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What the confusing election results might mean for health care policy

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

Robert B. Doherty

What a long, strange election it's been. From the election of a deceased Democrat to the Senate in Missouri, to the "wrong calls" by the networks covering the presidential race, to the days of wrangling over the final vote in Florida—this election has had more oddities than any other election in modern times.

With all of the uncertainties about who won—and by how much—one thing is certain: Voters were split down the middle. At press time, the presidency remained up for grabs. Vice President Gore was holding a narrow lead in the popular vote and the Electoral College pending a final count in Florida—where Gov. Bush held a 300-vote lead.

As I write this, it appears that the Senate will either be divided 50/50 between Republicans and Democrats, or that there will be a 51/49 split that favors the Republicans, with one race still unresolved.

(Even if the Senate is evenly split, the Republicans will end up with the tie-breaking vote. If Dick Cheney is elected vice president, he will cast the tiebreaking vote. If Sen. Lieberman is elected vice president, he will have to resign his Senate seat, and Connecticut's GOP governor will appoint a Republican to the open seat.)

At press time, House Democrats had a net gain of two or three seats, although two races had yet to be certified. The Republicans were left with just the barest of margins over the Democrats.

Even without the final results of the presidential race, we can begin to make some educated guesses about what this year's vote will mean for the ability of either party to govern next year.

What do the voters want?

Oddly enough, the virtual tie in voters' preferences between Democratic and Republican presidential candidates wasn't the result of a deep ideological chasm dividing the country into warring camps. Instead, the election was fought over questions of character and competence.

While the presidential candidates tried to persuade voters that the 2000 elections represented a turning point for the country, the issues were hardly the type that will trigger a decisive shift in the country's direction. Medicare prescription drug coverage, "lockboxes" and tax cuts are not in the same league as past issues that divided the nation and altered the course of American history.

No one would mistake this year's debate over patient rights for the polarizing but decisive fights in the 1960s over desegregation and the Vietnam War, for instance. To the extent that voters signaled that they want change, they seemed to be asking for a different style of government in Washington rather than major policy changes.

Voters did not vote to dismantle or dramatically reduce the role of the federal government in the health care system. Nor did they vote to expand its role. Voters asked for an end to "gridlock," but they gave no clear message on what they actually want to happen in Washington.

A President-elect Bush or President-elect Gore will no doubt try to claim a mandate from the voters. But any such claim is fanciful, given the mixed and confusing messages from the electorate, the tightness of the presidential race and the strange post-election circumstances under which the winner of the White House will ultimately be determined.

Who controls Congress?

Even if the new president claims a mandate for policy changes, in reality he will have to deal with a Congress that neither the Republicans nor the Democrats control.

Sure, the Republicans will maintain control of Congress on paper. They will elect the committee chairs and leadership. They will have more influence than the minority party over scheduling votes and bringing issues to the forefront. If the new president is from the same party, their ability to set the agenda will be strengthened.

But in fact neither party has the two-thirds majority needed to overcome a presidential veto, nor does either party have the 60-vote majority needed to overcome a filibuster in the Senate. On any given vote, the defection of a few Republicans to the Democratic side can give the Democrats a working majority (assuming that the Democrats themselves will unify).

In reality, members of Congress will find it easy to block legislation, but extremely difficult to pass it. Americans might have believed they were voting to end gridlock, but their votes may end up producing the exact opposite result.

An alternative scenario

This year's election results may favor gridlock, but they don't guarantee it. It's possible that the new president will reach out to congressional centrists in both parties to create a working majority for particular votes.

The president will have a strong motivation to show that he can get things done in Washington. One way to dampen continued questions about his "legitimacy" is to demonstrate the ability to achieve tangible legislative successes early in his presidency. For Congress, many members will have a strong desire to show that they can deliver on their campaign promises.

I'm betting that the new Congress and president will pass a strong patient rights bill. They will find a way to make Medicare prescription drug coverage available to beneficiaries. Major revamping of Medicare—such as converting it to a voucher system as Gov. Bush proposed—is unlikely, but more modest program changes may be achievable. Legislation to provide health insurance coverage to all Americans is unlikely, but sequential measures that gradually expand coverage may be possible.

For organizations such as ACP-ASIM, the lack of a clear mandate from voters creates an opportunity to draw more attention to our ideas about improving the health care system. In other words, we won't have to react to the perceived mandate of others.

Over the next several months, the College will issue its own proposals to expand health insurance coverage, reduce other barriers to care, improve patient safety and reform Medicare. The mixed and confusing results from the electorate give us a unique chance to put forward practical, innovative and constructive ideas that could appeal to what may be an emerging centrist majority in Congress—and to a new president who will be eager to make his mark.

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

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