Appropriations drama and the shutdown threat may be gripping the Hill. But Sept. 30 also marks the deadline for renewing a multitude of health programs due to sunset at the end of the fiscal year without congressional action.

• Community health centers and DSH payments are two of the more pressing items that could need short-term extensions on a CR, Victoria and Peter report.
• Others could be punted to later — or at least sustained through the appropriations process.

Community health centers

Extending funding for health centers that serve more than 31 million people has long had bipartisan support. Although none would immediately shut down on Oct. 1, backers argue they need the assurance of funding to keep workers and provide continuity.

• Joe Dunn, senior vice president at the National Association of Community Health Centers, said their workers "have a lot of different options" for employment, and that a lapse in funding would be "a signal to the workforce that there's instability and uncertainty."
• For a long-term reauthorization, there is still a question of whether the House's approach, with a modest increase, or Sens. Bernie Sanders and Roger Marshall's more ambitious increase, will win out.

DSH cuts

• Staving off scheduled cuts to DSH payments that offset uncompensated care is a recurring priority for hospitals, and a CR could also include some short-term relief here.
• America's Essential Hospitals warned in a letter to Congress this week of an $8 billion cut that would begin Oct. 1.
• "These cuts would undermine America's health care safety net and significantly reduce our hospitals' ability to provide lifesaving services to the communities you represent," the hospitals wrote.

PAHPA reauthorization

PAHPA reauthorization has been held up by partisan disagreements in the House around whether to use the legislation as a vehicle to address drug shortages.

• If PAHPA isn't reauthorized by the end of the month, pandemic preparedness efforts can still be funded through appropriations. The bigger deal, though, is that there are some provisions within PAHPA that do have expiration dates and would need to be extended.

The PEPFAR program that invests in the global HIV/AIDS response and efforts to address the opioid epidemic in the SUPPORT Act are also up for reauthorization.

Sen. Marsha Blackburn, one of the newest members of the Senate Finance Committee, hasn't wasted time trying to position herself as one of the panel's leaders on PBMs, rural health and other aspects of health policy.

• Blackburn seldom talks to the press in the hallways, but she sat down with Victoria last week to discuss next steps now that the bipartisan Patients Before Middlemen Act, which she co-sponsored, passed out of the committee. Responses have been edited for length and clarity.

Requiring PBMs to contract with rural independent pharmacies: "In Tennessee, we have 70 of our 95 counties considered rural. We have lost 15 rural hospitals over the last few years, so access is an issue."

• "Most of these towns have a pharmacy. It'll be there on the courthouse square. And this is the access point for a lot of health care and health care information for many Tennesseans."
• Blackburn has a bill with Sen. Joe Manchin that would address this PBM issue, and a bipartisan version was also introduced in the House this week.

How she addressed rural health access with a CMS waiver: "We assisted Fentress County, who got involved with the University of Tennessee Medical Center, and we got a waiver from CMS. At the end of June we opened a freestanding emergency room where you can get X-rays, you can get lab work."

• "So if people are going to Cookeville or Knoxville for a procedure, they don't have to go until it's time for the procedure. It gets them the urgent care they have not had."

Changing the VA care model to allow access at local facilities: "Having that local hospital, that local physician as the entry point for our veterans, that is something that they want. They want to be able to show that VA card and have the VA billed back for those services."

• "We have an enormous veterans population in the state. They don't want to have to go to Nashville or Knoxville or Memphis. They would like to be able to go in their community many times."
• Blackburn has a bill with Rep. Andy Biggs and several other Republican senators that would create a pilot program allowing veterans to access care outside the VA without a referral process.

We told you earlier today about the deal reached between Sens. Bernie Sanders and Roger Marshall on legislation to boost primary care and the health workforce.

• Since then, HELP Ranking Member Bill Cassidy is out with a more full statement explaining why he's not on board.

What they're saying: "The new bill lacks full Hyde protections and drastically increases spending without a plan to pay for it," Cassidy said.

Between the lines: The bill does include some payfors (that hospitals will not like!) but they do not add up to enough. Backers say additional payfors will be forthcoming.

Our thought bubble: There are other payfors floating out there, such as the Judiciary Committee's bipartisan drug pricing bills. But adding ones outside of HELP's jurisdiction would complicate matters.