Hospital groups are standing on the sidelines as Congress kicks around a political football containing a half-trillion dollars of relief for the beleaguered Medicare trust fund.
While the American Medical Association and other physician groups have been forceful advocates for national legislation to enforce an agreement between tobacco companies and the states, the American Hospital Association and other hospital groups have been conspicuously silent.
"AHA is sort of AWOL on the tobacco issue," said Tom Lehman, a federal lobbyist for Blue Cross and Blue Shield of Minnesota. "AHA is probably the single largest health lobby in the country that's not involved. I would like to see AHA step up to the plate."
The AHA and the Catholic Health Association claim they are spread too thin to take on tobacco; both are seeking changes in Medicare payment policies and the federal government's crackdown on fraud and abuse.
"To take some of our political energy and devote it to a debate in which we're one of the smaller voices doesn't seem like a good thing to do," said James Bentley, the AHA's senior vice president for strategic policy planning. "We aren't adding a lot by being in the third row of the chorus."
CHA lobbyist Jack Bresch echoed that sentiment: "I'm not sure we'd bring a whole lot of expertise to (the tobacco-settlement debate)."
The AHA plans to get more active as Congress nears decisions on how to spend the $516 billion sought in tobacco legislation, Bentley said.
But that may come too late. Last week, Steven Goldstone, chairman and chief executive officer of RJR Nabisco, declared the legislation "dead" and said he would no longer participate in negotiations, partly because the legislation contains huge tax increases.
"I am not going to spend time walking the halls of Congress in the context of an agreement that came out of a process that is broken," he said.
He threatened a grass-roots campaign against the legislation.
The AHA's board of trustees' chief concern with tobacco legislation is ensuring the money it generates is spent on healthcare. The original justification for state lawsuits against the tobacco companies that led to the initial national settlement last year was the cost of smoking-related illnesses to state Medicaid programs.
"If people on (Capitol) Hill perceive that there's going to be a settlement . . . then an increasing number of interests will seek to capture the money," Bentley said. "As it gets to be a real pot-of-gold situation, we'll have to get really active."
He added that there was a danger that too much lobbying by the AHA could endanger the legislation.
"The more parties that are arguing on particular niche issues, smoking prevention vs. care, the more you stand a chance of causing this thing to fall apart," Bentley said. "Our board wants to make sure we're not in a position where we help this thing fail."
Other hospital groups have lent their names to anti-tobacco efforts. The National Association of Children's Hospitals and the American Protestant Health Alliance have signed advertisements, sponsored by the Campaign for Tobacco-Free Kids, in favor of a tobacco bill.
The National Association of Public Hospitals and Health Systems has supported a policy passed by the National Association of Counties and the National League of Cities calling for reimbursement to Medicaid for the cost of smoking-related illnesses and to public hospitals for treating uninsured people with tobacco-related illnesses.
Meanwhile, the AMA and some of its specialty group affiliates have been far more prominent in pushing public health issues surrounding tobacco.
Functioning as a coalition called Effective National Action to Control Tobacco, physicians are urging Congress to give the Food and Drug Administration full authority to regulate nicotine as a drug and to impose tough penalties on cigarette makers if youth smoking doesn't decline over time.
A top AMA official said he believes all healthcare groups need to push Congress to pass the legislation.
Randolph Smoak, M.D., vice chairman of the AMA board of trustees, said: "Becoming involved in lobbying is important because the more the members of Congress hear . . . the more likely it is that we will have some action."
Similarly, the Minnesota Blues' Lehman, whose company last week won a legal battle with the tobacco companies to gain access to thousands of pages of secret documents, said he believes the AHA is missing the boat on the tobacco issue.
The hospital group, for example, could influence the debate because it has members in many congressional districts and their members' trustees often are community leaders with strong ties to Congress, Lehman said.
He added that some of the AHA's members have taken steps to try to stop youth smoking. The Minnesota Hospital and Healthcare Partnership, for example, last year was effective in urging state and local governments to pass tough laws against selling tobacco products to minors.
Legislation that passed the Senate Commerce, Science and Transportation Committee earlier this month would require cigarette manufacturers to pay $516 billion over 25 years to a trust fund.
Although it does not specifically allocate money from that trust fund, the legislation includes "sense of the Senate" language stating that the money should be used for smoking prevention and cessation programs, tobacco-related health research, and compensating Medicare and other public health programs for the costs of illnesses caused by tobacco use.