As the National Bipartisan Commission on the Future of Medicare nears its decision on how to reform the struggling program, observers are questioning what impact the blue-ribbon panel will have.
Several factors will determine whether the commission's report-scheduled to be released in March-immediately begins to gather dust on Washington shelves, results in short-term changes or leads to a grand scheme to ensure Medicare's health through 2030.
Can an ambitious plan to overhaul Medicare get the support of 11 of its 17 members-including Democratic and Republican appointees-as required by law? And if it does, will Congress pass and President Clinton sign legislation to enact the commission's recommendation in a year in which presidential campaigns will begin gearing up?
Or will Congress take a pass because it's unwilling to assume political risk and it feels safe in the knowledge that the Medicare Hospital Insurance Trust Fund isn't projected to go bankrupt until 2008?
"In political terms, the time horizon is the next election, and the Medicare Part A trust fund is not going to go broke between now and then," says James Scott, president of the Premier Institute in Washington, the lobbying group for Premier hospital alliance.
As for the prospect of the commission's reaching consensus, Scott says: "I can't imagine the commission could get 11 votes for the proposition that Wednesday follows Tuesday."
Even an ally of some of the Republican commissioners expresses doubt.
"I don't think we are going to see major restructuring of Medicare until the second half of the next decade," says Gail Wilensky, chairwoman of the Medicare Payment Advisory Commission and a HCFA administrator under former President George Bush. "Watch for 2005 or 2009, the years after presidential elections."
Wilensky advocates one of the leading proposals of GOP members and Democratic moderates: transforming Medicare's program from one in which Medicare pays fees directly to providers into one that helps Medicare beneficiaries buy their healthcare insurance.
Indeed, despite the odds against it, Sen. John Breaux (D-La.), the commission's chairman, plans to introduce at the next meeting-set for Jan. 26-a proposal that would change Medicare into such a "premium support" system.
Congress created the commission in 1997, with eight members to be appointed by Republicans and eight by Democrats. Under the law, the 17th member, the chairman, was to be an appointee approved by President Clinton, Senate Majority Leader Trent Lott (R-Miss.) and then-House Speaker Newt Gingrich (R-Ga.).
They settled on Breaux, a moderate Democrat who sits on the Senate Finance Committee, which has authority over Medicare.
Commission member Rep. William Thomas (R-Calif.), chairman of the House Ways and Means health subcommittee, also serves as "administrative" chairman, a position that was not specifically authorized under the law but was apparently a compromise.
But the political spectrum of commission members ranges widely. They include Rep. Jim McDermott (D-Wash.), an advocate of a national single-payer health plan, and Sen. Phil Gramm (R-Texas), an adamant opponent of government-run healthcare. Nine of the commissioners are members of Congress.
Weakness or strength? The wide diversity of opinion and the partisan balance of the commission could make reaching consensus difficult if not impossible, observers say. That's especially true because three Democratic appointees would have to go along with any proposal from the GOP, which now holds a majority in Congress.
Thomas, however, points to the 11-member threshold as a strength because such a majority should indicate strong political support. He adds that the presence of some members of Congress on the panel makes it more likely that some of the proposals will make it into law even if the commission can't reach a consensus.
"It could be moved as a piece of legislation that we can get to the president's desk," Thomas says.
That's why provider groups are watching the commission carefully, knowing that one of the easiest ways to improve Medicare's ailing financial health is to trim provider payments. That could come in the context of yet another comprehensive government revenue and spending bill next year, particularly since Republicans might be eager to pass a package of tax cuts.
The panel has "a heavier presence of people who can make things happen," says Richard Pollack, executive vice president of federal relations at the American Hospital Association. "Whether or not the commission reaches consensus on any one issue may not be the end of the story. It's got to be taken seriously no matter what."
Indeed, at the commission's meeting in December, some of the Democrats were angry that members were not allowed to debate provider savings when they were presented as an option to keep Medicare alive through 2030.
Meanwhile, Republicans and Democratic moderates were advocating a premium-support system, partly because they believe the savings would result from market forces and would not require Congress to vote for more reductions in the growth of provider payments.
A premium-support system, advocates say, would resemble the healthcare insurance plan the government offers federal employees. Under such a plan, the government would assist beneficiaries in buying private health insurance coverage. The government's contribution for each beneficiary would be roughly the same amount, and seniors would pay the portion of premiums exceeding the government contribution.
Congressional Republicans first proposed such a Medicare restructuring as they sought to balance the budget in 1995.
Democratic opposition and repeated vetoes and veto threats from President Clinton, based in part on objections to GOP Medicare reforms, led to the budget crises of 1995 and 1996, which resulted in government shutdowns and a public-opinion swing against Republicans.
Some observers say congressional Republicans risk a repeat of 1995 if they attempt such a reform, jeopardizing their chances of winning the White House and keeping their majority in Congress.
"I don't think Republicans want to give (House Democratic Leader) Dick Gephardt ammunition to be the next (speaker), and if they go too far, there's a real chance of that," says Howard Bedlin, vice president of public policy and advocacy for the National Council on the Aging.
Others, however, say public opinion turned against the GOP only on the issue of $270 billion in Medicare savings over seven years, which the balanced-budget bill sought.
"The big battle was over the amount of the cuts," says Commissioner Stuart Altman, a former chairman of the Prospective Payment Assessment Commission and a healthcare economist at Brandeis University, Waltham, Mass. "The premium-support idea wasn't really discussed."
Karen Ignagni, president of the American Association of Health Plans, adds that beneficiaries were uneasy about the GOP's 1995 plan because they believed it didn't connect the amount of the government's contribution to federal programs with the cost of healthcare.
But if the amount of the government's contribution was tied to the cost of the basic Medicare benefit package, for instance, the public might be more accepting, Ignagni says.
"I wouldn't necessarily think the past is prologue here, depending on how the program is defined," she says.
The commission's leaders, in fact, are warning against playing politics with the commission and its work.
Thomas, for one, doesn't necessarily believe panel recommendations will be the target of Democrats seeking to retain the White House and take back the congressional majority in 2000.
Likewise, at the December meeting, Breaux urged commissioners to reach consensus.
"I think we would do a disservice to the country if we were to politicize this issue," he said. "The best chance of fixing (Medicare) lies in this commission."