Sometimes all the political tumblers line up perfectly for Congress and the administration to address the thorny, interwoven issues related to healthcare. And sometimes those tumblers just lock up and nothing gets done. Some experts believe the latter is the likely forecast for the next two years of healthcare in Washington, D.C.To be certain, important decisions will be made on vital issues like the continuation of State Children's Health Insurance Program funding and the so-called doughnut hole in the Medicare Part D drug plan. But as far as a substantive policy debate on the fundamental issues in healthcare, the combination of a lame-duck Republican president in the middle of a war and a newly elected Democratic Congress does not leave much hope for revolutionary legislative action."On top of all that, you add the fiscal realities that are out there-and you have Democrats expecting to run these investigations of the administration-it all adds up to potential gridlock or incremental change at best," says Rick Pollack, executive vice president for the American Hospital Association.So what are the healthcare trends to watch as a new Congress assumes power and presidential hopefuls prepare for 2008?
1. The budget, of courseWith estimates that the wars in Afghanistan and Iraq could cost as much as an additional $170 billion, the squeeze will have to come from somewhere. In the last budget, President Bush recommended cuts of $12 billion in Medicaid and $36 billion in Medicare, the first time the administration had recommended such cuts in Medicare. "You have to expect that in this year's budget he will put something out there at least of that magnitude," says Pollack. In addition to the usual budgetary wrangling, with the Democrats in power in Congress, Pollack expects a return to a "pay as you go" mantra, where every spending increase, tax cut or extension of an expiring tax provision must be offset. "That will be a real new phenomenon and puts handcuffs around a lot of things," he says. The 109th Congress did, however, vote to keep Medicare physician reimbursement frozen instead of allowing a planned 5 percent reduction.
2. The uninsuredThe 109th Congress extended SCHIP through spring 2007, but left the issue of reauthorizing the program for the new Congress to decide. The issue is one with plenty of moral high ground for everyone, since few in Washington are against health insurance for children. But the issue is also one where the theater of the larger questions of the 45 million uninsured could get a voice. Whether this mini-debate spawns a broader discussion on the uninsured is an open question. James F. Blumstein, university professor and director of the Health Policy Center at the Vanderbilt Institute for Public Policy Studies, wonders whether the increasing pressure of the uninsured will force the debate into fundamental questions about affordability. "From the Democrats' point of view, the issue will be how to cover the uninsured, and the answer is that any solution is very expensive. So you must come to the costliness of doing it," says Blumstein, also a member of the legal team picked by Tennessee Gov. Phil Bredesen to reform the state's TennCare program. "You can't talk about access in the absence of determining what you are going to buy."Democrats have already signaled an attempt to seize the uninsured issue as their own. Sen. Ron Wyden, D-Ore., unveiled his Healthy Americans Act, a universal coverage proposal which he claims will guarantee access for all Americans and still shave $1.48 trillion off the cost in 10 years.
3. Faces in new placesSome of the most recognized faces in the Congressional healthcare debate have new or diminished committee assignments. Sen. Charles Grassley, R-Iowa, remains a powerful force on the Senate Finance Committee, but he no longer has the power of the committee chair to push his issues, including the focus on nonprofit hospitals' tax-exempt status. Rep. Pete Stark, D-Calif., who has been critical of concepts like health savings accounts, specialty hospitals and pay for performance, becomes chairman of the Ways and Means Health Subcommittee in the 110th Congress.While dramatic policy shifts may not come in the next session, a return to some Democratic party operating cultures may come. "What you probably will see a bit more of will be more attempts to do things through the regulatory process. People used to criticize the Clinton administration and call it 'small ball,' but I expect we will see a little bit of that going on," Pollack says.
4. So long, market-based solutionsThe first six years of Bush administration healthcare policy circled almost exclusively around the theme that the market would largely help to fix the problem. Whether it was HSAs being embraced by consumers or the private sector vendors coming up with their own interoperability standards for electronic medical records, there was little in the way of federal government aggressiveness. At least in tone, some of that may wither.
5. Setup for 2008Lame-duck years are less about politics and more about posturing. The next year will be filled with the behind-the-scenes work of raising money and setting up organizations. But when the candidates come out with their messages for the White House in early 2008, healthcare may well emerge as a more significant campaign issue than it has been in years.Some major healthcare players have either dropped out or face considerable problems of perception, however. Former Senate Majority Leader Bill Frist, R-Tenn, abandoned his projected presidential bid for 2008. Sen. Hillary Rodham Clinton, D-N.Y., is still associated with her failed foray into healthcare reform in her early years as First Lady.While it is impossible to say how the economy, war, gas prices, immigration and other key issues will affect voters in 2008, it may be a safe bet that healthcare's major flaws won't be fixed by then. But a combination of rising costs, growing uninsured and lack of access to care may force healthcare into play.
-Jim Molpus
Magazine
