The "toenail clipping" philosophy has guided Sen. Charles Grassley's political career since he was first elected to public office in 1958.
"When I came to the (state) House of Representatives, I asked the speaker what I should do to be a good representative for my constituents," says Grassley, 66, a Republican from Iowa. "He told me, `If a little old lady comes into your office and asks you to clip her toenails, you do it.' "
You might say Grassley has clipped a lot of toenails in his political career. The Almanac of American Politics calls him "the most popular politician in Iowa since 1980," when he unseated incumbent Sen. John Culver, a Democrat.
Grassley's passion for healthcare policymaking stems from his underlying belief that government should be accountable to its citizens. In healthcare, Grassley says, that means ensuring the solvency of Medicare and Medicaid for future generations and requiring both providers and government agencies to follow the law.
Perhaps more important, his constituents help set his priorities. Iowa boasts one of the oldest populations in the nation, with 20% of its 2.9 million citizens age 60 or older, according to the Iowa Department of Elder Affairs.
The greatest test of Grassley's popularity may come if he takes the reins of the Senate Finance Committee, which is one of the congressional panels that controls Medicare's purse strings.
"I've been involved in federal advocacy for 20 years," says Stephen Brenton, president of the Iowa Hospital Association, "and Grassley is really well-positioned to not only continue his role in healthcare, but even to have a greater impact on deciding policy changes and improvements for the upper Midwest."
Already chairman of the Senate Special Committee on Aging, Grassley now stands close to inheriting the coveted chairmanship of the Senate's most powerful committee. Its current chairman, 79-year-old Sen. William Roth (R-Del.), is facing a tough re-election campaign this year. If Roth loses his bid for a sixth term, Grassley, as the most senior Republican on the finance panel, would likely take over as chairman, assuming the GOP retains control of the Senate. Grassley isn't up for re-election until 2004.
If Grassley is eager to assume that post, he refuses to show it.
"Let's address that (possibility) right away: I hope (Roth) gets re-elected," says Grassley, who still returns to Iowa every weekend to help his son on the family farm in New Hartford. "I enjoy chairing the Aging Committee. And in another two years, under the Senate rules, I would get my chance to chair the Finance Committee anyway." That's because Roth's six-year term as chairman would expire.
If he does become chairman, Grassley would bring to the job his experienced support staff, his sense of thrift and his quiet way of doing business-not to mention some baggage from previous battles with healthcare interests.
Indeed, the Iowan admits that at one time or another he's raised the ire of hospitals, nursing homes and funeral homes.
For example, he clashed with the American Hospital Association in 1998. The AHA was pushing legislation to exempt hospitals from the False Claims Act. The U.S. Justice Department was using the Civil War-era law to demand from hospitals the return of Medicare overpayments.
That put the AHA at odds with Grassley, who had authored the 1986 amendments that put teeth into the False Claims Act. Specifically, the amendments require stiffer penalties for organizations that try to defraud the government and give richer rewards to the whistleblowers who sue violators on the government's behalf. Grassley held hearings on rampant waste and fraud in the defense industry, which led to the additions to the law. Grassley considers his contribution to the False Claims Act to be one of his greatest political accomplishments.
"Unwittingly, the AHA was carrying water for the defense industry, and they had the respectability to get something done that the defense industry didn't have," says Grassley of why he fought the AHA-backed bill.
John Phillips, a whistleblower attorney at Phillips & Cohen in Washington, says, "Over the years, there have been many attempts to weaken this law, but it'll only happen over (Grassley's) dead body." Phillips worked closely with Grassley on the 1986 amendments.
Compared with other lawmakers who like to stage showy press conferences and speak in pithy sound bites, Grassley prefers to work behind the scenes.
That's exactly what he did to ward off what he called "an unconscionable assault" on the False Claims Act. Grassley helped broker an agreement between the AHA and the Justice Department that led to the creation of federal enforcement guidelines for healthcare--and the demise of the AHA-backed bill.
"Passing a piece of legislation is the worst way of adopting public policy, so I try to use methods other than that," the senator says. "If there's a problem out there, I try to get a consensus. I guess my personality is such that I would prefer to work in a friendly way rather than a confrontational way. You can always throw hand grenades, but eventually you'd have to catch some."
What drives Grassley is genuine, old-fashioned outrage at the waste of taxpayer dollars, Phillips says.
"He watched the government get fleeced over and over again (by the defense industry), and what shocked him was that nobody, not even the Justice Department, was doing anything about it," Phillips says. "He wanted to change the culture at these contractors. He was a stalwart in defending those (whistleblowers) who came forward."
In 1998 the Senate Aging Committee held hearings addressing alarming quality lapses in the nation's nursing homes, putting that industry on the defensive.
"(Nursing homes) think I'm going after them, but what I'm really going after is the bureaucracy that is not enforcing the law," Grassley says. "What I wanted to do was take care of the dehydration, the bedsores, the malnutrition."
Despite the confrontations with the healthcare industry, "over the long haul and presently, my relationship with healthcare groups is very good," Grassley says.
Representatives of industry groups agree.
"With both the senator and his staff, we've had a long and constructive relationship," says Charles Roadman II, M.D., president of the American Health Care Association, which represents 12,000 long-term-care facilities. "We've met with Sen. Grassley on a number of occasions, and he's genuinely devoted to the well-being of seniors, as are we. Sometimes we differ on the best way to do things, but we're all working on it."
As further evidence of his constructive relationships with providers, Grassley introduced in June legislation that would increase Medicare payments to Iowa hospitals by basing the payment formula on actual labor costs for hospitals, not the general number used by HCFA.
Grassley focused the bill on Iowa because the Medicare payments for wages that Iowa hospitals receive are among the lowest in the nation. Grassley says the Medicare wage formula presumes that labor costs are a greater percentage of Iowa's hospital costs than they actually are, unfairly driving payments down.
And as part of the $352 billion appropriations bill for the Labor Department and HHS, Grassley won Senate passage of several healthcare projects, including $15 million in funds for HCFA's nursing home inspections and another $15 million for health insurance counseling for seniors.
"The only issue where there was some discomfort was on the (False Claims Act)," says the IHA's Brenton. "Our relationship with Grassley is exemplary. He and his staff have done a lot of work on rural healthcare and equity in Medicare payments. I think he has a real passion for improving access to healthcare in rural areas."
Many lawmakers find it difficult to retain experienced and personable staff, because they get lured away to become lobbyists or analysts. But many who have worked with Grassley and his staff, including Phillips and Brenton, say the senator has figured out how to keep good people. Several staffers have worked in Grassley's office for 10 years or more.
"I give my employees the freedom to screw up," Grassley says. "I want my people to be good staff people, because that makes me a better legislator."
While he gives his staff breathing room, Grassley likes to fill his day with appointments and keep busy.
"He never has any down time in his schedule," says Jill Gerber, Grassley's press secretary. "He doesn't like idle time at all."
"He is an incredibly hard worker," says Brenton. "Every year, he visits each county in Iowa, and Iowa has 99 counties. He often uses the local hospital as a venue for the event. His popularity relates to his hard work. He gets out and about. He's a regular guy, and people really like him."
When Grassley isn't working in Washington or meeting with constituents in Iowa, he spends time on his family farm, where his son grows corn and soybeans.
His wife, Barbara, who is a cancer survivor, works at the Washington lobbying firm Chambers Conlon & Hartwell. Four of the Grassleys' five children are married, and they boast nine grandchildren.
Grassley also enjoys running, which he started doing regularly at age 65. He even invites his staff to join him for his two-mile run at 5: 29 a.m. each weekday--choosing an odd time so that his jogging partners will better remember it and arrive promptly.
"I run because I've visited enough nursing homes and I know what a tough job they have," Grassley says. "I want to stay out of the nursing home, so I started running."
His competitiveness also shows up in his running.
"I ran a (five-kilometer) race a few weeks ago, and I didn't come in first, but I didn't come in last, either," he says of his 28-minute finish.
And Grassley is still running in the political sense, too. He says he will run for one more six-year term in 2004; if he gains that fifth term, the senator will retire in 2010.
"The people of Iowa don't like to be taken for granted," he says.