George W. and long-term care.

Here we are, nearly half a year before the New Hampshire primary, and the conventional wisdom is that George W. Bush, governor of Texas and son of our most recent Republican president, is a virtual shoo-in to win the GOP presidential nomination (barring any earthshaking revelations from his past). Incredibly, he has achieved this position without sharing any concrete information about his policies and preferences, and with little being said about his record in office. Part of this is intentional, of course: Late-summer Gallup polls indicated that at least 20% of the voters who plan to cast ballots for Governor Bush confuse him with ex-President Bush. However, unlike Bill Clinton, who served as governor and attorney general of Arkansas for nearly 12 years before running for national office, George W. Bush has served fewer than five years in any elected position. Consequently, he doesn't have a lot of policy record to examine.

Nevertheless, Texas is our third most-populous state, and the state government, headed by George W. Bush, is directly responsible for the care of approximately 66,000 nursing home residents per month. In addition, Texas regulates, licenses and investigates thousands of hospitals, adult day care centers, assisted living facilities, insurance carriers - the whole complex universe of modern long-term care. Even when George W. has not consciously made choices on long-term care policy, the nursing home industry has been affected by the representatives he has appointed to act on his behalf.

George Bush's first years in office gave him few opportunities to make a mark in the long-term care field. There has been major impetus in Texas to develop a managed care system for Medicaid, something most states are also trying to accomplish. Bush be came governor as the new system was leaving the planning stage and approaching legislative enactment; it is too early to say whether the result is better or worse than the public sector managed care systems established elsewhere. Unlike other states, however, Texas increased its Medicaid budget after managed care was in place, in part to increase payments to nursing home providers.

In 1997, during his third year in office, Governor Bush became more assertive on healthcare issues in response to the growing legislative battle over regulation of managed care. State Senator David Sibley (R-Waco), an oral surgeon with a law degree, introduced landmark legislation in the Texas legislature that would enable individuals to sue managed care organizations for malpractice. The Texas Medical Association weighed in on the side of Sibley's bill, while most business associations opposed it. George W. Bush chose to fight on the side of business and managed care, threatening a veto of the malpractice bill. The governor's office worried about unleashing "a Pandora's box of litigation," although the managed care industry itself argued that HMOs already were subject to common law civil actions alleging corporate malpractice. Instead, Bush argued for an independent review panel that would "protect people without causing a flurry of lawsuits." In the end, however, Sibley's bill passed and Bush backed away from his position.

George W. was firmer in his opposition to SB 273, a bill that would directly affect the relations between the long-term care industry and elderly consumers. SB 273 called for the development of a statewide consumer guide for senior citizens. It also asked for a broad coalition of public- and private-sector actors to develop consumer materials to assist Texas residents in preparing for retirement and aging. Neither of those elements was controversial. Bush's concern focused on a third part of the legislation: a joint study - to be coordinated by the State Controller of Public Accounts on planning and financial strategies for long-term care - to consider financial approaches to improving consumer access to nursing homes and other long-term care providers. SB 273 passed the State Senate unanimously on May 20 and arrived on the governor's desk in June, where he promptly vetoed the legislation. According to one of the bill's cosponsors, Governor Bush was unwilling to let Texas "drift" into experiments for financing long-term care unless his office could control the process.

Small reforms in long-term care have occurred under Governor Bush's watch since 1997. Texas increased the variety of offenses that bar convicted individuals from working in nursing homes, and has just changed its long-term care insurance regulations to require policies to incorporate a 5% annual increase in benefit levels as an automatic inflation adjustment. In general, however, most prospective changes to nursing home policy introduced in the Texas legislature have passed or failed without the governor's involvement. This was certainly true for the proposed legislation to establish a Public Employees Long-Term Care Trust Fund, modeled after similar long-term care insurance legislation for the federal civil service, which died in committee this year without Governor Bush taking a stand either way.

The most dramatic state actions in Texas relating to nursing homes and home care for the elderly have involved Bush's appointees rather than the governor himself. Earlier this year, for example, state trustees discovered that Sensitive Care, a nursing home management company, had significant financial problems that allegedly threatened the care of residents in the 13 facilities under its direction. The State Department of Human Services took over the operation of the homes, only to discover that the Texas Nursing and Convalescent Home Trust Fund had only $500,000 available - not enough to operate the facilities. Even as the state legislature moved quickly to replenish the trust fund, the Secretary of Human Services abruptly closed several Sensitive Care homes. It seems safe to assume that no one - residents, family members, provider staff or investors - felt that they had been treated with "compassionate conservatism."

In summary, the record of Governor George W. Bush on nursing home and healthcare policy in Texas suggests that the future Republican nominee has not yet been made aware of the crises affecting the long-term care industry. He has barely moved to advocate even minor reforms and retreated from the only position in which he found himself on the losing side - managed care accountability. Fortunately, with the primaries and the election months away, there is plenty of time for the long-term care community to educate the candidate on the issues that threaten long-term care access and quality, not only for Texans, but for all Americans.