Congress is finding that creating a healthcare agenda is like trying to assemble a poorly cut jigsaw puzzle: The pieces don't always fit well together.
With two months gone in a legislative year shortened by a presidential election, Congress finds its in-box still stacked high with healthcare legislation. It's made slow movement toward resolution on many bills.
No matter which way Congress turns on healthcare, it is looking at legislation that could anger providers, beneficiaries or consumers, making a usually tricky balancing act downright treacherous this year.
Where Congress turns may depend on what lawmakers hear from constituents during a mid-April recess.
"I don't think they've spent enough time at home," said Herb Kuhn, vice president of advocacy at San Diego-based Premier hospital alliance. "That two-week break allows us to take our shots."
The biggest question is the fate of managed-care reforms, being considered by a conference committee appointed to resolve major differences in legislation passed by the Senate and House.
The 33-member committee had set a March 31 deadline for producing a compromise bill, but that deadline now looks doubtful. Committee members have not reached an agreement even on issues on which they are in some accord, such as guaranteed access to specialists.
Those smaller disputes come even before the conference has begun trying to bridge the biggest gap between the two bills-whether to give HMO enrollees the right to sue health plans for damages resulting from the denial of covered benefits. The House bill allows such lawsuits, but the Senate bill does not.
"The momentum is not too great at the moment," Jack Ericksen, executive director of congressional relations at the Blue Cross and Blue Shield Association, said of the conference committee's work.
Physicians and consumer groups have pushed the House-passed legislation, arguing that managed-care plans have routinely been denying appropriate care to enrollees. Hospitals are opposing it, however, because of provisions that would prevent hospitals from firing workers who report legal violations.
But as those negotiations bogged down last week, another healthcare bill began moving on a separate track. That bill also could anger hospitals and health plans.
The House Judiciary Committee began moving toward passage of legislation that would allow physicians to bargain collectively for higher payments from health plans and other providers. Existing antitrust laws define such collective negotiations by physicians as illegal price-fixing.
There also is a strong push for a national reporting system for medical errors and public access to the National Practitioner Data Bank. Hospitals and physicians alike fear the potential lawsuits and bad publicity that could result if the reporting system or public access were to become law.
But Congress could be ready with some salve for providers' wounds.
The House Budget Committee also last week began work on a budget blueprint for federal fiscal 2001 that would reserve $40 billion of the federal budget surplus during the next five years for Medicare reforms and add prescription drugs to the array of Medicare-covered benefits.
Hospital lobbyists believe the language will open the door to another round of provider payment increases, reversing the payment cuts enacted under the Balanced Budget Act of 1997. Last year, Congress passed $16.1 billion in increased payments over five years.
Should Congress pass the managed-care reforms, antitrust exemptions for physicians or medical-errors reporting, the budget blueprint would allow Congress to shower hospitals and health plans with new cash to ease their pains.
Under such a scenario, beneficiaries could be left out, however, particularly with Congress muddled about how to construct a Medicare prescription drug benefit. Though President Clinton has proposed a universal benefit that would cover about half of Medicare beneficiaries' drug costs, some in Congress are arguing for a program to cover low-income beneficiaries or those with high prescription drug spending.
Beneficiary groups, led by the American Association of Retired Persons, have argued that they, not providers, should be first in the queue for increased expenditures from the surplus.
Clinton's plan makes that job of compromise harder, Ericksen of the national Blues association said.