As the deadline for passing federal appropriations bills for the next fiscal year quickly approaches, Congress continues to be deadlocked—with far-right representatives in the House blocking all attempts to advance spending bills. With no progress in sight, it is highly likely that the federal government will be forced into a shutdown. Health programs would be among those impacted, and the U.S. Department of Health and Human Services (HHS) has released their contingency plan for furloughed staff.
Leading up to the federal shutdown, researchers, advocates, media, and others often seek to identify what the implications are for specific federal programs, but one issue that is often overlooked is more cross cutting: how a federal shutdown would affect efforts to advance health equity and equitable governance. As a shutdown draws nearer, not enough attention is being placed on the people that Congress is supposed to be working for, especially those who are already marginalized, who may rely on government programs and thus have the most to lose during a shutdown.
HHS has already put forth an action plan on health equity, and as a shutdown approaches, it is past time to recognize that the work to pursue health equity is essential, not expendable. Here are three ways the shutdown would hinder essential work currently being done to advance health equity.
1. The Shutdown Would Interrupt the Current “All Hands on Deck” Approach to Medicaid
Our country is in the midst of one of the biggest health care coverage events since the Affordable Care Act passed in 2010. Only this time, movement is in the direction of coverage loss instead of coverage gain, impacting people who have been enrolled in Medicaid, the primary insurer for many of the people in our country, particularly families with low incomes, people of color, people with disabilities, and pregnant people.
In March 2020, at the start of the COVID-19 pandemic, a continuous enrollment policy was in place for Medicaid—meaning enrollees retained their coverage without needing to reapply or demonstrate ongoing eligibility for the program. But since this policy ended in April of this year, states have begun the redetermination process, known as Medicaid unwinding. So far, over 7.5 million people have been disenrolled from the Medicaid program, with three-quarters of these disenrollments occurring for purely administrative reasons, such as enrollees not returning forms to their state Medicaid agencies. Especially concerning is the fact that, according to the states reporting age breakouts for disenrollment data, children accounted for over 40 percent of Medicaid disenrollments.
So far, over 7.5 million people have been disenrolled from the Medicaid program, with three-quarters of these disenrollments occurring for purely administrative reasons, such as enrollees not returning forms to their state Medicaid agencies.
HHS has indicated that, in order to preserve coverage for as many people as possible, this requires an “all hands on deck approach” from across the federal government and from states, advocates, employers, providers, and community-based organizations. This kind of extensive, multi-directional outreach, workshopping, and communications—which have been ongoing since even before Medicaid unwinding began—is critical to advancing equity. The goal is to reach as many people on Medicaid as possible, through various means and networks, and help connect them to coverage—whether that means staying enrolled in Medicaid if they are still eligible, or finding other affordable plans, such as through subsidized coverage on the insurance marketplace.
Although the employees at the Centers for Medicare and Medicaid Services (CMS) central to overseeing the unwinding would be maintained, the level of communication with all of their partners would almost certainly have to be scaled back or eliminated during this time. This could mean missing identification of crucial challenges at the state level that require federal oversight and assistance. Even more important, from an equity perspective, it could hinder some key opportunities for workshopping new ways to reach people in states to help them either retain Medicaid coverage or find new coverage that they need.
2. The Shutdown Would Hinder Partnerships with Community-Based Organizations
As part of HHS’s commitment to health equity, many agencies have prioritized more meaningful engagement with the communities most impacted—through grantmaking, listening sessions, technical assistance, and more. Central to doing so is supporting community-based organizations (CBOs), who are made up of, accountable to, and serve the people most impacted by health inequities. Much like the shutdown’s impact on proactive outreach to states conducting Medicaid redeterminations, the valuable work to partner with CBOs may fall to the wayside, with HHS staff anticipated to be cut nearly in half—42 percent of the agency’s staff would be furloughed during a shutdown.
Much like the shutdown’s impact on proactive outreach to states conducting Medicaid redeterminations, the valuable work to partner with CBOs may fall to the wayside, with HHS staff anticipated to be cut nearly in half—42 percent of the agency’s staff would be furloughed.
The federal government, including HHS, is working to rebuild trust with communities of color, reckoning with a history of discrimination and disinvestment. With HHS serving as a major funder of health programs and research, making grants accessible to CBOs, especially those led by and serving people of color, is critical to embedding health equity in their work. In order to do so, agencies need to prioritize open communication, transparency, and engagement with CBOs throughout the funding process. With the looming shutdown threatening to delay funding processes and community engagement, these relationships are being put further at risk. The time and effort put into preparing for a shutdown and getting back on track afterwards would put a strain on already limited resources.
3. The Shutdown Would Delay Equitable Rulemaking for Health Programs
A third way the shutdown would harm efforts to improve health equity is by potentially delaying the implementation of rules for HHS programs. Much of the Biden administration’s recently proposed rulemaking has focused on advancing equity, particularly providing additional support for access and affordability for populations that have been most marginalized. These proposed rules include:
- expanding health coverage to DACA recipients;
- shoring up mental health parity protections;
- strengthening prohibitions against discrimination on the basis of disability;
- bolstering protections against discrimination based on race, color, national origin, sex, age, and disability in any federally-funded health programs—including critical protections for transgender and other LGBTQI+ individuals, individuals who have had abortions, pregnancy discrimination, and much more;
- partially repealing a Trump administration rule that allowed health care providers and institutions to deny patients care based on their personal religious or moral beliefs; and
- expanding the role of Medicaid beneficiary input in state Medicaid agency procedures.
A government shutdown, especially a prolonged one, would slow down efforts to finalize these rules. Federal law requires agencies to review the comments received on any proposed rule before they are finalized. During a shutdown, fewer staff members would be available to review and respond to comments and make final decisions, and agency staff that are still working would likely need to focus on more acute issues. This review process can often be quite lengthy: for example, the Biden administration took four months to review and respond to comments about its fix to the “family glitch,” a technical insurance marketplace issue. Longer, more complicated regulations could take more time, making a shutdown more significant for their implementation.
Slowing down finalization of these rules not only delays the important equitable protections they would provide, but a significant holdup could also put them at greater risk of repeal if there is a new administration in 2025. The Congressional Review Act allows Congress to invalidate rules set by a previous administration that have been finalized within a certain look-back window (sixty legislative days—a much longer window than sixty business days, given the Congressional calendar). If there is an administration and Congress hostile to health equity after this term, important regulations could be in jeopardy. For example, in 2017, a newly elected President Trump and a supportive Congress overturned fourteen rules that had been finalized in President Obama’s last year in office. If the proposed rules are delayed as a result of a shutdown and we have a new administration in 2025, these rules face heightened risk of being repealed at that point, even if they are eventually finalized in the meantime.
A government shutdown would have harmful effects across many sectors of American life, especially if it is prolonged. Efforts to advance health equity have been a priority of the Biden administration and a shutdown has the potential to set these efforts back in profound ways that should not be overlooked. Health equity is essential and should not be shut down.