Remember the episode of "Seinfeld" where George and Jerry pitch network executives the idea of a TV show about nothing? The story on major healthcare legislation coming from Capitol Hill this year might well be summed up the same way.
Last year at this time, Medicare dominated the health policy landscape. Congress was embroiled in the early stages of a six-month legislative lap to add a $400 billion prescription drug benefit to the program. Since passage of the bill, it has been caught up in a number of controversies. The administration estimated the legislation would really cost $534 billion but didn't bother to tell Congress before it passed the bill. And CMS Chief Actuary Richard Foster alleged he was threatened with being fired if he disclosed the higher price estimate to Congress. HHS' Office of the Inspector General is looking into those allegations.
The fight to produce a bill, and the controversy that followed, occupied headlines and lawmakers' time for months.
With that bruising battle a done deal, at least until after the election, it appears any talk about the uninsured or other high-priority issues for the industry will amount to much ado about nothing.
With an election roughly four months away and nominating conventions interrupting Congress' routine in the meantime, lawmakers have precious few days to pass bills before the year closes. The House and Senate will adjourn July 23 for the Democratic National Convention and return on Sept. 7 after the Republican National Convention. With other holidays and the election figured in, there are no more than 50 legislative days left before Dec. 31.
As with all "Seinfeld" episodes, however, there is at least some semblance of a story. To be sure, healthcare hasn't faded altogether from the legislative scene, and it won't. Healthcare costs continue to be very much on Americans' minds, and polls indicate the issue will be a factor during the November elections. But after the Medicare ordeal, legislators are just plain worn out, many in Washington say.
"We're in an environment where there's a lot of healthcare fatigue," said Rick Pollack, executive vice president of the American Hospital Association. Instead, he and others say, the emphasis for the remainder of the year will be on regulation. Though the Medicare legislation has been written, the CMS still has the huge task of implementing it.
Most recently, the CMS unrolled its Medicare drug discount card, intended to provide seniors with savings on their drug costs. Over the next several months, committees in the House and Senate will continue to monitor the drug card program and other aspects of the law that require CMS action to implement.
"Everybody on Capitol Hill is taking a deep breath after the (Medicare modernization act)," said Herb Kuhn, director of the CMS' Center for Medicare Management. Now, Kuhn said, it is the CMS' turn to translate the law into workable regulations.
Congressional aides confirmed their role has switched to one of oversight. "This is a 700-page bill making the most sweeping reforms to the Medicare program in decades," said a House GOP aide. "We need to make sure it gets implemented correctly."
Among the issues that the AHA will be following closely are the "75% rehab rule" that determines which facilities will be paid rehabilitation payment rates, 2005 prospective-payment system rules and the voluntary hospital-quality initiative.
"All of this stuff marches on in an election year," Pollack said.
In perhaps the most significant example of new oversight from Congress, hospitals will also want to pay close attention to lawmakers' growing interest in not-for-profit organizations and whether they continue to merit their tax-exempt status.
In June, Congress held three hearings exploring hospitals' business practices, including their tax status, charitable activities, governance boards and allegedly aggressive patient billing practices (June 28, p. 6). The hearings did not do much to resolve the issues, although more may be coming. If legislation emerges, it will probably not happen until next year, industry observers say.
On the hospital payment front, the CMS is scheduled to publish final inpatient prospective-payment regulations for 2005 on Aug. 1 and final outpatient regulations sometime around Nov. 1, Kuhn said. The agency is also working to enact a provision of the Medicare law designed to help hospitals absorb the cost of treating illegal immigrants (June 7, p. 14).
CMS officials say they have no new plans to link Medicare payments to quality of care, a top priority of former CMS Administrator Tom Scully. The Premier hospital alliance and the CMS are still conducting a joint demonstration project testing the pay-for-performance concept, Kuhn said, and the agency is also moving forward with a Scully-era plan to have hospitals voluntarily administer patient-satisfaction surveys to better monitor quality (July 7, 2003, p. 4).
"There are a lot of major milestones to hit this year with (the Medicare modernization act), and with (CMS Administrator) Mark McClellan's leadership, we're moving along and hope to achieve our objectives," Kuhn said.
If there is one healthcare issue capturing the attention of Washington, it is the challenge of the uninsured. At last count, 43.6 million Americans, or 15.2% of the population, were uninsured in 2002, according to the U.S. Census Bureau, the latest official figure available.
Lots of talk, little action
During Cover the Uninsured Week in May, legislators on both sides of the aisle rushed to grab media attention by unveiling proposals to provide more health insurance coverage (May 17, p. 8). First, a Republican panel stitched together by Senate Majority Leader Bill Frist (R-Tenn.) released its wide-ranging plan that included expanding health- savings accounts, using tax credits and reforming medical liability laws. The recommendations would bring down the number of uninsured by as many as 29 million, the panel estimated.
That proposal is being crafted into legislation and, according to the aide of a high-ranking Republican senator, leaders are likely to put their ideas into several smaller bills to improve the chances of passage. When such legislation might be introduced is unclear.
During the same week in May, House Democratic leaders also introduced three pieces of legislation to expand Medicaid and the State Children's Health Insurance Program, allow Americans ages 55 to 64 to buy into Medicare, give tax credits to small businesses and create purchasing pools to make health insurance more affordable. In total, the proposals would cover more than 20 million uninsured Americans, House Democrats estimated.
Sen. Edward Kennedy (D-Mass.) is floating a proposal that would require employers with more than 50 employees to provide healthcare coverage. He also would create a program to cover those not eligible for other government or employer-sponsored coverage. The bill was expected to be introduced months ago, but the issue has been sidetracked. A Kennedy spokesman said the senator has not decided when he will introduce the bill.
There has also been a push to provide tax credits to unemployed individuals to help pay for their health insurance, and mandate that individuals purchase health insurance in the same way most states require residents to buy auto insurance.
While no major legislation is expected from Congress on the uninsured, there is strong interest in at least making a down payment on the issue, said Karen Ignagni, president and chief executive officer of America's Health Insurance Plans, a managed-care trade association.
"There still is some chance that something small can happen," such as providing tax credits to individuals to be used to purchase coverage, she said.
Many are hopeful that a slate of IT bills will pass Congress this year. At least five bills, one of which would tie IT use to higher Medicare payments, have garnered bipartisan support. Members of both parties in the Senate Health, Education, Labor and Pensions Committee are working to combine the various bills into one measure that has a good chance of passing, aides said (May 17, p. 28; June 28, p. 56).
Other pieces of legislation important to healthcare providers are languishing in various committees. One is a bill that the House passed last year that would, among other things, protect caregivers who report adverse events to a patient-safety organization. House Republicans have accused Kennedy of holding up the legislation in the Senate committee, where it has been sitting since last November.
Kennedy is not holding up the legislation, said his spokesman, Jim Manley, but he has concerns about the bill. Specifically, he objects to provisions that would place conditions on the public disclosure of certain patient-safety information. Kennedy has offered an alternative measure to Sen. Judd Gregg (R-N.H.), chairman of the Health, Education, Labor and Pensions Committee, but has not heard back from him, Manley said.
Medical malpractice liability reform could also emerge again this year. The House in May passed a bill identical to one it passed last year that would put a $250,000 cap on non- economic damages. Most Democrats strongly oppose the bill, however, as well as similar proposals that passed the House but failed twice in the Senate already this year.
"It's a tough lift this year," Ignagni said.
That may be an understatement.
Frist, a surgeon, has vowed to continue bringing the issue to the Senate floor in order to keep it alive, but the consensus is that he's fighting a losing battle. After the recent losses in the Senate, it's unclear whether Frist will bring a bill up again for a vote this year.
"The votes aren't there" in the Senate, Pollack said, echoing the views of many on Capitol Hill and the health policy community.
But an aide to Frist said, "We're looking for the right opportunity and the right mix to bring it up. ... We've already been successful in getting patients aware of the problem."
American Medical Association officials said the organization will be relentless in trying to get something similar to what passed in the House through the Senate. "We believe that we will get Senate passage at some point in time. Hopefully, it'll be sooner (rather) than later," said Donald Palmisano, immediate past president of the AMA.
Prescription drug reimportation is also a hot issue and one that could see congressional action before year-end. For months, bipartisan support for allowing drugs to be reimported from Canada and other countries has been growing in Congress even as the Bush administration opposes such a move, citing safety concerns.
Last year, the House passed a reimportation bill, but the measure failed in the Senate. During McClellan's confirmation hearings, he was pelted by questions about his opposition to reimportation. At one point, a bipartisan group of senators threatened to hold up his confirmation until he could explain his stand.
Eventually Sen. Byron Dorgan (D-N.D.), a proponent of reimportation, struck a deal with Frist under which Dorgan would not hold up McClellan's nomination and in return, Frist would schedule a vote on the drug legislation.
Some senators estimate that they have the 60 votes needed to overcome a possible Republican filibuster and were pushing Frist to schedule a vote on Dorgan's bill before the July 4 recess. That did not happen, said Dorgan's spokesman, and the senator will now try attaching the bill to other legislation to force a vote.
"There is no question there will be a vote on reimportation this year on meaningful legislation," said Barry Piatt, a spokesman for Dorgan.
Finally, and as another example of the shift from legislating to regulating, in coming months the growth of long-term acute-care hospitals will be watched closely by health committees in Congress, said the House GOP aide.
"The real policy question here is: `Are these (long-term acute-care hospitals) even appropriate?' " he said. The proposed 2005 prospective- payment regulations would place new restrictions on the hospitals, especially those that operate within general acute-care hospitals (May 17, p. 8).
As growing numbers of patients are admitted to a dwindling number of nursing homes over the coming years, hospitals will become more crowded with long-term patients who are likely to clog the delivery system, said Stephen Guillard, chairman and CEO of Harborside Healthcare, Boston, a skilled-nursing-care provider. Unless lawmakers act, he added, "You have the potential for the breakdown of the system."
That doesn't mean Congress or the administration is ready to do anything decisive. "It's an election year and no one wants to play any cards right now," Guillard said.
Some 1,000 nursing homes have closed since the Balanced Budget Act was passed in 1997, according to Charles Roadman, out-going president and CEO of the American Health Care Association. Roadman said if there is to be significant action taken on healthcare reform, it will have to get a boost from the White House. "No one below the president has the cachet to say, `We're going to do this and do it right because not to would make us a Third World nation.' "
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