A nursing home owner in Congress.

Dan Miller isn't happy.

Miller is a successful businessman who has guided his family' s nursing home business into a diverse group of related companies. He holds a doctoral degree from Louisiana State University. He has been honored several times by his southwest Florida community and, two years ago, capped his first serious effort in politics by winning election to Congress. In September, he easily won the Republican primary and is about to be reelected without Democratic opposition.

This string of successes does not make Dan Miller content. In a telephone interview conducted with Nursing Homes on September 1, the only nursing home owner and administrator serving in the House of Representatives revealed that he was angry and upset about the level of partisanship and the ignorance of health care issues that he has encountered on Capitol Hill. Congressman Miller's observations, excerpted below, help to explain why we shouldn't expect a quick solution to the national financial problems facing long-term care.

Miller: I ran for Congress two years ago, having never been involved in politics, because I was mad at Congress and the system. Now that I'm there, I'm madder than I was two years ago.

Congress is a very partisan institution. It has a seniority system that makes it difficult to accomplish anything. As a Republican in an institution that has 78 more Democrats than Republicans, it's extremely frustrating.

Stoil: Do you see the partisanship affecting health care reform?

Miller: I'm on the Health Care Task Force for the Republicans, chaired by Bob Michel and Newt Gingrich. Last year, it met on a weekly basis. The first meeting I went to in February 1993 was with Hillary Clinton. We also met with [White House director of health care reform] Ira Magaziner a lot. We had a lot of communication last year on health care as the health care plan was being developed, speaking with the President and Mrs. Clinton and others.

Unfortunately, after the plan was developed, it basically rejected a lot of Republican ideas and thought. Since last fall, there has been very little communication between Republicans and Democrats on health care.

Health care reform should be bipartisan. We need to have Democrats and Republicans working together on this legislation. It shouldn't have a one-vote margin to pass; it needs to have strong support from both sides of the aisle because it is something that is going to affect all Americans.

I originally was a co-sponsor of the Cooper-Grandy bill [an alternative health reform bill]. That was the first bipartisan bill that came out. I supported it initially because it had a lot of ideas that I thought were worthwhile. I thought it better represented my thoughts on fixing the current health care system without reinventing it.

I eventually withdrew my co-sponsorship of that bill, and am now a co-sponsor of the Bilirakis and Michel bills, which are Republican bills.

Stoil: Almost all of the bills that have been introduced are financed in part through cuts in Federal Medicaid payments. Since Medicaid is the single most important source of payments to nursing homes, is this a serious flaw in all of the legislation?

Miller: There are degrees of cuts in Medicare and Medicaid. For example, the Gephardt health care reform bill introduced in the House has about $100 billion in Medicaid cuts over five years; the Bilirakis bill has about $60 billion in cuts. Some of the cuts come from pushing Medicaid in the direction of managed care, which has been successful in Arizona and some other areas. Of course, managed care for nursing homes raises some special issues.

But, yes, there should be concern about proposed Medicaid cuts, especially about the bills introduced by (Senate Majority Leader) George Mitchell and Mr. Gephardt (House Majority Leader). These have huge cuts that in all reality would never be enacted. They say they're going to enact them, but things don't happen that way, as with a lot of the budget cuts that were made last year. A financing plan over several years in the future pledges actions by the next two or three more Congresses. Those actions don't always materialize.

There' s no consensus among the American people on health care reform and there' s no consensus in Congress. You need the support of the American people. Two-thirds of the people feel we should wait until next year on health care reform.

Stoil: What do you see as the most important elements of the health care reform proposals concerning nursing home care?

Miller: The Federal government is the major payor in the long-term care arena, but long-term care and the nursing home field had a limited role in almost all of the [health care reform] plans. In President Clinton's plan, Senator Mitchell's plan, and Mr. Gephardt's plan, the long-term care provisions all concern home care, and that's related more to the needs of the disabled than to the seniors. No one seriously addressed long-term nursing home care except for the single-payor group [advocates of Canadian-style national health insurance]. It was not a serious part of any of the discussion, to be truthful.

There was some discussion of use of life insurance or other taxable savings ideas to finance long-term care, but that' s not going to have a major impact. The dollars involved are too big. What happened with Catastrophic Health Care back in 1988 has got some people scared that creating new entitlements at this stage is not feasible.

I personally do not think we are going to see a lot of changes in long-term institutional care, besides managed care proposals for Medicaid. We will see legislation to encourage more use of private long-term care insurance. That doesn't have a major short-term impact, but it may give states more flexibility to try alternatives and to get people to shift to lower levels of care.

There's no federal money to create new entitlements. Insurance changes -- you'll see some of that -- and tax incentives are more likely.

Stoil: Does the long-term care industry have effective representation on Capitol Hill? For example, how effective were the representatives of AAHSA and AHCA on long-term care issues?

Miller: They're effective, but long-term care just was not a major issue. Actually, the nursing home industry was more concerned about the proposed employer mandate [for paying employee health care expenses]. The employer mandate, both as a direct cost and a pass-through cost, had a bigger impact on nursing homes than other aspects of the Clinton, Mitchell, and Gephardt bills and other bills that are being talked about.

My district has the largest number of seniors of any district in the country. They like to write and express their opinions. They are concerned and want prescription drug coverage and long-term care coverage. The prescription drug issue actually affects more people than the nursing homes issues. But they also are conservative enough to realize that you have to pay for everything.

I think we' re going to see more encouragement of the states trying to do what they can do to keep costs under control. Florida is developing the group purchasing program -- the CHPA's, we call them -- and they're slowly getting started, but that's the managed competition idea. Oregon has an interesting new Medicaid that involves rationing. I'm not sure that Florida would want that program, but let's see how it works in Oregon.

States are ahead of the federal government on health care issues, and so is the health care industry. When the debate on health care started, with the Pennsylvania Senate race [in 1991, to replace the late Senator John Heinz] and the '92 campaign, costs were increasing at 12 to 14 percent. Now increases are down to six or seven percent. This is because of pressures within the industry and within the business community. We need to keep changing, whether through managed care or other programs. The federal government has only a limited role in helping move that along.