While last week's election results left the nation up in the air over who will occupy the White House beginning Jan. 20, voters made clear that congressional leaders must compromise on healthcare issues next year or face gridlock.
An even tighter Republican majority in the House, and the possibility of a 50-50 split between Democrats and the GOP in the Senate, mean that congressional leaders will need bipartisan agreement over such issues as broad Medicare restructuring, a Medicare prescription drug benefit and HMO reforms if they want legislation to pass.
"Given the closeness of the margins and the presidential race, lawmakers will have to act more like statesmen than partisans to get things done," said Jim Edwards, spokesman for the Healthcare Leadership Council, a group of top executives of health systems and healthcare companies. "Will that happen? We don't know."
"If not, we're going to have a two-year knife fight," added Thomas Scully, president and chief executive officer of the Federation of American Hospitals, who served in the White House budget office of the father of GOP presidential nominee George W. Bush.
At deadline, the campaign of Vice President Al Gore was threatening legal action over the design of ballots in at least one Florida county. Meanwhile, Florida was completing a ballot recount to determine who won the state's 25 electoral votes after the initial results showed that Bush had won by a slim majority.
Both sides hoped a victory in Florida would clinch the presidential contest in the Electoral College.
That uncertainty could filter down to the key healthcare-related legislative action that Congress failed to complete before the election: Medicare provider payment increases.
Should the providers fail in their Medicare payment relief campaign this year, the loss of such prominent healthcare figures as Senate Finance Committee Chairman William Roth (R-Del.), Sen. Spencer Abraham (R-Mich.) and the retirement of Sen. Daniel Patrick Moynihan (D-N.Y.) could mean trouble.
Hospitals and other providers were asking both the Bush and Gore camps to make clear that they wanted Congress to roll back payment-growth restraints enacted under the Balanced Budget Act of 1997.
That legislation, worth more than $30 billion to providers and beneficiaries between now and 2005, had been caught in the pre-election budget showdown between President Clinton and congressional leaders.
The House passed that legislation, but the Senate has not voted on it yet. Clinton has threatened a veto.
Provider group lobbyists had been hoping cooler heads would prevail in a lame-duck session scheduled to begin this week. In addition, they were hoping that spending time in their states and districts would allow providers an extra chance to persuade lawmakers to roll back the spending-growth caps.
"I think members of Congress, now that they've been away, have had an opportunity to talk to seniors, talk to hospitals, talk to health plans about the need for this legislation," said Karen Ignagni, president and CEO of the American Association of Health Plans.
Yet without a clear presidential winner, it may not be a focus of the lame-duck Congress without direction from a president-elect.
"Having the presidential election in the air makes it more difficult (to get the Medicare bill passed)," said William Bruno, director of congressional affairs for the American Association of Homes and Services for the Aging, which represents not-for-profit nursing homes.
Another uncertainty is the shape of the new Congress once it convenes in early January.
The arrival of one new senator will loom large over the healthcare scene.
First lady Hillary Rodham Clinton, who took a prominent role in directing President Clinton's abortive effort to pass a massive healthcare reform bill in 1993 and 1994, won the seat vacated by Moynihan.
As a first-term senator, it's unlikely that the Democratic leadership would appoint her to a seat on the Senate Finance Committee, which has exclusive authority over Medicare, according to provider group lobbyists. Seats on that powerful committee usually go to more senior senators.
Yet she could take a seat on the Health, Education, Labor and Pensions Committee, which governs employer health plans and federal public health programs.
Key upsets also saw the defeat of one Senate committee chairman with power over Medicare and one of the hospital industry's chief Senate allies.
The Finance Committee's Roth lost his re-election bid to Delaware's Democratic Gov. Tom Carper, most likely leaving the committee in the hands of Sen. Charles Grassley (R-Iowa).
Grassley said in a statement last week that he had hoped to see Roth return as chairman, echoing a previous interview with MODERN HEALTHCARE (Aug. 14, p. 34). Based on the procedures and practices of the Senate, Grassley said he does expect to become finance chairman in January.
Despite Grassley's history of conflict with providers, some said his ascension might be a boon to the industry.
Among legislation he sponsored in the past two years that aims to help rural providers is one bill that would improve the accuracy of geographic adjustments to Medicare hospital payments based on local labor costs and another that would extend a prospective payment system to federal rural healthcare clinics.
"We would certainly appreciate having someone as chairman who has a clear and high level of expertise and leadership on these issues," said the AAHSA's Bruno.
With the retirement of Moynihan, the Senate Finance Committee's senior Democrat, the committee's leadership also will take on a more rural flavor. Sen. Max Baucus (D-Mont.) is Moynihan's likely successor.
Like Grassley, Baucus has made the needs of rural hospitals and providers a chief part of his Medicare agenda.
Still, provider lobbyists said there will be as many as four Democratic vacancies on the committee, which will allow for appointment from more urban states to offset the rural slant.
"I don't think the needs of urban hospitals will be left behind," said Richard Pollack, executive vice president of the American Hospital Association.
Hospitals also lost a friend in the Senate when Rep. Debbie Stabenow (D-Mich.) upset Sen. Spencer Abraham, a first-term Republican. This year he has been one of the strongest advocates for Medicare payment increases for hospitals.
He co-sponsored with Sen. Kay Bailey Hutchison (R-Texas) legislation giving hospitals a Medicare inpatient payment increase equal to an inflation measure called the hospital marketbasket index in 2001 and 2002.
Earlier this year, Abraham appeared with Hutchison and other lawmakers at an AHA-sponsored rally on Capitol Hill in support of rolling back provisions of the balanced-budget law.
For that, Abraham was rewarded by the two top hospital lobbying groups. As of Oct. 1, the Federation of American Hospitals' political action committee had given the senator's re-election campaign $2,000, and the AHA's PAC had contributed $9,000.