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Washington Perspective

A look at the College's top issues and where they stand in Congress

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

By Robert B. Doherty

Baseball fans know that the six weeks between Memorial Day and the mid-July All-Star Game are critical to determining which teams will still be playing after the regular season ends in September. It's a time when pretenders—teams that looked good in early spring but don't have the talent to go all the way—get winnowed out, and surprising long-shot teams reveal whether they have the stuff to make it to the end. It is also a time when the early favorites must show if they will be able to deliver on high expectations.

Congressional observers know that these same six weeks largely determine which bills stand a chance of enactment by Congress. If a bill is not well on its way to approval by both the House and Senate by mid-July, it is very unlikely that it will be passed before Congress adjourns in October.

With that time frame in mind, I would like to examine the prospects of three legislative proposals that are among the top issues for ACP-ASIM: a patient bill of rights, firearms injury prevention and Medicare reform.

Patient bill of rights

When the 106th Congress took office in January, there were high expectations that it would pass a patient bill of rights. Since then, however, the political obstacles have proven to be great.

House Speaker Dennis Hastert (R-Ill.) has promised a vote on patient protection legislation, but GOP leaders appear unwilling to back key proposals that most supporters—including ACP-ASIM —believe are necessary.

In the College's view, individuals must have the right to sue health plans if they are harmed by that plan's denial of services. Medical necessity must be defined by accepted professional standards, not by insurers' own criteria. And patient rights should apply to all insured Americans, not just those in self-funded employer-based plans.

The best chance for getting a favorable vote on an acceptable patient bill of rights is via the House Commerce Committee. Rep. Tom Bliley (R-Va.), chair of the committee, asked two of the health professionals on his committee—Charles Norwood (R-Ga.), a dentist, and Tom Coburn, MD, (R-Okla.), a family physician—to develop a "consensus bill."

The Norwood/Coburn Consensus Managed Care Improvement Act includes all of the key elements that ACP-ASIM believes are necessary. It's unclear, however, if the committee will vote on the bill, and even if a vote is held, whether there are enough votes to send it to the full House without substantially watering down the key requirements. Even if the committee sends the bill to the full House, Rep. Hastert could still block a vote on the floor. (For more details, see "College supports patient rights legislation.")

Prospects in the Senate are less favorable. The Senate Health, Education, Labor and Pensions Committee sent a bill to the full Senate that ACP-ASIM feels is wholly unsatisfactory. The bill applies only to the 40 million Americans in self-insured plans, leaving out everyone else. It also allows insurers to arbitrarily write the rules on medical necessity and provides no recourse to the courts if a patient is harmed by a health plan.

Firearms injury prevention

Back in January, no one would have predicted that legislation to reduce the availability of guns would have a chance of being enacted. Unfortunately, it took the tragic shooting at Columbine High School to persuade the Senate to adopt a modest package of firearms controls. The Senate package includes background checks at gun shows, a ban on the import of high-capacity ammunition clips and mandatory safety locks on all guns.

House Speaker Hastert proposed a similar package for House approval. Intense lobbying opposition from the National Rifle Association, however, has stiffened opposition to the package among lawmakers in "pro-gun" districts, calling into question the ultimate fate of the proposals. ACP-ASIM lobbied hard for the Senate-passed firearms controls and is continuing its efforts to persuade the House to enact comparable legislation.

Medicare reform

Earlier this year, the Bipartisan Commission on the Future of Medicare was expected to endorse a package of proposals that would lead Congress to enact major reforms in the Medicare program. The Commission tried and failed to reach a consensus on a proposal by co-chairs Sen. John Breaux (D-La.) and Rep. Bill Thomas (R-Calif.) to convert Medicare into a premium-support program. (A premium-support program would provide beneficiaries with a fixed amount of money to buy coverage.) Even without the Commission's endorsement, Sen. Breaux and Rep. Thomas have vowed to introduce a bill calling for a premium-support program. The Clinton administration plans to introduce its own Medicare bill by the end of June.

ACP-ASIM has questioned the practical and philosophical underpinning of a premium-support model. The main objection is that such a model could erode Medicare's goal of providing all beneficiaries with access to a defined set of benefits, regardless of their income or health status. Many members of Congress share the College's concerns, and it is unlikely that there are enough votes in Congress to enact the Breaux proposal.

One aspect of Medicare reform—adding a prescription drug benefit—is gaining popularity with lawmakers. But unless it is combined with other reforms to restrain the overall increase in Medicare costs, a drug benefit could make Medicare's long-term economic woes even worse. The College is currently developing a position statement on adding prescription drugs to Medicare benefits.

Season's end

Although the baseball analogy may help to explain the congressional process, there is one important difference between a baseball season and a congressional session. By the time the baseball season is over in October, one team will always be on top. Congress, by comparison, is quite capable of adjourning for the year without making any major bill successful.

This is not to predict that issues like firearms injury prevention and patient rights will be defeated. Though the obstacles to enactment are substantial, ACP-ASIM is actively engaged in influencing Congress so that the issues we favor will succeed.

Like long-suffering Cubs or Red Sox fans, we also realize that there is always next year. Patience is a necessity when it comes to both baseball and Congress. ACP-ASIM will continue to lobby Congress to produce winning legislation for internists and their patients, and we'll keep at it for as long as it takes.

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

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