Throughout his campaign, George W. Bush touted his ability to bring Republicans and Democrats together and achieve consensus. As president, he will attempt to prove it. And given the bipartisan feud that lasted for much of President Clinton's eight years in office, that will be no easy task.
If Bush can pull it off, those who watch Washington health policy predict movement on such issues as a patient bill of rights, reducing medical errors and prescription drug coverage for seniors. If Bush can't make headway, those issues could remain prominent or could fall by the wayside as he tries to pass a tax cut--the central plank of his campaign platform.
"It's very hard to predict" what will happen, says attorney Bruce Fried, who heads the healthcare practice group at Shaw Pittman in Washington. Fried previously served as director of the Center for Health Plans and Providers and as director of the Office of Managed Care at HCFA.
Bush not only must deal with losing the popular vote but also a Congress that picked up Democratic seats and is almost evenly divided between the two parties. As a result, Democrats are in an even better position to potentially block GOP initiatives than they were last session.
While both parties have called for bipartisanship and expressed their willingness to cooperate, it's far from clear whether that will actually happen, says Joe Karpinski, spokesperson for the Senate committee on Health, Education, Labor and Pensions.
"We will have to wait to see what impact bipartisanship will have," Karpinski says. "Members have not been around to talk about the issues, and we'll have a number of new senators. We also don't know who committee members will be and the balance between Republicans and Democrats" in the committees. Such questions about both houses will be answered later this month by the new Congress.
One key position, however, is certain. Sen. Charles Grassley (R-Iowa) will be the new chairman of the Senate Finance Committee, which has jurisdiction over Medicare, among other issues. Sen. William Roth (R-Del.), the former chairman, lost his re-election bid.
Grassley has a great deal of interest in healthcare, particularly rural health and other underserved areas, says Bob Doherty, senior vice president of governmental affairs and public policy at the American College of Physicians-American Society of Internal Medicine. Grassley also is one of the most persistent legislators in "browbeating" HCFA to reduce fraud and abuse by providers. "That means for the provider community continued vigilance," Doherty says. "Grassley is not going to back off."
In the House, Bill Thomas (R-Calif.) was named chairman of the Ways and Means Committee, which oversees tax policy, Medicare and Social Security. Former Chairman Bill Archer (R-Texas) retired. Rep. W.J. "Billy" Tauzin (R-La.) was named chair of the Commerce Committee, which also has jurisdiction over Medicare.
The level of bipartisanship Bush will encounter was unclear in early January. The Senate announced Jan. 5 a radical power-sharing agreement that gives Democrats and Republicans an equal share of committee members, staff budgets and the ability to bring legislation to the Senate floor. But Democrats have voiced serious opposition to three of Bush's cabinet nominees. Nasty confirmation hearings for any one of them could poison the atmosphere for what was hailed as unprecedented cooperation.
The first test of bipartisanship will be regarding President-elect Bush's key campaign issue of tax cuts. While this will dominate other issues in the first half of 2001, there certainly can be movement on other fronts, Karpinski says. A patient bill of rights, prescription drug coverage for seniors, Medicare, medical errors and privacy will at least be debated at the committee level, he and other observers say.
While Fried is neutral about the prospects for a rights bill coming out of Congress, Lee Newcomer, M.D., CMO at Minneapolis-based Vivius, is more optimistic. Vivius, a startup, will allow individuals to create their own network of doctors and hospitals via the Internet.
"What's going to move people (into action) is Republicans and Democrats have the same agenda," Newcomer says. He noted that House Minority Leader Dick Gephardt (D-Mo.) made patient rights a key Democratic issue in the fall elections and Bush allowed a patient protection bill to be signed into law in Texas during his term. When asked whether Bush would oppose liability limits on HMOs, which Democrats find critical to any patient bill of rights, Newcomer, the former vice president of health policy at UnitedHealth Group, notes that the Texas law has no such restrictions and says that "I'm not sure this is an issue Bush would fight over."
As for prescription drug benefits, it too was a key campaign issue, but compromise will be more difficult to find, says Doherty.
Bush's plan to provide drugs is part of a "radical" plan to change Medicare and create "in essence a voucher system," Doherty says. "I think that this kind of revamping is not in the cards," he says. He notes that compromise will be difficult because Bush's vision is so different than the plan laid out by and supported by the majority of Democrats.
General Medicare reform isn't likely to face much tinkering, Newcomer says, because there isn't enough consensus among the electorate about what to do.
"I don't think Medicare can be attacked until it's truly in crisis, and it's not there yet," he says.
Medical errors legislation is even more uncertain, Fried says. Although medical errors was the subject of hearings and several bills in both houses last year, Fried says, "everyone is waiting to see what HCFA does on it as a condition of participation" in Medicare. A follow-up study to be released early this year by the Institute of Medicine may help to focus attention on the issue, Fried says.
Karpinski says legislators haven't agreed on what the appropriate role the federal government should play in medical errors, and that is critical before bills can move forward.
Finally, on the issue of medical records privacy, providers and payers aren't likely to accept recently issued regulations without a fight, Karpinski says. Under the regulations that take effect next year, health plans, doctors and other providers are required to tell patients about how their medical records are being used and who is privy to the information. Patients also will have a right to receive a record of all of the entities that have viewed their medical information.
"Pretty much everyone has agreed that legislation on medical records privacy is better than regulations," Karpinski says, adding that his committee will hold hearings on the matter this year to see "what more needs to be done."
Newcomer also believes that the issue is "much too dear to every voter to let the bureaucracy issue regulations." As the regulations stand now, researchers doing medical research will have to get hand-signed consent forms each time they use a patient's data even if the results of the study are aggregated and contain no information about individuals, Newcomer says. Such regulations would effectively shut down research at institutions like the Mayo Clinic.
In Doherty's estimation, the uncertain outlook on key issues is positive. Generally, healthcare providers and other groups must react to the agenda of a party winning decisively in elections. In the November elections, voters gave no clear mandate.
"When there is no mandate, a vacuum is created, which creates an opportunity for the healthcare community because (policymakers) are going to look for ideas," Doherty says. "Usually, our ideas may get crowded out."
While far from clear, there are some signs that the bickering may cool off. In December, House Majority Whip Tom DeLay (R-Texas) met with conservative Democratic legislators to seek common ground. Sen. John Breaux (D-La.) revived the Senate Centrist Coalition, a group of 10 moderate Democrats and Republicans. Yet key Republican leaders, such as Senate Majority Leader Trent Lott (R-Miss.), rejected calls for evenly divided committees and reiterated their position that Republicans should have a one-vote majority on the panels.
"It takes two to have bipartisan cooperation," Karpinski says. "We will have to see."
Clinton healthcare initiatives that failed
- Healthcare reform: seen by Republicans as too large and unwieldly, unpopular with public
- Patient bill of rights: primary concern was over liability (patient's ability to sue health plans)
- Medicare prescription drug coverage: Democrats favored much more coverage than Republicans, who sought more means testing
- Medical records privacy: Democrats favored stronger regulation over paper and electronic records than Republicans
Key healthcare items in fiscal 2001 budget
- $35 billion to providers who were hit by Medicare cuts as a result of the 1997 Balanced Budget Act, including $12 billion for hospitals, $11 billion for Medicare managed care plans, $5 billion for new benefits and $3 billion for other healthcare providers
- Delayed implementation of a payment system for ambulatory surgery centers, many of which are owned by doctors, until 2002
- Glaucoma screening every other year for Medicare beneficiaries
- Demonstration project for disease management for severly chronically ill Medicare beneficiaries
- Expansion of Medicare's Pap test coverage to once every two years instead of once every three years
- Continuation of medical savings accounts for another two years, which were set to expire at the end of 2000
- Medicare Payment Advisory Commission to study coverage barriers and payment issues for outpatient pain management procedures