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Washington Perspective

What should internists expect from the 106th Congress?

From the March 1999 ACP-ASIM Observer, copyright 1999 by the American College of Physicians-American Society of Internal Medicine.

By Robert B. Doherty

Now that the year-long impeachment drama is finally over, what can we expect from the 22 remaining months left in the tenure of the 106th Congress and the Clinton administration?

Many pundits are predicting that the president and Congress will overcome partisan differences and reach agreement on a host of legislative initiatives. President Clinton has a strong incentive to demonstrate that he can still wield influence over Congress, and Republican leaders want to get things done so they aren't remembered solely as the Congress that tried and failed to remove a popular president from office.

Neither can get things done without the support of Democratic lawmakers, however. The Democrats can use the power of the filibuster to block Senate bills they don't like. And with the Republicans holding only an 11-vote majority in the House, it takes only a handful of GOP defectors to join House Democrats to stop a bill in its tracks.

Instead of obstructing legislation, Democratic lawmakers could choose to use their leverage to force the Republicans to adopt a legislative agenda that is more to the Democrats' liking. But with heightened prospects for taking control of the House in the year 2000, Democrats may conclude that they will fare better running against a "do-nothing" impeachment Congress than in helping the Republicans—and the president—get bills enacted into law.

It is in this highly volatile political environment that Congress will be debating legislation on two issues of great importance to internists: patient protection and access to care.

Patient protection

Last year's effort to enact legislation to guarantee a core set of patient protections for people enrolled in managed care and other health plans collapsed because of strong partisan differences over the scope and degree of protections that are needed. On the Senate side, the differences were so great that the body adjourned without passing any bill. In the House, a bill that was patently unacceptable to most Democrats and the president passed on a virtual party-line vote, but only after a Democratic alternative was rejected by the narrowest of margins.

Rep. Dennis Hastert (R-Ill.), the new House Speaker, has stated that he is committed to getting a bipartisan bill passed this year. The Democrats will likely use their increased clout to force the Republicans to accept a bill that makes ERISA plans accountable to the same standards as other plans, puts more teeth into appeals and grievance rights, and expands patient choice of physicians and health plans.

The Senate is another matter. The partisan alignment remains the same as last year, and Majority Leader Trent Lott (R-Miss.) has given no signals that he plans to go beyond the modest leadership bill that he submitted last year.

ACP-ASIM will continue to advocate for a bill that guarantees patient access to specialty care, strong grievance and appeals procedures, and recourse to the courts when plans deny necessary care. Because a bill will need bipartisan support to have any chance of success, ACP-ASIM will work with both Democrats and Republicans on fashioning a bill that includes as many key protections as possible—while recognizing that compromises will be necessary to get a bill enacted.

Expanded access

Guaranteeing protections for individuals who have insurance coverage is a good thing, but it does nothing to help those who lack coverage altogether.

On Feb. 12, ACP-ASIM released a new plan to make health insurance coverage available to 10.5 million uninsured Americans who earn up to 150% of the poverty level. (See "College unveils new plan to care for the uninsured".) In issuing this call to action, ACP-ASIM is challenging Congress and the president to commit more resources to helping the most vulnerable of the uninsured than either has been prepared to commit so far. Unfortunately, it will be an uphill battle to persuade policy-makers to make the problem of the uninsured a top priority. But ACP-ASIM has launched a sustained effort to keep the pressure on Congress and the president, and we will be asking a broad-based group of like-minded organizations to join us.

One element of the College's proposal—the use of refundable tax credits to make coverage affordable—has already received very favorable responses from key Republican and Democratic lawmakers. Tax credits are expensive, but they allow the federal government to subsidize the purchase of health insurance by low-wage, uninsured employees. Members of Congress who have expressed support for enactment of health insurance tax credits span the ideological spectrum and include conservative lawmakers like Rep. Dick Armey (R-Texas) and liberal legislators like Rep. Pete Stark (D-Calif.).

While tax credits alone won't solve the problem, they could make coverage more available for more than three million uninsured Americans with incomes between 100% and 150% of the poverty level. The other pieces of ACP-ASIM's plan, particularly the expansion of Medicaid to all Americans with incomes at or below the poverty level and expanded funding for outreach, will be needed to further close the gaps. And while we are calling on lawmakers to extend coverage to lower income Americans, ACP-ASIM is also renewing its call for Congress to begin discussing longer term strategies to achieve universal coverage.

Other priority issues

Patient protection legislation and expanded access rank among the College's highest priorities, but there are a host of other challenges that require our attention.

Medicare "user fees," which ACP-ASIM helped defeat last year, are back in the president's proposed budget. Another bill the College helped defeat last year, the Lethal Drug Abuse Prevention Act, remains a favorite of congressional leaders. (The bill would allow the DEA to take away physicians' licenses to prescribe pain relief narcotics if the agency concluded that the drugs hastened death.)

Congress is also likely to consider proposals to move funding for graduate medical education (GME) out of Medicare and into the annual appropriations process. Preserving a predictable and stable source of funding for GME will be among the College's top priorities. (See "At risk: Medicare funding for GME".)

In these volatile and unprecedented times, no one can predict how Congress and the president will deal with these or other issues of importance to internists and their patients. But there is one prediction that can be made: Whenever decisions are being made in Washington on policies that will affect you and your patients, ACP-ASIM will be there representing your interests.

We can't promise success on every issue. But we can promise that no decision will be made without your views being heard.

Robert B. Doherty is ACP-ASIM's Senior Vice President for Governmental Affairs and Public Policy.

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