2019 in the USA: shutdowns and showdowns

Abstract

If the events of the end of 2018 and early days of 2019 in Washington, DC, portend anything, it will be yet another contentious year ahead in the USA at the intersection of politics, governance, and health. The engine of much of the conflict is the acrimony resulting from years of partisan political entrenchment. Far-right conservatives within the Republican party, who have found an ally in President Donald Trump, have narrowed their political focus to essentially a single issue—national security. The resistance, in the form of reluctant moderates and a unified Democratic party, tried to broaden the discussion during spending bill debates, but the two sides were unable to reconcile a budget, and on Dec 22, 2018, the US federal government was partially closed. Increasing border control and stemming immigration have evolved into Trump's relentless pursuit of the building of a massive wall, the hyperbolic totem of American nationalists, along 1000 miles of the nearly 2000-mile border between the USA and Mexico. Democrats are unilaterally opposed both to the construction of the controversial wall but also to the US$5·6 billion price tag that Trump, who on the campaign trail repeatedly asserted that Mexico would finance, now insists should be paid for as part of the federal budget. In mid-November, 2018, Trump claimed that if he did not receive the requested funding for the border wall, he would consider shutting the government down in response, but he thought that outcome was unlikely. Importantly, the impasse that developed did so against the backdrop of a change in congressional leadership ushered in by the 2018 midterm elections and the highest voter turnout in more than a century. Although Republicans held onto the Senate, control of the House of Representatives flipped to the Democrats, signalling voters' substantial opposition to the border wall and other key Republican agenda items, such as the ongoing efforts to undermine the Affordable Care Act (ACA). The stalemate between Trump and the split-controlled congress has calcified in the intervening weeks, as stopgap bills to keep the government open in the interim, introduced by both parties, have not moved forward and negotiations for spending bills have stalled. The most recent bill put forward on Jan 3, 2019, by new House Majority Leader Nancy Pelosi, who has called the building of the wall an “immorality”, did not include any funding for the border wall, indicating that Democrats are unwilling to negotiate without the government being reopened. In a news conference, Trump said that he was willing to keep the shutdown going for months, even years, if necessary. The shutdown affects approximately 800 000 federal employees from nine Cabinet departments whose funding has lapsed, including the Environmental Protection Agency, Department of Agriculture, and the Food and Drug Administration (FDA). The shutdown speaks to the complexity and distributed nature of the American political system that impinges on health. For example, although part of the Department of Health and Human Services (HHS), which, along with the National Institutes of Health, has already received its 2019 operating budget through another appropriation bill, portions of FDA are funded through the Department of Agriculture, which is part of the current budgetary crisis. Similarly, the Indian Health Service (IHS) budget is imperilled because, although operated by HHS, it receives funding from the Department of the Interior. Not only are health workers from agencies such as IHS and the Department of Homeland Security affected by the shutdown by being considered “excepted” and working without pay but also direct funding for programmes such as preventive health clinics on tribal lands are suspended until the government reopens, a dual burden for some of the most underserved Americans. The conditions under which that reopening is achieved will have tremendous implications for the coming year. With Pelosi at the helm leading an assertive congressional cohort who are comfortable disagreeing with the president, there could be more action specifically around lowering drug prices, which continued to rise in 2018, and increasing health coverage. Two key improvements with much better chances of occurring in 2019 would be allowing direct negotiation by the Centers for Medicaid and Medicare Services and eliminating barriers to introducing generic drugs to the market. Moreover, with the past few years of a Republican stronghold on congress and the plausible legislative threats to the ACA removed, a distinct opportunity now exists to revisit all the possibilities for expanding and achieving universal health coverage in the USA, from Medicare for All to a public option. It will take a showdown, but the show must—and will—go on.