As a key actor in the broader field of medicine and academia, the pipeline of health services researchers is also likely to be impacted amidst the introduction of the new H-1B visa fee. Health services researchers can further urge their representatives to exempt HSR researchers and students as they, like physicians, are crucial to the sustainability of the U.S. health care system.
Stay Informed: September Advocacy Update Available Only to AcademyHealth Members
AcademyHealth's September Read on Washington, includes updates on appropriations, impoundments, new strategic guidance from AHRQ, and more. Not a member? Join today to access exclusive advocacy insights. Read it here.
Previous Editions
This is the latest in a series of Situation Report updates from AcademyHealth. You can find prior issues here.
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