Charles Grassley as long-term care power broker.

Until the 1980s, the real legislative power in Washington often lodged with the chairmen of the House and Senate committees. President Lyndon Johnson once referred to the chairmen as "herd bulls," implying that he couldn't get the Democratic majority in Congress to move unless he convinced committee chairmen to take the first steps in the right direction. The major source of their influence was their ability to use committee schedules to block votes on legislation and to hold hearings on issues that they wished to receive extensive attention.

For the field of geriatric healthcare, the best known of these legislative giants probably was Wilbur Mills, an Arkansas Democratic congressman who chaired the House Ways and Means Committee from 1959 through 1974. Once known as the "most powerful man in Washington," Mills played the key role in shepherding the enactment of the first Medicare legislation. His career crashed, however, after he drunkenly participated in a very public late-night scuffle with an exotic dancer.

Since Mills's time, the influence of congressional committee chairs has weakened significantly. They now are selected by secret ballot of the committee members rather than by seniority, so they cannot run counter to the will of the other party members on the committee. Moreover, the increased partisan divide between Democrats and Republicans these days tends to make chairmen subject to the control of their party's whips, whose function is to enforce discipline in support of party positions.

Fall 2005 may be remembered as a pivotal period when all of these influence-defining factors suddenly changed. The powerful GOP whip of the House of Representatives, Congressman Tom DeLay (R-Texas), and Senate Majority Leader Bill Frist (R-Tennessee) both were focused on defending themselves from prosecution and, in Frist's case, balancing that with strategizing about his political future. The White House, meanwhile, was beset by a series of setbacks, including failure to obtain conservative support for a Supreme Court nomination, the perception that its appointees to the Department of Homeland Security--and the President himself--had mismanaged weather emergencies, and a criminal indictment for committing perjury to a federal grand jury. Healthcare financing issues seemed to be definitely on the back burner.

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As ever, Washington abhors a power vacuum--and Sen. Charles "Chuck" Grassley (R-Iowa), chair of the Senate Finance Committee, has stepped in vigorously to fill the void on Medicare and Medicaid issues. Grassley and his Democratic colleague, Sen. Max Baucus of Montana, responded within days after Hurricane Katrina with legislation to provide Katrina survivors with health coverage through Medicaid in any state that has provided shelter. The legislation would temporarily ease enrollment requirements for state Medicaid programs and provide full federal funding for Medicaid services in hurricane-affected areas, with no state contribution or enrollee copayment required. Meanwhile, the Emergency Health Care Relief Act of 2005 crafted by Grassley made health providers caring for evacuees eligible for federal add-on payments through an emergency relief fund to alleviate the burden of uncompensated care. The same funds would also be available to long-term care facilities that have lost their patient base because of Hurricane Katrina.

But he that giveth may also taketh away. Grassley followed up on these legislative proposals with his own plan to reduce federal Medicaid spending by $12 billion over the next ten years--$2 billion more than proposed by the Bush administration. Unlike the administration, however, Grassley has identified specific areas for reductions, derived heavily from proposals made by the National Governors Association and these, fortunately, have skirted major long-term care cuts thus far.

Grassley has been more long-term care-focused when it comes to Medicare. He has attacked the Centers for Medicare & Medicaid Services for failing to deter improper Medicare billing practices; for example, an independent audit ordered by Grassley reported in October that the National Supplier Clearinghouse, the contractor hired by Medicare officials to verify that suppliers meet standards before they can bill Medicare, failed to check state licensure of suppliers effectively. "Medicare dollars have gone to pay bills from suppliers that aren't properly licensed and who may be under investigation for fraud," Grassley said. "There are cases where Medicare has re-enrolled suppliers in its system even when those same suppliers had their billing privileges revoked by Medicare just three months previously."

In sponsoring budget reconciliation legislation aimed at federal budget deficit reduction, Grassley has championed proposals to roll back the 75% rule to allow more competition in long-term rehabilitation services and a 30% reduction in skilled nursing facilities' allowable claims of bad debt. The latter, long-term care associations have asserted, will leave facilities holding the bag for Medicare copays never paid for dual-eligibles by their states.

Chuck Grassley defies easy description as a legislator. He is the only member of the Senate who lives and works on a family farm, but he also holds a graduate degree in political science and has served continuously as a legislator since his election to the Iowa House of Representatives at age 25 in 1958. He is best known for fiscal conservatism and for taking unusual pride in having civil working relation ships with both Republican and Democratic colleagues.

Grassley's activism on Medicare and Medicaid, specifically, seems to result from a combination of deep personal concern and political pragmatism. Grassley has been a gadfly on long-term care issues for years, organizing hearings to draw attention to alleged nursing home financial abuses and shortcomings in quality. The long-term care industry has gradually succeeded in educating the senator about the realities of providing skilled nursing care but, with 14 counties in his home state where the elderly represent more than one-fourth of all registered voters, Grassley continues to benefit from the perception that he is a tough-minded advocate for the health care interests of older Americans. The result is a committee chairman who is eager to make policy on Medicaid and Medicare rather than waiting on any White House timetable. And increasingly, as the Bush administration is perceived as lacking serious commitment to governmental efficiency and effectiveness, Grassley is willing to criticize his own party's stewardship of healthcare.

It is conceivable that, with three years left to go, the Bush administration will recapture some degree of initiative in healthcare policy making. And in the process, many committee chairs may lose their newly regained influence. However, if Grassley, in collaboration with Baucus, succeeds in advancing a bipartisan agenda on Medicare and Medicaid, one can look to the Senate Finance Committee as a continuing hotbed of independent policy making in long-term care.

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