Perceptions of hospitals as crooked, doctors as greedy and managed-care plans as stingy are likely to dominate the public debate in Washington in 1998, but the real action will be behind the scenes where regulations are made.
For the first time in many years, fights over balanced budgets, Medicare cuts and major healthcare reform have receded. In their place are fraud and abuse in the healthcare industry and protecting patients from the supposed evils of managed care.
Driven by consumer pressure and election-year worries, Congress is almost sure to debate -- and might be more likely than ever to pass -- broad legislation governing healthcare quality and patient protections.
The debate probably will center around such issues as "gag clauses," or contractual restrictions on what physicians can tell health-plan enrollees about their treatment options, as well as access to emergency and specialty care.
The first salvo of 1998 actually was fired last November when President Clinton endorsed the "Consumer Bill of Rights and Responsibilities" approved by his Advisory Commission on Consumer Protection and Quality in the Health Care Industry.
Clinton called on federal agencies that administer healthcare programs to abide by the patient protections in the bill of rights. He also sought "appropriate" legislation to reinforce those protections.
The guidelines in the bill of rights will join a bubbling stew of legislation introduced in the past year by numerous members of Congress.
"There's a 100% probability that they're going to consider legislation under the quality banner," said Brent Miller, vice president of public policy and political affairs for the American Medical Group Association.
"Whether or not the process results in convoluted legislation that's unworkable and never gets signed, or whether it becomes a pitfall to trap unwary legislators, or whether it becomes a pig in a poke, remains to be seen," Miller said.
In Congress, it will not become simply a Republican vs. Democrat issue. Many of the chief sponsors of patient-rights legislation are Republicans such as Rep. Greg Ganske (R-Iowa), a reconstructive surgeon; Rep. Charles Norwood (R-Ga.), a dentist; and Sen. Alfonse D'Amato (R-N.Y.), who must win re-election in 1998.
But the chief opposition to patient-rights legislation also will come from the Republican Party, including some members of its congressional leadership. Their claim is that patient protections will saddle employers with new costs and lead to a greater number of uninsured.
In a memo sent to House Republicans, House Majority Leader Richard Armey (R-Texas) warned members that quality mandates "are not well-suited to enhance the quality of our market-based healthcare system."
Armey also contended that patient-protection legislation could be "hijacked" to implement much of Clinton's failed 1994 healthcare reform plan.
Those more conservative members appear to have many employers and insurers on their side. Among the voices opposing the potential for regulation stemming from the bill of rights were the National Federation of Independent Business, the Health Insurance Association of America and the Business Roundtable.
Given the opposition, it's unlikely a comprehensive anti-managed-care bill will pass Congress. It is much more likely that the two sides will choose several provisions that managed-care plans and employers can live with, reject the remaining mandates and pass a smaller bill. That will allow Congress to declare victory and return home for the 1998 elections having passed "patient protection" legislation.
Another politically popular area for Congress is healthcare fraud and abuse.
"I'm not sure where the pendulum is right now," said Robert Falk, an attorney specializing in fraud issues with Powell, Goldstein, Frazer & Murphy in Washington. "It has been swinging to the Tora, Tora, Tora (attack, attack, attack) side, and I don't see the end of that."
Meanwhile, it seems that every new healthcare spending initiative in Washington these days is funded by savings from combating healthcare fraud.
For example, earlier this month, the Clinton administration proposed allowing early retirees and those 55 and older who lose their job to buy into Medicare. Administration officials admitted that the premiums charged the new enrollees would not completely cover the cost to Medicare. The $3 billion difference would be made up, the officials said, through increased anti-fraud activity.
The reliance of both Congress and the White House on budget savings from fraud and abuse makes it difficult for them to take their hands out of the cookie jar.
In fact, with the new tools and funds given them in the 1996 insurance reform bill and last year's balanced-budget law, federal investigators are being more active than ever.
Too active, according to some. The American Hospital Association is organizing a grass-roots campaign to win passage of a bill to rein in some of the federal government's anti-fraud power (Jan. 12, p. 21). But it's an uphill battle. Denouncing fraud and abuse is fashionable, and no politician wants to be seen as soft on fraud, especially in an election year.
The White House is banking on election-year politics to win passage of its proposal to allow early retirees into Medicare. Under the plan retirees age 62 and anyone losing his or her job after turning 55 could buy into Medicare.
Critics say it will cause adverse selection and further strain the already shaky finances of the Medicare trust fund. But supporters of the measure, including John Rother, director of legislation for the American Association of Retired Persons, said it can pass next year.
"This will be very popular (among seniors), and in an election year it will be very hard not to (support)," Rother said.
Even if it is a slow year on the legislative front, it will not be on the regulatory side. HCFA still was digging out from under the blizzard of rules and new regulations promulgated by the Health Insurance Portability and Accountability Act of 1996 when the balanced-budget law was enacted last year.
The budget created a whole new structure for Medicare -- called Medicare+
Choice -- and allowed retirees to choose new delivery system options, most notably provider-sponsored organizations.
HCFA is struggling to meet hundreds of deadlines for new regulations implementing Medicare+Choice. Publicly, HCFA officials say they hope to meet all the deadlines called for in the balanced-budget act. But privately, they say they will have to pick and choose which regulations to finish on time and which can wait.