Predictions on how Congress
will handle three issues in 2000

Washington Perspective

From the January 2000 ACP-ASIM Observer, copyright 1999 by the American College of Physicians-American Society of Internal Medicine.

By Robert B. Doherty

Political forecasting is much like long-range weather forecasting: notoriously untrustworthy. Predicting how Congress will act on an issue is difficult enough when the vote is only a few days away, let alone months in the future.

But that difficulty doesn't stop people from asking for predictions, and it doesn't stop those of us who work with Congress from taking our best shot. So with the caveat that the following may be no more accurate than forecasting when the next snowstorm will hit Washington, here are my predictions on what to expect from Congress in 2000 on three key issues: access to care, patient rights and collective bargaining.

The year of the uninsured?

Last October, ACP-ASIM invited House Majority Leader Dick Armey (R-Texas) to brief reporters on the prospect that Congress would act to reduce the number of Americans without health insurance. During his remarks, Mr. Armey boldly predicted that 2000 would become the year of the uninsured in Congress.

He speculated that Congress and the president will be highly motivated to agree on reforms, in part because voters in the upcoming elections are likely to judge Congress on how well it addresses the uninsured problem. Mr. Armey suggested several approaches that might command bipartisan support, including refundable tax credits that would help subsidize the cost of buying coverage.

In reality, however, the president would likely veto many of the solutions preferred by Republican leaders, such as medical savings accounts. And refundable tax credits may cost more than the current Congress and administration are willing to spend. The promise by the president and Congress to not raid the Social Security trust fund to support other governmental spending will greatly limit the amount of money available to fund measures to help the uninsured.

Mr. Armey certainly deserves credit for exercising his leadership to make 2000 the year of the uninsured. It is more than likely, however, that substantial progress will not be made until after the voters have spoken in the November elections—by electing a president and Congress committed to working together to reduce the number of uninsured Americans.

Patient rights

On Oct. 7, the House of Representatives passed the Norwood-Dingell patient bill of rights by a solid margin of 275 to151. Sixty-eight Republicans bucked their own party's leadership to vote for the bill.

Any celebration by ACP-ASIM and other supporters of the bill was quickly dampened, however, by Speaker of the House Dennis Hastert (R-Ill.), who put opponents of the bill on the team that will represent the House in negotiations with the Senate. While conferees are supposed to support the bill originally passed by the House, only one of the members picked by Mr. Hastert voted for the Norwood-Dingell bill.

Nonetheless, the conferees will face tremendous pressure from their colleagues and voters to push for a strong bill. National polls have put patient bill of rights legislation at the top of the list of voters' concerns, and many independent analysts believe that the Republicans risk losing control of the House if they fail to agree on a strong measure that includes the key provisions established in Norwood-Dingell. My guess is that enlightened self-interest will ultimately rule the day, and Congress will agree on a patient rights bill that is closer to Norwood-Dingell than the weak Senate bill passed last spring.

Collective bargaining

In a Dec. 7 speech to the AMA's House of Delegates, Rep. Tom Campbell (R-Calif.) announced that Mr. Hastert had promised an early vote on his bill to allow physicians in independent practice to engage in joint negotiations with payers. He confidently predicted that the bill would get through the House Judiciary Committee and then be approved by the entire House.

Despite the applause that Mr. Campbell's remarks elicited from the AMA's physician-delegates, it is far too early to declare victory. First, there is no guarantee that the bill will even pass the House. Many members of Congress have reservations about any legislation that could encourage physicians to unionize. The recent ruling by the National Labor Relations Board that residents are employees, not students, and thus can unionize, is adding to some lawmakers' nervousness about physician unions.

It is important to note that the Campbell bill does not advocate for traditional labor unions. Rather, it seeks to ease anti-trust restrictions and allow physicians in independent practices to negotiate with health plans on issues affecting quality and access. Mr. Campbell has explained that such negotiations could take place outside of a physician union.

Even if the bill passes in the House, it will still have to make its way through the Senate. So far, the Senate has shown no inclination to take up the bill, and the rules of the Senate make it easy for any individual senator to block the bill unless it commands a super-majority of votes (60% or more) in the chamber.

My prediction? The bill will most likely be passed by the House but will then stall in the Senate. The next Congress will be left to start the process all over again.

Taking action

I could be wrong about all of these outcomes, but there is one lesson to be learned either way: Whatever Congress does or doesn't do, we need to remember that we can be more than passive bystanders. Effective advocacy by national organizations like ACP-ASIM, backed up by grassroots advocacy from internists at the local level, can move Congress to do the right thing on access, patient rights, joint negotiations and other critical issues. And it sure beats the alternative of sitting back and complaining when things don't turn out right.

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



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