As John Kerry hiked the campaign trail in an attempt to take the White House from President Bush, the Massachusetts senator often invoked the refrain that a second Bush term would offer "more of the same." It turns out that for healthcare providers and the industry overall, Kerry-while moti-vated by politics-may have had a point.
Hospital executives and health policy experts say that in many ways Bush's next four years will be a lot like his first-favoring market-based approaches to the uninsured and Medicare instead of sweeping, costly new mandates for coverage.
With another four years in his pocket and a Republican Congress to back him up, it is somewhat unclear how Bush plans to use his "political capital" on the healthcare front. Some are worried that single-party domination doesn't bode well for systemic reform. The Republican stronghold, they argue, could diminish healthy debate among the parties and even shrink the number of ambitious ideas that get airtime.
"I would have felt more comfortable if there was more balance of power (between the parties)," says Glenn Fosdick, president and chief executive officer of 500-bed Nebraska Medical Center in Omaha.
In particular, Fosdick and others point to the uninsured as a problem that could continue to pressure hospitals. The Republican remedies-giving tax credits to purchase insurance and advancing the availability of health savings accounts and association health pans-constitute a modest solution to a monumental problem.
"I am not optimistic at all," says Michael Dowling, president and CEO of 10-hospital North Shore-Long Island Jewish Health System in Great Neck, N.Y., referring to the uninsured and other issues that will confront hospitals in coming months.
Healthcare officials and advocates expect Bush's healthcare agenda to closely resemble the one he has already advanced. Progress may be possible on some issues, like medical malpractice reform, but with growing budget deficits and a massive new Medicare benefit, major new healthcare initiatives are unlikely.
"If you're a Jeffersonian Democrat who believes that the government which governs least governs best, you'll just love (the Republicans') tepid healthcare agenda," says Jack Shapiro, a healthcare futurist and marketing consultant. "Otherwise, you're in for huge frustrations as the nation's healthcare crisis continues to mount."
In Congress, Republicans strengthened their grip in both chambers. In the Senate, Republicans will hold a 55-44 lead over Democrats with one independent, up from a 51-48-1 lead before Nov. 2. In the House, the GOP gained at least four seats and will hold a lead of at least 231-200 over Democrats with one independent.
In the Senate, the most significant casualty for Democrats was their minority leader, Tom Daschle of South Dakota, who lost to Republican John Thune in a race the Bush administration watched carefully. Daschle opposed Bush's policies on nearly every issue including healthcare and has been one of the biggest thorns in the president's side. So intent was the GOP in unseating Daschle that Senate Majority Leader Bill Frist (R-Tenn.) campaigned for Thune in South Dakota, a highly unusual move.
Also, Sen. John Breaux (D-La.) is retiring after three terms and will be replaced by Republican David Vitter. A centrist Democrat, Breaux was particularly active in healthcare legislation and was instrumental in writing the Medicare Modernization Act of 2003, which included a Breaux-sponsored provision to limit the development of controversial specialty hospitals.
"Breaux loved to make the deal," says one healthcare lobbyist. "He usually was the guy who tried to make something happen. Who fills that role now?"
Hospital opponents of specialty hospitals will have to find a new champion if they want to make a temporary moratorium on their development permanent. The Medicare Payment Advisory Commission is set to issue a final report in March 2005 on a study of the impact of these niche facilities.
In the House, two members with strong healthcare ties are retiring in January. They are Rep. Billy Tauzin (R-La.), former chairman of the Energy and Commerce Committee (which has jurisdiction over Medicaid and shares oversight of Medicare), and Rep. James Greenwood (R-Pa.), the main author of legislation to put limits on medical malpractice damage awards.
Billy Tauzin III, a Republican, will face Democrat Charlie Melancon in a run-off to replace Tauzin's father. Michael Fitzpatrick, a Republican, won Greenwood's seat.
In other House races, Republican Bobby Jindal, assistant secretary at HHS from 2001 to 2003, won the House seat vacated by Vitter in Louisiana. In Georgia, Democrat John Barrow won on a platform that included rejiggering parts of the new Medicare law to provide coverage to more seniors at lower premiums. And Gwen Moore, a Democrat, won in Wisconsin by advocating universal health coverage.
Despite the GOP's resounding win in the election, there is still no guarantee that the Bush administration will come any closer to fulfilling its healthcare agenda in a second term. In the Senate in particular, where 60 votes are needed to overcome a filibuster, many of the president's healthcare initiatives could be stalled.
The battle to reform the medical malpractice system is expected to be especially contentious. The House has repeatedly passed legislation placing a $250,000 limit on noneconomic damages, only to see the bills sink in the Senate as a result of Democratic opposition. Unless Republicans relent on placing limits on damages, Democrats in the Senate will almost certainly block any GOP-authored medical liability bill.
For hospitals, the biggest battle could be avoiding a rehash of the Balanced Budget Act of 1997, which imposed payment cuts on hospitals and other providers to help reduce federal deficits. As Modern Healthcare has been reporting for months, the prospect of another such act is significant, especially given a budget deficit that is projected to exceed $400 billion this year.
Recent rumblings on Capitol Hill, however, indicate that this possibility has waned in the past few weeks. With interest rates still low, and leading indicators like new housing starts still posting solid numbers, lawmakers may not resort to the same cuts they did seven years ago.
Some hospital officials are still worried, though. "I fully anticipate that as we go into next spring there will be attempts to cut domestic spending, and one of (the programs to get cut) will be Medicare," North Shore's Dowling says.
Otherwise, hospitals should expect increased attention to quality issues, including new and expanded efforts to link payments-from both the government and private insurers-to the quality of care provided. "There is bicameral, bipartisan interest in tying payment increases to quality standards, reporting and/or adoption of IT," a Senate aide says.
Finally, although he didn't get very far with it in the last Congress, there is noise on Capitol Hill that Medicaid reform may resurface, especially since Medicare reform seems out of the way for now. Bush has backed a plan to give states much more flexibility to restructure their Medicaid programs without a federal waiver, in exchange for making the federal allocation a lump-sum payment instead of tied to state spending. Critics decry the effort as turning Medicaid into a block grant as a way of decreasing the size of the program.
If Bush really wants to make changes such as overhauling Medicaid, he is going to have to put his capital on the line.