Budget brinkmanship may yet impact health care reform

An election is held. The political party that promised to change the direction of American politics wins a lopsided victory. Emboldened, the party claims a mandate from the American people to rush through a massive piece of legislation to deliver on its promises, involving hundreds of billions of dollars on programs affecting every American. The legislation is so polarizing that it is unable to get support from even a single lawmaker from the other party and is passed on a party-line vote.

If this sounds familiar, it is how many characterize the enactment of the Affordable Care Act after the Democrats enjoyed a decisive election win in 2008. Today it can be said of the Republican-controlled House of Representatives, which in February passed a massive and highly controversial spending bill with no Democratic support.

The most recent legislation in question was a continuing resolution to fund the federal government through Sept. 30. A new resolution was needed because last year's Democratic-controlled 111th Congress failed to pass a budget for the government's current fiscal year, which runs from Oct. 1 of last year through Sept. 30. Instead, the 111th Congress funded the government through a series of temporary resolutions, with its final resolution running out on March 4. Ordinarily, a resolution continues funding for federal agencies at current budget levels, with some modest adjustments.

The GOP leadership of the new 112th Congress, though, looked at the new continuing resolution as the vehicle to begin to implement its pledge to voters cut $100 billion out of the discretionary budget. The resolution, which passed the House on a party-line vote on Feb. 19, terminated or deeply reduced spending for hundreds of federal programs. Prior to the vote, ACP wrote to the House leadership to support bipartisan efforts to reduce funding for programs that do not achieve sufficient value. The letter also urged the House to fund programs to address a growing primary care shortage, citing studies that too few primary care physicians in a community is associated with higher health care spending, poorer outcomes and longer waits for appointments.

Despite ACP's efforts, the House-approved resolution mandated deep cuts in programs to expand coverage, train more primary care physicians and fund research.

• Coverage: The bill would prohibit federal agencies from spending any money on staff salaries to implement and enforce the programs authorized by the Affordable Care Act, which effectively would halt implementation in its tracks. It also struck all funds for the White House Office of Health Reform.
• Health professions training programs: (scholarships, loan forgiveness): The bill would cut $145.119 million (29.1%) below FY2010 enacted levels, which represents a $386.1 million (53.2%) cut from the president's FY2011 request. Included in the cut is the only federal program (Title VII) that provides grants to institutions to establish or expand primary care training and education.
• National Health Service Corps (NHSC): The bill would cut $141.925 million in discretionary funding, which would mean that some 2,365 health professionals would no longer be able to receive NHSC funding.
• Community health centers (CHCs): $1 billion would be cut from FY2010 enacted levels; as a result, CHCs will lose the capacity to serve 3.3 million current patients in the next few months and over 11 million patients over the next year.
• Medical and health services research: The National Institutes of Health would be cut by $1.629 billion (5.3%) from FY2010 enacted levels and $1.569 billion (5.1%) from the president's proposed FY2011 budget, and the Agency for Healthcare Research and Quality would be cut $25 million (6.3%) from FY 2010 enacted levels and $39 million (9.4%) from the president's FY2011 budget request.

For all of its success in pushing the bill through its own body, the GOP-controlled House encountered an obstacle that the Democrats didn't have in the last Congress: The Senate and White House are controlled by the other party. The Senate made it clear that the House's resolution was dead on arrival, and President Obama threatened to veto it if it somehow survived the Senate. Even House Republicans were forced to concede that the final bill would be very different from the one they passed, but also insisted that any temporary resolution would have to reduce spending. At press time, it wasn't clear how or if the impasse would be resolved in time to avert an imminent government shutdown. No matter how it gets resolved, the battle over the resolution is only the first of a series of fights over spending.

As both parties seek the edge in budget brinkmanship, they might remember that voter mandates are usually more fleeting than they seem in the heady days after an election. The Democrats found this out with health reform; polls to this day show that as much as half of the electorate remains opposed. The GOP may find the same to be true with its effort to impose unprecedented cuts in federal spending.