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What can internists expect from the 108th Congress?

From the January ACP-ASIM Observer, copyright 2003 by the American College of Physicians-American Society of Internal Medicine.

By Robert B. Doherty

With the Republicans back in control of Congress, they have an opportunity to show that they can overcome the gridlock and partisanship that stymied progress on so many issues last year. Some of the issues at stake for internists include Medicare pay, medical liability reform, modernizing Medicare and coverage for the uninsured.

It won't be easy. The Republicans hold only the narrowest of majorities in the Senate: 52 votes (including Vice President Cheney) vs. 48 Democrats and one independent who usually votes with them. Because Senate rules require a 60-vote super-majority to get most bills passed, the Democrats are in a position to slow down or block legislation the GOP favors.

Obstacles to bipartisanship

Many Democrats believe they did not do well in the 2002 elections because they sounded too much like the Republicans. The party's renewed desire to distinguish itself was affirmed when House Democrats elected liberal Rep. Nancy Pelosi (D-Calif.) to replace former minority leader Dick Gephardt (D-Mo.), a centrist. Rep. Pelosi is among those who have promised to challenge a conservative Republican agenda.

Changes in the Senate leadership may also create difficulties for the Republicans. At press time, Senate majority leader Trent Lott (R-Miss.) was fighting for his political life after suggesting the country would have been better off if it had elected then-segregationist Strom Thurmond to the presidency in 1948.

If Senate Republicans replace Sen. Lott as majority leader, they will likely bring in a leader whose skills in developing a legislative majority are uncertain and untested. If Sen. Lott remains as majority leader, he will be a tempting target for Democrats who wish to accentuate the differences between the parties.

The 108th Congress will also take office just as the 2004 presidential race begins to take shape. Because presidential candidates typically try to appeal to the most partisan "base" voters in primaries, Democratic contenders, who may include Senate minority leader Tom Daschle (D-S.D.), Sen. John Kerry (D-Mass.) and Sen. Joseph Lieberman (D-Conn.) will be seeking opportunities to challenge President Bush's legislative agenda.

President Bush's role

President Bush will be the most important player during the 108th Congress. Despite the evident obstacles to achieving a bipartisan accord, he enjoys political circumstances most would envy. He has strong, enduring public approval ratings as well as a resurgent, motivated Republican majority in Congress. He received rave reviews from the press for his political skills in helping Republicans win Senate seats. The Democrats are divided and uncertain about how best to respond to their losses.

The president also understands that 2003 is likely to be his last, best chance to move his legislative agenda forward. If he fails to do so, he is unlikely to succeed in the intensified partisan environment of the 2004 election year.

The president's health care agenda

President Bush's influence will be tested on a number of health care priorities this year. He has promised to work to reform the medical liability system. Last year, the Republican-controlled House passed a $250,000 cap on non-economic damages, limits on contingency fees and other essential reforms. The bill, however, died in the Senate.

With the Republican gains in Congress, the climate for federal tort reform is as good as it has ever been. But it will be no easy task to find the 60-vote super-majority that will likely be required to overcome a Democratic filibuster.

The president also wants to help low-income seniors with prescription drug costs, through private sector prescription drug plans or grants to states to set up their own assistance programs. His larger, more ambitious and controversial vision is to convert Medicare from a government-run fee-for-service program to a voucher system in which beneficiaries use government funds to buy coverage from private sector plans.

By tackling Medicare reform, the president will be taking on an issue that repeatedly eluded compromise in the 107th Congress. As I reported in my December column, Congress' inability to agree on a broader package of Medicare reforms was the principal reason it failed to halt scheduled cuts in Medicare payments to physicians. (The December column is available online.)

Congress could once again delay passing legislation to halt the next round of physician payment cuts, which are now expected to take place on March 1, until it takes up a broader Medicare reform package. ACP-ASIM is therefore continuing its campaign to get Congress to halt the cuts as its first order of business, rather than linking the issue to the broader reform debate.

Finally, President Bush and Republican leaders have expressed a desire to enact legislation to provide uninsured Americans with tax credits to help them buy coverage. Tax credits are a major feature of the College's proposal to cover all Americans within seven years. (The proposal is online.)

The ACP-ASIM proposal, however, goes further and borrows ideas from both Republicans and Democrats to provide all Americans with a source of coverage by the end of the decade. Legislation based on our proposal is expected to be introduced early in the 108th Congress. Our admittedly bold ambition is for our proposal to serve as the basis for bipartisan consensus on health care coverage.

Chance of success?

Compared to its dysfunctional predecessor, it would seem that the new Congress has nowhere to go but up. A cynic, however, would say there are plenty of reasons to believe this Congress will repeat the sorry record of partisanship and gridlock that paralyzed the 107th Congress.

But this time, the issues may simply be too important for Congress to fail again. Tens of millions of Americans are experiencing access problems because of skyrocketing medical liability premiums, an underfunded and overregulated Medicare program and a lack of health insurance coverage.

Voters are counting on President Bush and the 108th Congress to overcome partisan differences and to work together to right the wrongs in our health care system. If they do, there will be plenty of credit to go around for both parties. If they don't, they will have to face re-election next year with a record of standing by as the world's best health care system collapsed around them.

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

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