With Medicare reform largely complete, Washington lawmakers have their eyes focused on resolving healthcare issues begun last year but stalled by the gargantuan effort to bring drug benefits to seniors.
During any given year, hundreds of healthcare proposals are submitted to Congress and 2003 was no different. But so great was the energy expended on Medicare reform that during the second half of the year lawmakers devoted little thought to any other healthcare topic.
Although Medicare will continue to be on the radar screen for the next several months and beyond, attention now will shift mainly to three other areas, Washington observers say: the medically uninsured, medical liability and Medicaid reform.
Whether Congress will make any headway on those issues remains questionable. The Medicare fight left many Democrats angry about what they saw as arm-twisting and bulldozing political tactics used by Republicans to get the legislation through Congress, experts say, and lingering resentment could result in future measures being stonewalled by Democrats in retaliation.
In an election year that also is likely to see growing federal deficits, major new initiatives by Congress and increased spending on healthcare are unlikely, even if the rhetoric gets heated at times. Democratic presidential candidates will continue to roll out ambitious health reform plans, but the politics of campaigning could put a damper on both the Bush administration and Congress in touting politically sensitive policies.
The current Congress marks the last term of Sen. John Breaux (D-La.), which could make bipartisan agreements even dicier. A moderate Democrat, Breaux has been instrumental in brokering deals between his own party and Republicans on healthcare issues, including Medicare legislation.
"Breaux's decision not to seek re-election to the U.S. Senate after serving 31 years in Congress means a voice of moderation will be missed on Capitol Hill, especially in the area of healthcare," says the Rev. Michael Place, president and chief executive officer of the Catholic Health Association.
"As a valued member of the Senate Finance Committee and co-chair of the National Bipartisan Commission on the Future of Medicare, Sen. Breaux has worked to reach out to his colleagues on both sides of the aisle and in both houses to find common ground in improving the health delivery system in this country," Place says.
After the grueling Medicare debate, many in Congress could be wary about tackling any new big healthcare issue. Says one lobbyist who asks not to be identified: "Unless it's already been deep in the pipeline, it doesn't stand a chance of going far with Congress."
Even though it's now on the books, the Medicare law will put the CMS in the position of establishing a raft of rule changes to implement the law. That's no small undertaking. "There is a huge amount of work to do for my successor," says Tom Scully, the agency's former administrator who was instrumental in getting Medicare legislation crafted.
Democrats also will continue to search for ways to repeal provisions of the legislation they find particularly troubling. Already, Sens. Tom Daschle of South Dakota and Edward Kennedy of Massachusetts have introduced bills to allow for the importation of drugs from Canada and Western Europe, a step that would lower prescription drug costs for seniors but is highly controversial.
The Democrats also want to allow the federal government to be able to negotiate with drug manufacturers on prices, a practice not allowed in the Medicare legislation, and to scrap a six-year demonstration project set to begin in 2010 that would put Medicare in direct competition with private health plans in six geographic areas.
Jim Manley, a spokesman for Kennedy, says a caucus bill will be introduced this month to "fix the Medicare bill," though details of that proposal were not available at deadline.
The consensus view, however, is that any such bill will never see the light of day. After the protracted and bruising Medicare reform effort, lawmakers don't have the will to make major changes, particularly on provisions that won't take place for years and whose effects are still unknown, experts say.
Kennedy, along with Sens. John McCain (R-Ariz.) and John Edwards (D-N.C.), also introduced a patient-protection bill in reaction to the Medicare legislation, allowing patients to see some specialists without prior approval and authorizing patients to sue their health plans. That too will probably go nowhere, observers say.
"I don't know if that horse is even in the race, much less will win the race," says Ed Howard, executive vice president of the Alliance for Health Reform, Washington.
Revisiting the uninsured
Instead, the focus is expected to shift to the uninsured. According to the U.S. Census Bureau, 43.6 million Americans-or 15.2% of the population-were uninsured in 2002, the second consecutive year that the total number and percentage of Americans without insurance shot up.
The uninsured has long been an issue that Democrats have held close to their hearts, and over the years, "it's been a Tower of Babel in Congress-there are so many approaches," Howard says. Even so, in the end little has been done about it.
This being a presidential election year, however, there are some guarded predictions that the uninsured problem may get fresh attention. Karen Ignagni, president of the AAHP-HIAA, the managed-care lobby, says access will be a "central issue" of the presidential campaign.
Most of the Democratic presidential candidates have included plans to address the issue in their healthcare proposals, with the most radical idea coming from Rep. Dennis Kucinich of Ohio who wants to create a government-run, single-payer system. Former Vermont Gov. Howard Dean, considered the front-runner for the Democratic nomination, promotes a healthcare reform plan that would expand Medicaid and the State Children's Health Insurance Program (SCHIP); use tax credits to help people pay high premiums; and encourage corporations to broaden coverage.
Republicans, meanwhile, have been pushing for tax credits to help individuals buy health insurance. They also support a proposal to allow small businesses to band together to buy insurance through association health plans, a proposal that has met strong resistance from commercial health plans that say it will drive up costs.
State governors and regulators similarly have given the idea the thumbs down, saying legislation before Congress allowing for such health plans would exempt the plans from state mandates to guarantee certain types of care-including mental health and mammograms.
The association health plan bill passed the House last June but stalled in the Senate where it remains in the Health, Education, Labor and Pensions Committee.
Sen. Bill Frist (R-Tenn.), the majority leader, also has appointed a 10-person panel, all Republicans and chaired by Sen. Judd Gregg of New Hampshire, to explore ways to cover the uninsured. The panel has held initial meetings but has yet to release any proposals.
"We may look at some legislative solutions based on that," says Nick Smith, a spokesman for Frist.
Meanwhile, several bipartisan bills were introduced in recent months aimed at bringing down the uninsured numbers. Kennedy and Sen. Olympia Snowe (R-Maine) reintroduced a bill last November to extend health insurance to parents of children already on Medicaid or enrolled in SCHIP. That bill is awaiting action in the Senate Finance Committee.
In October, Sens. Charles Grassley (R-Iowa) and Max Baucus (D-Mont.) introduced legislation to extend existing law to help individuals on unemployment pay for health insurance. Under their bill, which also is in the finance committee, tax credits would be provided to pay 65% of health insurance premiums.
Malpractice and Medicaid
Aside from the uninsured, the other major healthcare issues that could be revisited with gusto are malpractice tort reform and Medicaid reform. Those two topics attracted much attention in 2003 but later were pushed to the margins amid criticism of proposals made by Republicans and the Bush administration. Opponents say the Medicaid and tort reform proposals would be hard on states and too restrictive for victims of malpractice.
Malpractice reform in particular continues to linger in the background, though hope that Congress will make substantial progress in pushing through reform legislation does not run high. In March 2003, the House voted 229-196 for a bill, introduced by Rep. Jim Greenwood (R-Pa.), that would have capped noneconomic damages at $250,000. Economic damages would have been uncapped and punitive damages would have been limited to $20,000 or double the economic damages, whichever was greater.
Senate Democrats, however, blocked the bill from ever reaching the floor for a vote and no action on the issue was taken again. While there appears to be no call to reconsider the House bill, there has been talk of addressing malpractice reform through more incremental steps, such as arbitration panels that could substitute for courts in some disputes.
The Senate Republican leadership and the Bush administration "see the Greenwood bill as the best bill out there, but they are having conversations to see what else should be looked at," says Christian Shalgian, chairman of the Health Coalition on Liability and Access, a Washington-based group made up of 83 provider groups, health plans and business organizations that support medical liability reform.
Last July, Sen. Michael Enzi (R-Wyo.) introduced a bill to authorize demonstration programs to lower malpractice costs. Under one model program, special healthcare courts would be established to resolve malpractice claims. Another model would define classes of avoidable injuries and create administrative boards to resolve those claims. That bill is in the Senate health and education committee.
Smith, Frist's spokesman, says malpractice issues remain on the majority leader's agenda but provided no other details. Others, however, say there have been discussions among Senate Republican leaders to break out specialties such as obstetrics/gynecology and emergency medicine as targets for reform rather than trying to make changes for the entire medical industry.
Republicans and Democrats remain deeply divided about how to solve the malpractice problem. In fact, many don't believe it is even a problem. Says one lobbyist: "The odds of it being seriously addressed aren't very strong."
Medicaid reform also may be revisited when Congress reconvenes, but its future is uncertain.
In early 2003, the Bush administration tried to push through a proposal to change the program to what amounts to a block-grant approach to save money in the long run. That move backfired, however, as states and consumer groups revolted and argued it would create hardship for the indigent and put states in financial jeopardy.
Under the Bush proposal the federal government would have provided fixed amounts of funding to states that agreed to sign up for its plan. Consumer advocates say that approach would have led to large parts of the population being thrown off the Medicaid rolls. States, meanwhile, were concerned that if they couldn't find ways of keeping their Medicaid spending down and federal funding fell short of what they needed, the states would have to make up the difference.
If the issue is revisited, experts say, the framework will need to be changed.
"I don't know if there is anything close to a consensus to let (the original administration proposal) go anywhere," says Howard of the Alliance for Health Reform.
The House Energy and Commerce Committee conducted several hearings on Medicaid reform last year and had intended to hold more during the summer before Medicare pushed everything else aside. A committee aide says that the committee plans to look at it again when Congress returns, but no hearings have been scheduled.
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