January 9, 2019Mindy Levine, PhD
There are a number of healthcare-related issues that can arise during a U.S. government shutdown, some of which are immediate, others that may not manifest themselves until several days have passed, and still others that arise only once the government is re-opened. This article is relevant to all cases of a full or partial government shutdown (22 instances since 1976), including the current 2018-2019 shutdown.
An immediate healthcare-related concern during a federal government shutdown is funding for the Center for Disease Control and Prevent (CDC) and for the Food and Drug Administration (FDA). During the January 2018 government shutdown, the CDC suspended its program to monitor the flu virus, as well as the planning for flu vaccination protection for the following winter. That shutdown lasted only three days (January 20-23rd, 2018), which limited the long-term damage. By contrast, the 16-day shutdown of 2013 led to furloughing of more than two-thirds of the workers at the CDC. The disease and outbreak hotline of the CDC was closed as a result, and many other program activities were decreased. Fortunately, in the 2018-2019 government shutdown (currently ongoing), there has been no measurable decrease in CDC-related activity to date, including in their flu monitoring and response programs.
The FDA, like the CDC, runs a number of programs of significant public health interest, including monitoring of commercial food safety, certifying agricultural operations, and ensuring the safety of pharmaceutical products. Approximately 40 percent of the FDA workforce has been suspended without pay during the current 2018-2019 shutdown, meaning that public health-related work in food and drug safety is substantially curtailed. The likelihood of illness from exposure to unsafe foods or drugs, by contrast, is raised, because less active oversight means that pathogen contamination in foods and/or counterfeit ingredients in drugs will go undetected. Other shutdowns in recent memory (2013, 2018) have led to similar curtailments on FDA activity, especially in terms of decreased inspections of external sites, monitoring for regulatory compliance, approval of new drugs, and involvement in internal laboratory research.
NIH-related activities are also often diminished during a shutdown. This means that new public health-related research cannot be funded, that new patients cannot be enrolled in clinical trials, and that NIH employees cannot communicate with NIH-funded researchers to facilitate efficient research progress. Patients who enroll in clinical trials are often in severe medical distress, and delays in enrollment can prove to be fatal. Moreover, delays in providing research funding means that less research is funded overall, and potential life-saving treatments for cancer, diabetes, and other diseases are slower to reach the people who need them.
One population that is particularly at risk for healthcare disruptions during a government shutdown is the Native American population, which receives services through the Indian Health Service (IHS). Compared to other United States citizens, Native American tribes tend to rely more on federally-funded healthcare clinics to provide critical care. A government shutdown that causes these healthcare workers to be furloughed without pay can lead to life-threatening staffing shortages. This is proving to be a key issue during the current government shutdown, as it was in 2013.
One health-related concern that occurs over the long-term is whether there will be funding for Medicare and Medicaid programs, which are administered through the Center for Medicare and Medicaid Services. These programs are not immediately affected by a government shutdown, because there are often contingency plans that enable uninterrupted funding, and because most administration of Medicaid and Medicare payments occur through state disbursements, many of which are already disbursed prior to the start of the shutdown. Eventually, however, Medicare and Medicaid disbursements to the states can run low, and lead to slowdowns in such payments and resultant decreases in reimbursements to vulnerable patient populations.
The longer that a shutdown goes on, the more apparent cumulative negative effects become, especially in terms of CDC- and FDA-related activities. More people are likely to be affected by the flu virus, for example, if the CDC has a prolonged period in which it is not actively monitoring public health during the flu season. Illness outbreaks from exposure to contaminated meat, produce, or drugs can occur from lapses in FDA-related regulatory activities. Federal employees who do not receive a salary during a government shutdown have less money available for themselves and their families to meet basic food, shelter, and healthcare needs.
Restarting the government
Eventually all government shutdowns end, whenever the federal leadership is able to come to an agreement on a spending plan to fund the government. Whether the government shutdown is measured in hours, days, or weeks, procedures to reopen healthcare-related agencies can be tedious. This is especially true for the NIH, where reopening of clinical trials and of medical instrumentation can take significant time. In contrast, other healthcare services, especially the IHS, can be fully functional as soon as healthcare workers can be sent to the affected areas. State disbursements for Medicare and Medicaid may be slow to re-start, especially in cases where the shutdown was prolonged, but services provided through these programs are likely to be less affected, as providers generally continue to provide service even with delayed reimbursements.
After the shutdown ends
Lingering impacts of government shutdowns on healthcare are difficult to measure. For individuals who were forced to forgo prescription medications due to fiscal challenges brought on by the shutdown, effects can range from minimal to lethal. Hampering the ability of the CDC and the FDA to conduct crucial regulatory oversight means less control over disease outbreaks, weakened ability to control food or agricultural contamination, and spikes in illness due to contamination. Native American populations who experience a disruption to healthcare may lose faith in federal government institutions. This erosion of trust can deter individuals from seeking medical care federally funded healthcare workers in the future, resulting in more disease, disease-related injuries, and death.