This
is an exceprt of a post originally published on Sarah Fontenot’s website.
As other industries are struggling through
the partial government shutdown, it would be easy to feel positive about health
care. Funding for both Health and Human Services (HHS) and the Department of Veteran
Affairs (VA) are secure due to appropriation
bills that predate the current crisis. VA benefits, Medicare,
Medicaid and the Affordable Care Act (also known as Obamacare) are — at least at
face value — protected.
The Centers for Disease Control and Prevention
(CDC) is up and running, the National Institutes of Health (NIH) continues to oversee
biomedical research, and Food and Drug Administration
(FDA) responsibility for drug approval is not affected.
But that is not the whole story.
The shutdown is impacting — even risking
— the health of countless Americans. Protections and processes all of us rely on
are on hold. Innovations and developments in science, policy, and the law are being
delayed or subverted.
Starting with the most important examples
— people who are directly affected — here are 12 ways this shutdown is doing damage
in the realm of health care.
1.
Some Federal Workers are Losing Their Health Benefits
The 800,000
employees at shut down federal agencies who fall under the Federal Employees
Health Benefits (FEHB) program are not
at risk of losing their health care insurance. But they could
start
to receive bills for their dental, vision, and long-term care
coverage if the crisis continues.
The federal employees most in jeopardy are
those working under contracts not
eligible for the FEHB program. Not only are contract workers potentially
not
going to get paid when the shutdown ends, they lost their health
care benefits at midnight on Dec. 22. A poignant story highlighted by NBC
News and the New
York Post covers a young woman from the Interior Department now rationing
her insulin because she cannot afford the cost.
2.
Many Native Americans are Going Without Health Services
The Indian Health Service — run by HHS but
funded through the Department of the Interior — is directly affected by the shutdown.
Native American tribes have already missed millions
of dollars in essential services; only health care that meets
the "immediate needs of the patients, medical
staff, and medical facilities" are included in the department’s shutdown plan.
Some clinics serving Native Americans have closed already; others are expected
to cease services by the end of this week.
3.
Some People Eligible for ACA Subsidies May Have Their Applications Delayed
Many (if not most) people who purchase insurance
on the Affordable Care Act (ACA) Exchanges (or “Marketplaces”) receive a subsidy
from the government to help them afford health care coverage. Applications for subsidies
may require an Internal Revenue Service (IRS) review in some circumstances, such
as when applicants lose their job, a baby has been born, or the person involved
filed for an extension on paying income taxes or signed up for insurance outside
of the open enrollment window.
With 90 percent of IRS workers out of the
office, these
applications are now delayed — and the patients involved could
lose their insurance entirely if they can’t pay the full premium while they are
waiting. (As a bonus, the IRS Call Center is closed so these people can’t get information
on what they should do.). Democratic senators andrepresentatives sent a letter
Monday to HHS and Treasury asking for protection from unexpected premium costs due
to the shutdown.
4.
People Who Receive SNAP Benefits (Food Stamps) Have Another Month of Coverage
The United States Department of Agriculture,
Food and Nutrition Service (FNS) released funds to each state to provide February
Supplemental Nutrition Assistance Program (SNAP) benefits two days before the shutdown.
This means people who receive SNAP (food stamps) must ration their benefits to last
two months; it is unclear
if there will be any further assistance if the shutdown continues into March.
People who were in the process of applying
for food stamps when the shutdown began may have to go without until the reopening
of the government. Although the SNAP program is administered through the states,
“FNS does not guarantee eligible applicants will receive food stamp benefits while
the partial federal shutdown is in effect,” St.
Louis Public Radio wrote.
5.
Food Safety Issues May Affect Public Health
Food safety is a basic component of public
health, and it is now threatened by the interruption of routine food safety inspections.
However, the day after FDA Commissioner Scott Gottlieb confirmed
the cessation of food control efforts, the FDA announced
that “high-risk”
inspections, including infant formula, shellfish, and prepared
salads and sandwiches, will resume with the return of 150 furloughed (but still unpaid) people next week.
6.
Industry Developments Are Affected by Government Regulators’ Lack of Funding
The Antitrust Division of the Justice Department
asked the U.S. District Court in Washington, D.C., last week to suspend review of
the $70 billion CVS-Aetna merger due to lack of resources. The judge told them to
keep
working.
This “mega-merger” is a highly publicized
case — and the judge’s opinion presumably reflects that. Undoubtedly there are lesser-known
business dealings and corporate plans that cannot come to fruition while the necessary
federal agencies are unavailable to serve their role.
7. The Safety of Drinking Water
is Threatened
After
what is happening in Flint, Mich., water safety is top-of-mind for all health care
providers, but with more than 13,000 workers furloughed, the Environmental Protection
Agency does
not have enough staffing to inspect drinking water adequately.
8. State 1332 Waivers for Innovations
in Marketplaces are on Hold
IRS evaluation of the financial impact of
proposed innovations is a central component in a state’s process to obtain a 1332
waiver, but because the IRS is currently crippled (see above) that agency can’t
work with HHS to evaluate
state initiatives to revamp their ACA marketplaces, a chief focus
of conservative efforts to alter the ACA.
9.
The Appeal of the Texas Decision Striking Down the ACA is on Pause
The federal court system has survived the
shutdown by conserving resources as best as possible (although a closure could happen
as early as next
week), but the shutdown has still impacted the most prominent
court case in health care today: the Texas
lawsuit decided in December declaring the entire ACA invalid.
On Jan. 11, the 5th Circuit Court of Appeals in New Orleans issued
a stay in the appeal of that decision until the government reopens.
10. The FDA is Open — but New
Drug Treatments may be Delayed
The FDA, as a branch of HHS, is up and running,
but even so, some pending new drug treatments (including those for multiple sclerosis,
depression, and diabetes) may be delayed if the shutdown continues, as the
agency cannot process the application fees paid by drug manufacturers
during the shutdown. Funds available at FDA are expected to be exhausted before
March.
11.
It is Increasingly Difficult to Hire Researchers at the FDA
In 2016, the
passage of the 21st
Century Cures Law (Pub.
L. 114-255) was “designed to help accelerate medical product development
and bring innovations and advances to patients who need them faster and more efficiently.”
Part of that directive was to accelerate hiring scientists (and increase their pay)
at the FDA. However, as recently reported by Bloomberg,
the shutdown is making it difficult to entice the best minds away from the private
market — to reinforce the argument that the government is “a good place to
work.”
12.
Activities of Homeland Security Related to Health are at Peril
The division of the Department of Homeland
Security that monitors threats related to infectious diseases, pandemics, and biological
and chemical attacks (the Office of Health Affairs) is scaled
back throughout the shutdown. Of the 204 people who typically
address these threats as well as others in the Countering Weapons of Mass Destruction
Office, only 65 remain active.
Other Homeland Security employees who will
continue to work without pay include border health inspectors and members of the
border patrol.
This shutdown is a world of pain for all
of us. But for many, it is an actual threat to life (such as living without insulin).
2019 will be a year of political battles
over the future of the American health care system on both a federal and state level.
The Trump Administration will (presumably) continue to erode protections provided
in the ACA, and the December case ruling the entire ACA unconstitutional will continue
to wind its way toward a newly constituted conservative U.S. Supreme Court. The
ying and yang of “Medicare for All” and “Free Market Health Care” will be the debate
of the year. All of that, and much more, will be the subject of future Fontenotes.
But until our government fully reopens —
those debates all seem irrelevant — if not irreverent.