House Ways and Means health subcommittee Chairwoman Nancy Johnson (R-Conn.) is a powerful figure in healthcare policymaking. She's a 10-term lawmaker and a known friend to the hospital industry. In fact, she ranked No. 50 in Modern Healthcare's inaugural list of the 100 Most Powerful People in Healthcare (Aug. 26, p. 6). And now her power is up for grabs.
Johnson is in a tight race with Rep. James Maloney (D-Conn.), a three-term congressman who has moved into Johnson's territory as a result of redestricting in Connecticut. For many, including two major hospital lobbying groups, Johnson's race is one of a handful around the country that could change the course of healthcare policy starting next year.
If Johnson is replaced as health subcommittee chair after the election, "we would hope it would be someone who would reflect the moderate sensitivities Ms. Johnson has," says the Rev. Michael Place, president and chief executive officer of the Catholic Health Association.
Up to the voters
When voters cast their ballots on Nov. 5, attention from the White House and in the newspapers is almost certain to focus on Iraq, terrorism and other national security issues. And scarred by corporate scandal, the economy is likely to still be in low gear.
With these weighty concerns joining voters in the booth, there may not be much room left for issues such as Medicare, rural hospitals and prescription drugs. Most polls in recent weeks indicate voters are mostly watching the economy and Iraq. They'll only take healthcare to the booth if they see it tied to the larger issues-which can and will happen, according to some analysts.
"The two overwhelming issues in this election cycle are national security and economic insecurity," says Whit Ayres, a Republican pollster based in Atlanta. "The second-tier issues that will get traction are those that can be linked to national security or economic insecurity . . . anything involving paying for healthcare at a time of economic insecurity will get an eager hearing."
Some argue that healthcare issues will play prominently in the upcoming election, especially if voters view their congressional representatives as more responsible for bread-and-butter matters such as jobs and Medicare than for less close-to-home matters such as international relations.
"I think healthcare is moving to the center stage in the national political arena," says Oregon Gov. John Kitzhaber, M.D. "It's being overshadowed right now by Bush's war, but in the next three years it'll be right in the middle," says Kitzhaber, a former emergency-room doctor who is one of only two physician governors in the nation. The two-term Democrat, who cannot seek re-election because of term limits, will leave office in January.
An AARP poll conducted last month found that 26% of voters age 45 and older would vote against candidates who fail to support a Medicare drug benefit. "Voters expect something to be done this year, and we're running out of time," says AARP Director of Advocacy Chris Hansen.
Prescription drugs are mostly an issue for seniors, but they vote in large and confident blocks. Even as many other voters are more concerned with the struggling economy, healthcare is in the election game this year-maybe as a starting player.
"Any issue that disproportionately affects seniors will have more of an impact in a nonpresidential year election," Ayres says.
Political scholars agree. "When the economy is an issue, healthcare is often the tail on the dog," says Robert Blendon, professor of health policy and management at the Harvard School of Public Health. "People worried about the economy often want more aggressive action on healthcare."
With the national security debate garnering much of the public's attention, it's difficult to get agreement on how much healthcare will figure in the midterm election. But prognosticators and politicos agree on this much: Healthcare policy will shape some races, and some races could reshape healthcare policy. If the election gives control of Congress to one party, for example, the landscape for healthcare legislation could become more fertile.
"If Congress went significantly Democratic we would see a prescription-drug benefit," Blendon says. "If it really went Republican we'd see a drug benefit run by private companies."
On the other hand, "if we continue to have a split between the House and the Senate in terms of party affiliation, that always makes any legislative agenda more difficult to move forward," Place says.
It is the first election since President Bush took office that voters will recast the nation's leadership. It is also the first one since Sept. 11, 2001; since the possibility of invading Iraq re-entered the national debate; and since the Senate failed this summer to pass a drug benefit for seniors.
"Half to three-fourths of the country may not even know Iraq exists, but they know where their drugstore is and the difficulty they have affording prescription drugs," says Ron Pollack, executive director of Families USA, a Washington-based consumer advocacy group. In the upcoming midterm election, Pollack says, "I think healthcare is going to be huge."
It's likely to be bigger in some races than in others. In Maine, healthcare is a hot campaign issue. Sen. Susan Collins, a Republican, and former state Senate majority leader Chellie Pingree, a Democrat, are competing in a Senate race dominated by discussions of prescription-drug coverage. Pingree pioneered Maine's controversial and trendsetting law to rein in drug prices, but her opponent is hardly viewed as a slouch on healthcare issues, especially those of concern to hospitals.
"(Collins) served on a hospital board before she went to the Senate," says Al Jackson, vice president of political affairs and grass-roots advocacy at the American Hospital Association, which is donating roughly $2.3 million to candidates on both sides of the aisle in the election season. "We expect and we hope that Sen. Collins will be re-elected."
It's a close one. As of last week, Pingree had closed to within nine points of Collins in state polls. Both candidates have their ammunition-Pingree sponsored the drug price containment law she promises to nationalize; Collins voted this summer in favor of federal legislation that would restrict drug companies from extending their patents at the expense of generic competitors.
Pingree is "running against an admittedly popular incumbent who is viewed as fairly moderate in the whole scheme of things," says Dave Lemmon, a spokesman for Sen. Debbie Stabenow (D-Mich.), who as a freshman lawmaker has sponsored several proposals to reduce the cost of pharmaceuticals.
The bid for Senate control
On the Senate side, 34 seats are up for re-election. Democrats control the Senate by one seat. In the House, Republicans defend a six-seat advantage as all 435 members face re-election. Healthcare advocates are closely watching Senate races in Iowa, Minnesota, Missouri, Montana, New Hampshire and South Dakota, where a range of issues from prescription drugs to rural access are fueling the campaign engine.
In addition to a Medicare drug benefit, some races have included discussion of the growing number of uninsured Americans. But that issue has yet to become a centerpiece of any races, observers say.
"There are some areas of the country, if you read the editorial pages, where there is more attention to the issue of the uninsured," says the CHA's Place. "Unfortunately that does not seem, according to the polls I've read, to have resulted in (healthcare) being one of the top three issues by which people are making election decisions."
In South Dakota, Sen. Tim Johnson, a Democratic incumbent, faces Republican Rep. John Thune in a close race that many say could determine which party will control the Senate. As of last week the candidates were in a dead heat, with each garnering about 40% support among South Dakota voters, according to one newspaper poll.
Johnson, who represents the same state as Democratic Senate Majority Leader Tom Daschle, sponsored Senate proposals this summer allowing the re-importation of prescription drugs from Canada and expanding the availability of generic drugs. Meanwhile, as a member of the House's bipartisan Rural Health Care Coalition, Thune is viewed as a rural hospital advocate running in a state so small he is its only member of the House.
"If there's any race in the country that is the focus of everybody in Washington, it's the South Dakota Senate race," says the AHA's Jackson. The association hasn't yet weighed in on that race; in others it supports Rep. John Dingell (D-Mich.), "who's been very helpful to us," and Rep. Jim Nussle (R-Iowa), "whom we consider a real friend and leader."
In the Iowa Senate race, incumbent Tom Harkin, a three-term Democrat, faces Republican Rep. Greg Ganske, M.D., in a battle pitting a lawyer against a doctor. "Lawyers are trained to argue. Physicians are trained to solve problems," Ganske told Modern Healthcare earlier this year.
Harkin, meanwhile, has been a strong supporter of boosting Medicare payments, especially to Iowa, where "we pay the same Medicare taxes as everyone else in the country, yet we are dead last in reimbursement. It affects seniors, businesses, hospitals, doctors, nurses and the entire economy in the state of Iowa. It's simply unfair and must be fixed," Harkin has argued.
Although some state polls have given Harkin a slight edge, most show a slim margin separating him and Ganske.
Focus on the House
Perhaps most important in the House is Connecticut's Johnson, viewed by many in the hospital community as a moderate lawmaker who's sharp on healthcare issues and often a friend to providers. If she loses to fellow lawmaker Maloney, hospitals and other providers could suffer the fallout, industry observers say.
"Johnson has been a moderate influence on the Republican side, and I think it would widen the split between Republicans and Democrats if she were to lose," Blendon says.
Many election forecasters say it's still too early to know how healthcare will shape such contests and their outcome.
"Where is the president going in terms of Iraq?" asks Place. "Depending on where the conversation about that is, the national awareness could be in a very different place" by Nov. 5.
Regardless of voters' mindset on election day, some healthcare advocates hope for a change in party leadership in the House that could bode well for consumers and hospitals alike. "I have no doubt that Democratic control of either or both houses augers much more optimistically for healthcare legislation being considered early and seriously," Pollack says.
Political analysts, including Pollack, agree for the most part that Democrats-generally perceived to be strong on healthcare issues-have the most to gain from a debate dominated by medical matters. That could change, however, if voters blame the Democratic Senate for failing to pass a prescription-drug bill after the Republican House did so in July.
"There are slight advantages for Democrats on the (prescription-drug) issue," Blendon says. "Seniors think Democrats might do more." Even so, he adds, the House can brag about what it passed, while "the Democrats don't have a clear picture on this."
In terms of hospital payment issues, control of Congress doesn't matter as much because those issues tend to be bipartisan, according to Richard Pollack, executive vice president of policy and advocacy at the AHA. "You don't see Republicans and Democrats fighting over improving provider payment," he says.
To at least one politician intimately familiar with healthcare issues, a change in party leadership-in either house of Congress-wouldn't do much to advance the cause of issues such as unaffordable drugs and the uninsured.
"I don't think it matters which party is in charge" in terms of moving forward healthcare issues such as prescription drugs, Kitzhaber says.
"All they're talking about is how to pay for the existing system. No one is asking why these drugs cost so much in the first place." As costs continue to rise alongside the number of uninsured, Kitzhaber adds, "I have no faith whatsoever that Congress will deal effectively with the issue." [[[[