In the last weeks of this year's healthcare reform debate, provider groups were almost unanimously against the scaled-down, "incremental" reform plans sprouting up almost daily on Capitol Hill.
Providers were worried because such plans generally contained large reductions in projected Medicare spending to finance programs or reduce the federal deficit, while moving only marginally toward universal coverage.
But as they opposed the plans, they acknowledged they were taking a huge risk.
Even in the incremental plans, at least some of the Medicare revenue lost through spending constraints would remain in the healthcare system in the form of increased insurance coverage or a prescription drug benefit. Some lobbyists now fear a more Republican and more conservative Congress will be elected this fall, one more inclined to reduce Medicare spending to cut the budget deficit.
Frederick Graefe, a healthcare lobbyist with the law firm of Baker and Hostetler in Washington, said the Medicare reductions in the reform plan offered by a self-styled group of politically "mainstream" senators-$255 billion in cuts made over 10 years-are likely to be the starting point for congressional debate next year.
He speculated that Rep. Fortney "Pete" Stark (D-Calif.), chairman of the House Ways and Means health subcommittee, will continue to push for reductions in Medicare payments to providers. That, combined with more conservative forces in the House, will create pressure for Medicare cuts.
American Hospital Association President Richard Davidson agreed that the threat of large-scale Medicare cuts looms over next year, especially if Republicans gain control of the House and Senate.
"One thing that's certain, Medicare is going to be on the table....It's going to be a hell of a challenge," Mr. Davidson said.
While deficit reduction is likely to be one of Congress' priorities, healthcare reform may resurface, but on a much more modest scale. Those close to the White House during the reform debate say the Clinton administration is already considering whether it is better to regroup behind a more modest plan next year; push forward on the larger goals such as universal coverage; or try to get some healthcare reform agenda items through other legislative vehicles.
Irwin Redlener, M.D., president of the Children's Health Fund and a strong supporter of the Clinton plan, said last week that he had spoken to first lady Hillary Rodham Clinton and found her "still committed to fixing the healthcare system." He said she hoped to revive the theme of universal coverage next year.
William Cox, vice president of government relations at the Catholic Health Association, said the administration "is absolutely intent on continuing a strong leadership role for healthcare reform. I'm absolutely convinced of that."
Others predicted it will be virtually impossible to pass a healthcare reform plan next year and that the administration will instead use the budget to push some of its reform agenda.
Mr. Graefe predicted "the administration in its fiscal year 1996 budget proposal will include a scaled-back, modest healthcare reform proposal financed by huge Medicare cuts. They will seek to cover pregnant women and children; there will be some modest insurance reforms, malpractice reforms, administrative simplification, and some fraud-and-abuse provisions."
Another outcome of this year's healthcare reform failure will be increased activity at the state level, according to provider groups.
"All of the same problems are going to be there next year; they aren't going to go away. So I think, out of frustration, the states are going to try just about anything," Mr. Davidson said.
To that end, the administration last week said it would make it easier for states to experiment with health reforms by streamlining the process through which states receive federal authorization to make Medicaid program changes.
The idea of more state experimentation worries some providers.
"We have been concerned that we can't have 50 different healthcare systems," said American Medical Association Executive Vice President James Todd, M.D. "That will make it even harder to get a national healthcare reform plan through."