Washington Insight

Looking back, looking ahead

By Julie Rovner, Contributing Editor

Health care issues will be front and center in official Washington in 2001, but advancing an agenda will be no easy task. Just look back at the 106^th Congress' record on health issues in 1999 and 2000. While a long list of items were debated—Medicare reform, a Medicare prescription benefit, medical errors, medical records confidentiality and a managed care patients' bill of rights only topped the list—barely a handful became law.

About the only thing anyone agreed on was that the Medicare cuts imposed by the bipartisan Balanced Budget Act of 1997 did indeed go deeper than expected. In 1999, Congress approved (and President Clinton signed) legislation to restore about $16 billion to Medicare providers. In its closing hours, the 106^th coughed up another $35 billion.

Casual observers attributed the lack of progress on health issues to partisan posturing for the 2000 elections. Republicans accused Democrats of saying No to everything so they could pin a "do nothing" label on the party in Congressional power. Democrats countered that Republicans were pretending to act on issues that polled well (primarily Medicare prescription drugs and managed care reforms) while in reality devising plans that would provide little benefit to ordinary citizens, but would please major contributors in the insurance and drug industries.

But underlying the partisanship were very real philosophical divisions over issues that both sides do, in fact, want to address.

Democrats are nearly united in their belief that prescription drugs should be an integral part of Medicare benefits, noting that no one would imagine creating a health program for the elderly without such coverage today. Republicans are nearly as united in their belief that a drug benefit would threaten Medicare's already fragile finances, and say it should be "dessert" after the politically distasteful task of restructuring the program to withstand the retirement of the baby boomers.

Similarly, on the patients' bill of rights, Democrats—and many Republicans—firmly believe that there should be a federal standard for everyone in every health plan, including a right to sue for damages arising from care denials. Conservative Republicans, however, worry that such protections could accelerate premium increases and, combined with unfettered lawsuits, prompt employers to drop coverage altogether.

The voters, who told pollsters that health issues were among the most important to them, gave no clear indication which approach they prefer. In fact, they simply made the split worse. In the House, Republicans were returned to power, but with their razor-thin margin narrowed to barely a half dozen seats. The Senate, for the first time in more than 100 years, will be divided evenly.

While some are calling for a new era of bipartisanship, there is already evidence that this year's bickering will simply pick up where last year's left off. Senate Republican Leader Trent Lott (R-Miss.), said in December he expects Congress will move quickly on a Medicare drug plan—but likely one that would benefit only those with low incomes, something Democrats have vehemently opposed. Not to be outdone, Senate Democratic Leader Tom Daschle (D-S.D.), said he expects Congress to quickly approve a patients' bill of rights similar to the one that passed the House but foundered in the Senate last year.

Interestingly, an area of potential agreement is the one most ignored by official Washington—the plight of the nation's 43 million uninsured. Last month, the unlikely alliance of the Health Insurance Association of America (whose "Harry and Louise" television ads helped sink the Clinton health reform plan in 1994) and Families USA (who sponsored the nationwide bus tour in favor of the plan), unveiled a plan that would combine tax credits and expanded coverage through Medicaid and the Children's Health Insurance Program to cover every uninsured American with income under twice the federal poverty level.

Some Republicans, including influential House Ways and Means Health Subcommittee Chairman Bill Thomas (R-Calif.), have criticized the plan as too reliant on expanding government programs. But the fact remains that unlike Medicare prescription drugs and patients' rights, where Democrats and Republicans have mutually exclusive approaches, on the uninsured they have separate approaches that could, at least in theory, be combined.

Republicans want to use the tax system to help people buy their own policies, while Democrats want to expand existing programs. Policy analysts say the GOP approach makes sense for those with higher incomes, and the Democratic approach would help those who earn less. Doing both at the same time could in fact address a major portion of the problem. Whether such a compromise can be forged will be a key test for the next Congress and administration, not just on health issues, but all issues.

 

Julie Rovner. Looking back, looking ahead. Business and Health 2001;1:11.