Published 9/1/2015
Elizabeth Fassbender

Dollars and Sense of Federal Funding

Why orthopaedic surgeons should care

Elizabeth Fassbender

With government funding set to run out in a matter of weeks (Sept. 30), Congress is once again considering a stop-gap funding bill—also called a continuing resolution or CR—to avoid a government shutdown. CRs are short-term funding measures that typically extend funding at current levels until agreement can be reached on new appropriations bills.

The 12 regular appropriations bills (Table 1) must be approved annually and provide discretionary funding for numerous activities, including national defense, education, and health and human services (HHS). Each must be approved by both the full House and the full Senate. Before Congress recessed in August, both the House and Senate Appropriations Committees had passed all 12 bills, and the full House had taken action on 6, passing all. None of the appropriations bills has been considered by the full Senate.

The impasse on the Senate side is due not only to disagreements about spending levels, but also to pressure by legislators willing to risk a government shutdown to achieve other goals. Before heading back to their home states for the August district work period, legislators acknowledged the standstill and stressed that no decisions have been made on how to address the issue.

“It’s pretty clear, given the number of days we’re going to be here in September, that we’re going to have to do a CR of some sort,” House Speaker John Boehner (R-Ohio) said. “But no decisions have been made about that. We’ll deal with it in September when we get back.”

Appropriations and orthopaedics
Several appropriations bills have an impact on orthopaedics, including the Labor-HHS-Education spending bill and the Defense appropriations bill. The House Appropriations Committee has approved a $153 billion Labor-HHS-Education spending bill, but the measure has yet to be considered by the full House.

If enacted, the funding measure would cut $4 billion from 2015 appropriations levels. It would also provide $71.3 billion for HHS—an increase of $298 million above last year’s level. The bill also increases funding for the Centers for Disease Control and Prevention (CDC) by $140 million and for the National Institutes of Health (NIH) by $1.1 billion.

That’s good news for orthopaedics, and shows that ongoing efforts to educate Congress about the importance of federal funding for research are working. The funding announcement comes several months after orthopaedic surgeons and their patients met with members of Congress to discuss the need for increased musculoskeletal research funding. (See “Snow, Shutdown Don’t Stop Research Advocacy Efforts,” AAOS Now, April 2015.) The physicians and their patients specifically urged Congress to appropriate adequate funding to NIH.

“The AAOS has continually advocated for increased research funding for the NIH and we applaud the inclusion of critical financial resources for the agency,” stated AAOS President David D. Teuscher, MD. “Nearly one in three Americans has a musculoskeletal impairment that requires medical care. Each year, the United States spends $874 billion on health care for persons with musculoskeletal diagnoses.

“NIH funds support research that provides new and innovative treatments to help people regain lost mobility and return to a higher quality of life,” he continued. “We thank Congress for this important investment in our nation’s health.”

The Appropriations Committee report accompanying the bill also contains language regarding ICD-10. While report language is not statutory (and so is not legally binding), it does put the Centers for Medicare & Medicaid Services (CMS) on notice and may be helpful in generating support for other bills aimed at delaying or relaxing current implementation requirements.

“The Committee is concerned that implementation of the ICD-10 coding system will place a hardship on physicians, in particular those in small practices,” the report states. “The Committee urges the Secretary (of HHS) to work with medical providers to establish a hardship exemption for those practices that would be harmed by the change.”

Defunding AHRQ
However, the House bill would eliminate funding for the U.S. Agency for Healthcare Research and Quality (AHRQ), an organization that works with the HHS department to “produce evidence to make health care safer, higher quality, more accessible, equitable, and affordable.” The agency also supports research to improve healthcare quality and outcomes, and is currently funded with a $440 million operating budget through the end of the current fiscal year (Sept. 30). Under terms of a draft funding bill, the AHRQ would be “terminated,” effective Oct. 1, 2015.

The AAOS joined more than 140 other groups in opposing the proposed cuts. In a letter to Congress, the groups explained the significance of maintaining funding for the AHRQ.

“AHRQ-funded research … fuels innovation and improves quality, identifies waste, and enhances efficiency in the health care system,” the letter states. “To ‘terminate’ AHRQ in the current fiscal environment is pennywise and pound foolish. Our nation spends $3 trillion annually on health care—the largest share of which are federal purchases through Medicare, Medicaid, the Federal Employees Health Benefits Plan, insurance exchanges, TRICARE, and veterans’ health care. Americans deserve reliable information on how to deliver the best possible care, at the greatest value, with the best outcomes. AHRQ-funded health services research provides those answers.”

Like the House bill, the Senate appropriations bill for Labor-HHS-Education would increase funding for NIH while cutting spending from 2015 levels by almost $4 billion. However, the Senate bill does not terminate the AHRQ, although it does cut AHRQ’s funding by $100 million. The Senate measure would also eliminate funding for the Independent Payment Advisory Board (IPAB), created by the Affordable Care Act (ACA) to recommend Medicare spending cuts under certain circumstances. (See this issue’s cover story, “IPAB Could Set Rules for Medicare in 2017”)

“This year’s Labor-HHS appropriations bill prioritizes programs that will provide a significant benefit to all Americans and, most importantly, provides the National Institutes of Health with a $2 billion increase to make critical life-saving medical treatments and high-quality cures available to all Americans,” said Sen. Roy Blunt (R-Mo.), chairman of the Senate Labor, Health and Human Services, and Education and Related Agencies Appropriations Subcommittee.

Defense appropriations
The House Defense Appropriations bill includes $30 million for the AAOS-supported Peer-Reviewed Orthopaedic Research Program (PRORP). The program provides direct grants to research institutions to support focused basic and clinical research aimed at optimizing recovery and restoring function to military personnel affected by orthopaedic injuries.

A U.S. Army analysis of soldiers injured in Iraq and Afghanistan shows that extremity injuries account for the greatest proportion of medical resource utilization and cause the greatest number of disabled soldiers. In fact, soldiers with extremity injuries had the longest average inpatient stays and accounted for 65 percent of total inpatient resource utilization. In addition, it is projected that musculoskeletal conditions will account for 69 percent of those who are deemed medically unfit to return to duty. Exclusive of any short- or long-term medical costs, the projected disability cost for extremity injuries sustained in these conflicts to date is approximately $1.2 billion.

“The PRORP program is critical to the treatment of our wounded servicemen and women returning from Iraq and Afghanistan, and an increase in program funding is essential to fulfilling the debt of gratitude we owe to those who protect our freedom,” said Rep. Tammy Duckworth (D-Ill.) earlier this year. “The need for this research has never been greater and more immediate.”

For more information on AAOS advocacy efforts, visit advocacy.aaos.org

Elizabeth Fassbender is the communications manager in the AAOS office of government relations. She can be reached at fassbender@aaos.org

Additional Information:
Congress Supports Peer-Reviewed Orthopaedic Research Program