What the 2016 Labor, Health and Human Services Appropriations Bills Really Mean for Palliative Care

Congress recently introduced funding bills that could destabilize many of the Federal health programs that support palliative care through large funding cuts.

As mentioned in a recent issue of CAPC News Bites, both the House and Senate Appropriations committees approved the FY 2016 Labor, Health and Human Services (LHHS) funding bills (H.R. 3020 and S. 1695), meaning that they have been sent to the full House and Senate floors for consideration and debate. While this is an accomplishment of sorts – it is the first time since 2009 that all 12 appropriations bills have made it through committee – stakeholders are concerned about how cuts to certain agencies could impact both current coverage and the development and testing of new models that will improve future delivery of care.

Key Health Agencies and Programs Facing Cuts

One of the most dramatic proposed cuts comes from the House bill, which terminates funding for the Agency for Healthcare Research and Quality (AHRQ). AHRQ is the Federal agency specifically charged with conducting and/or funding research on healthcare delivery and development. The committee’s justification for this cut is that ARHQ duplicates the efforts of other Federal agencies such as the National Institutes of Health (NIH) and the Centers for Medicare and Medicaid Services (CMS); however, this is incorrect. AHRQ focuses on professional tools and health systems research, while NIH and CMS focus on biomedical research and public health. The agency also collects and makes available basic data on healthcare delivery, which helps address patient safety and broadens access to effective services – all of which are critical for providers and researchers working in palliative care. This is not the first time that AHRQ has been targeted for cuts by the House, but it is the first year that the Senate bill also proposes significant cuts to the agency.

The House bill also rescinds funding for the Patient-Centered Outcomes Research Institute (PCORI), an entity established by the ACA to support comparative clinical effectiveness research and make this information available to patients and clinicians. PCORI has awarded funding to a number of projects looking at the impact of palliative care on patient outcomes, including studies on whether outpatient palliative care improves outcomes for patients with Parkinson’s disease and whether palliative care team interventions improve nursing home residents’ end of life outcomes.

Finally, both the House and Senate bills attempt to derail the implementation of the Affordable Care Act (ACA) through cuts to both CMS and the Center for Medicare and Medicaid Innovation (CMMI). CMMI is charged with developing and testing new models of care delivery while accomplishing the triple aim of improving the experience of care, improving population health and reducing overall costs to the system. The innovation center has established or supported numerous demonstration projects that evaluate the impact of palliative care such as the Medicare Care Choices Model and the Oncology Care Model. Meanwhile, CMS administers Medicare, Medicaid and the Children’s Health Insurance Program, as well as parts of the ACA. The cuts in the House and Senate bills, along with certain provisions specifically disallowing the use of discretionary funds to support ACA-related initiatives, could threaten the benefits of millions of people who receive coverage under these programs.

Next Steps in the Appropriations Process

On paper, these cuts can appear alarming. However, it is helpful to keep in mind that that bills passed by the House and Senate Appropriations committees are just the starting point in a long and complicated process. In theory, the next steps would be for both chambers to discuss and vote to pass the bills. Representatives from the House and Senate would then come together to compare the passed bills and reconcile any differences. This would result in Congress sending two identical bills to the President for his signature. After this, the bills would be passed into law and all the provisions would go into effect on October 1, 2015.

Yet a review of the appropriations process in recent years suggests that this year’s process will not be that simple. When it comes time to debate the LHHS bills on the House and Senate floors, several provisions including the cuts listed above will be “non-starters” for many members. In the past, this situation has lead to an impasse wherein both chambers are unable to pass an appropriations bill by October 1. In some cases, this has lead to government shutdowns; in other cases, Congress has passed continuing resolutions that allow federal agencies and programs to continue operating at current funding levels. The continuing resolution essentially buys time for Congress to either continue debate on the appropriations bills or put together an omnibus bill. The omnibus bill combines several appropriations bills, simplifying the voting process, but also limiting the opportunity for scrutiny and debate.

The Takeaway

It is difficult to tell at this point how the FY 2016 appropriations process will resolve. The extent of the cuts to health programs is concerning and palliative care stakeholders are encouraged to monitor the process. However, the checks and balances in the political process, as well as diverse representation in Congress, will likely limit the number of cuts to health programs that will eventually be passed into law.

For more information on how the LHHS bills might affect programs for seniors, including some of the positive budget increases, see the National Council on Aging’s coverage. Readers can also find a more thorough analysis of the provisions in the House appropriations bill on the Center on Budget and Policy Priorities’ website.