Action on health care in 2002?

The wars, foreign and domestic, continue to preoccupy Washington, but issues like patients' rights, Medicare hassles, and the uninsured won't go away.

By Wayne J. Guglielmo
Senior Editor

No one knows what last year's Washington health care agenda might have looked like had the events of Sept. 11 and its aftermath not taken place.

Perhaps 2001 would have been the year, finally, for an acceptable patients' bill of rights, including at least an attenuated right to sue health plans. Perhaps doctors struggling through the thicket of Medicare red tape would have been granted some long-sought regulatory relief. Or perhaps, despite budget woes, a potentially costly issue like expanded medical coverage for the uninsured might have gained some traction among lawmakers willing to split the difference between Democratic and Republican approaches.

Perhaps. But Sept. 11 did take place, of course. And that fact not only radically altered last year's health care agenda—redirecting lawmakers' attention to matters of war both foreign and domestic—but could very well do the same this year.

"If the war goes on for a while, its needs will dominate," says Harvard health care pollster and political analyst Robert Blendon. Certainly, a deep recession could alter the picture somewhat, he acknowledges, giving prominence to issues like the uninsured. But short of that, it's the war, stupid.

Most groups previously focused on health care won't let mere Congressional inattention stop them from pursuing a range of issues, though. After all, priorities can turn on a dime in Washington. And, in any case, just because health care isn't grabbing the headlines doesn't mean it's completely out of the legislative picture.

With that in mind, we look at the issues left over from 2001 and assess which are most likely to survive our current preoccupations.

Patients' rights redux: Is fatigue setting in?

The tortuous road to a patients' bill of rights looked like it was coming to an end last summer, at least in Congress.

In late June, a bill sponsored by Arizona's John McCain and Massachusetts' Edward Kennedy, among others, passed the Democrat-led Senate by a vote of 59 to 36. Backed by the AMA and a host of other medical organizations, the bipartisan bill granted patients wide-ranging rights in their dealings with health plans, including the right to sue in state or federal court. On the House side, similar legislation sponsored by GOP Rep. Greg Ganske of Iowa looked like it might carry the day as well.

But support in both houses didn't guarantee a presidential signature—something co-sponsor Charlie Norwood (R-GA) knew full well. On Aug. 1, a day before debate on the House bill was to begin, Norwood met with President Bush and worked out an amendment to his own legislation. Essentially, the amendment scaled back liability provisions, limited federal remedies, and imposed caps. The bill as altered passed the House the next day by a 23-vote margin.

With two competing versions of patient protection, the next step would have been to reconcile House and Senate differences in conference committee. Then Sept. 11 occurred, and all bets were off. "The only way a reconciled bill would happen is if the people who wanted a bigger bill just gave in and agreed to the president's more limited bill," said Harvard's Blendon in November. "The president has no need to even look at this thing."

The prospect for legislation this session depends on the war, of course, but also on the ability of backers like McCain, Kennedy, the AMA, and consumer groups to rally public support for a stronger measure. But is the public still interested, even assuming terrorism concerns abate? Some people are clearly suffering from patient-protection fatigue after seven years of dead-end debates.

Others think health plans have already come a long way, at least in the areas of access and choice. "Right now Congress isn't getting pressure to pass a bill of rights," says Rosi Sweeney, vice president for socioeconomics and policy analysis at the American Academy of Family Physicians. "And if it doesn't have to pass a bill, it probably won't. The liability issues are just too contentious."

Medicare: hassle relief, but not major reform

Medicare poses other contentious issues, and some are more contentious than others.

Even before Sept. 11, the disappearance of the budget surplus made all but marginal Rx relief for seniors seem like a nonstarter. This isn't to say a prescription drug benefit for Medicare recipients is a dead issue, though. "As we get closer to the 2002 elections, incumbents [who campaigned on Rx relief] are going to feel very nervous about coming back to their constituents empty-handed," says Ron Pollock, executive director and vice president of Families USA, the Washington-based consumer-advocacy group.

Other observers think the issue will surface again, but not until after the 2002 elections. "If the economy doesn't turn around, it will be the pivotal domestic issue in the elections," says Blendon. "There'll be nothing on Rx relief for seniors until after the 2002 election, and then we'll have to see where the issue is."

Two more immediate Medicare issues for Congress this session—at least if doctors have any say about it—are boosting physician pay and relief from regulatory hassles.

Marginal help for the uninsured

Expanded health coverage for the uninsured is another item left over from the sidetracked 2001 health agenda. But unlike Medicare regulatory relief, it faces a far more uncertain future.

To be sure, the president's economic stimulus package last year included a provision to help newly unemployed workers maintain health coverage. But the proposal, which wasn't adopted by Congress, contained no new allocations, relying instead on shifting funds from other Medicare programs. If and when the issue of the uninsured resurfaces, look for physician and consumer groups to push a bipartisan approach that combines some form of GOP tax credits with the expansion of Medicaid and the State Children's Insurance Program favored by Democrats.

"We support both these initiatives," says radiologist Timothy T. Flaherty, chair of the AMA's Board of Trustees. Ron Pollock of Families USA agrees, to a point: "We don't think you can pass something significant without doing it in a bipartisan fashion, and that probably means some mixture of public programs and tax-related benefits."

But unlike the AMA, which has long endorsed individual tax credits, Families USA and other consumer groups favor employer tax credits in order to expand employer-provided coverage. "I think that's the better direction to go," says Pollock, whose organization reached an agreement along those lines last year with the Health Insurance Association of America and the American Hospital Association.

Most advocates keep up the pressure

Physician and consumer groups will also do their best this year to focus Washington's attention on several of their pet issues.

The rise in the number of states applying for and receiving Medicaid waivers is a major area of concern for Families USA. So-called 1115 waivers, which are authorized by the secretary of Health and Human Services, give states wide flexibility in how they carry out the provisions of the federal Medicaid statute. As of early December, 17 states had received and implemented waivers.

Consumer groups worry that, in a time of budget shortfalls, states will take advantage of this flexibility, as Pollock argues, "to water down the entitlement provisions of Medicaid." He promises to monitor the situation, "taking whatever steps we need to, including litigation, to prevent a wholesale obliteration of the statute."

For their part, physician groups will be pressing for more funding for graduate medical education. "Notwithstanding two relief bills, the impact of the Balanced Budget Act of 1997 on teaching programs throughout the country continues to be severe," says John B. Crosby, executive director of the Chicago-based American Osteopathic Association. With Section 747 of Title VII of the Public Health Services Act up for reauthorization this year, the AAFP promises to work with Congress to ensure sufficient funding to train a new generation of family physicians.

AAFP would also like to see increased funding for HHS's Agency for Healthcare Research and Quality, formerly known as the Agency for Health Care Policy and Research. The name change, authorized by Congress in 1999, is meant to underscore AHRQ's mission as the lead federal agency on quality-of-care research.

"The agency's role has become more visible and important in light of the Institute of Medicine's report on patient safety," says the AAFP's Rosi Sweeney. "The academy is heavily invested in this issue."

Worthy goals all, to be sure. But just how much pressure advocates can put on a Congress and administration preoccupied with matters of war and a sagging economy remains to be seen. As some see it, the best short-term strategy is to back off and let Washington leaders go about their business. Says AOA boss John Crosby: "The last thing they need right now is John Crosby at their doorstep."

 

Wayne Guglielmo. Washington outlook: Action on health care in 2002?. Medical Economics 2002;2:22.