The Next Administration and Congress: A New Look at Old Problems.

The next administration and Congress will have several issues on the health policy agenda during 2001. A budget surplus and reduced spending for national defense will allow the new leadership to focus on domestic programs and tax cuts. Tax policy will determine how much money is available for domestic programs and will indirectly affect funding for them.

During the next year, the top health care issues that Congress and the administration will address include Medicare reform, prescription drug coverage, insuring the uninsured, managed care reform, public health infrastructure, and health care quality. The political makeup of the Congress and the new administration will have a profound influence on the direction of health policy.

Medicare reform

Changing the Medicare program will be an area of substantial debate over the next several months. This debate will include a discussion of how to best integrate prescription drugs into the Medicare program, whether to build on the current structure or make fundamental change, how to best extend the life of the trust fund, and how to control costs. The debate may actually result in delaying progress on expanding prescription drug coverage because some in Congress want to use this issue to leverage broad Medicare reform. Consequently, Medicare reform will be complicated and more difficult to accomplish then commonly believed.

Prescription drugs

Providing prescription drug coverage to seniors may be the first health policy issue tackled next year. The expected January 1, 2001 exit of several Medicare HMOs from the market with the accompanying loss of prescription drug benefits for numerous seniors will precipitate an early crisis for Congress and the new administration. The result will be a new look at several patient-centered issues, such as cost and access, as well as industry specific concerns, such as paying for pharmaceutical research and the federal drug approval process.

The expense of prescription drugs and the global pricing practices of the industry will be examined as drug costs continue to rise disproportionately, at an increase of 15 to 28 percent per year. These costs significantly threaten to limit access to needed medications for many individuals.

Covering the uninsured

Despite the profound prosperity of the late 1990s, the number of uninsured people continues to increase.

Today, there are more than 44 million uninsured Americans. The recent focus on children in the federally sponsored Children Health Insurance Program and the rise in small business-sponsored insurance has offset some of the potential growth. This expansion in the uninsured will keep up pressure to find both public and private sector solutions.

Managed care reform

A variety of managed care issues continue to take center stage in the debate on health care reform and patient protections. The Patient Bill of Rights is controversial because of the liability measures. With both major political parities recently agreeing to some version of liability reform, the sides are closer to a solution, but fundamental differences remain.

States are looking at problems with providers assuming downstream risk and receiving prompt payment. These problems may soon become federal issues if providers continue to become bankrupt or have cash flow problems.

Public health infrastructure

The U.S. public health infrastructure remains weak and in need of repair. Recent food-born outbreaks, efforts to advance immunization efforts, new disease outbreaks, and our lack of readiness for bioterrorism paint a disturbing picture. Having an adequate work force that is well trained and has the right tools is in the nation's interest. Legislation to address this problem, as well as increased funding, has been introduced by Senators Frist and Kennedy. The next administration and Congress will need to make this a priority in order to prevent further erosion.

Health care quality

Concerns about quality of care will remain on the health care policy agenda for the new leadership. Anxiety over medical errors, by both physicians and nurses, who were most recently targeted, and questions about provider competency will add fuel to the fire. The Balanced Budget Act returning dollars to the industry will positively impact the budget process, but hospitals, nursing homes, physicians, and other providers will still worry about shrinking reimbursement and its effect on quality of care. A recent study by the U.S. Department of Health and Human Services cited concerns about staffing levels in nursing homes and their relation to quality. [1] This finding will have implications in other institutional settings. The growing nursing shortage, as well as the inability to find qualified workers in several fields, also threatens quality in our health care institutions.

Leadership changes

A new administration brings significant leadership changes to several health agencies, regardless of the appointing political party. These changes often delay the policymaking process because:

* New leadership often changes the policy direction of the agency.

* Most major policy decisions will wait until the new director is on board and can determine where he or she wants to take the agency. This is true even for policy decisions that are "in the pipeline."

* The policy direction may change dramatically even if the same party has the White House.

* A significant change in the Congress will influence how quickly change occurs and in what direction.

Conclusion

Many of the issues on the health policy agenda will remain the same after the 2000 general election. The direction of these policies and the speed with which they are implemented depends upon the new leadership, the public's continued demand for change, a thriving economy, and the absence of major internal and external conflict that would drive the dollars elsewhere. Physician executives should hold on to their seats. 2001 is going to be an interesting ride.

Georges Benjamin, MD, FACP, is the Secretary of the Department of Health and Mental Hygiene in Maryland, Baltimore.

Reference

(1.) "Report to congress: Appropriateness of Minimum Nurse Staffing Ratios in Nursing Homes," Health care Financing Administration, August 1, 2000, (www.hcfa.gov/medicaid/reports/rp700hmp.htm).

KEY CONCEPTS

* 2000 General Election

* Tax Policy

* Managed Care Reform

* Public Health Infrastructure

* Medicare Reform

The 2000 general election brings a new administration and Congress to Washington. It also provides the opportunity for a fresh look at the national health policy agenda. Both of the major parties have focused on health as one component of their national agendas. A booming economy and growing public concern about domestic issues presents policymakers with the opportunity to resolve some of the nation's long-standing concerns about the health of its citizens. The year 2001 can be a bust or boon for human health. Top health care issues include Medicare reform, prescription drug coverage, insuring the uninsured, managed care reform, the public health infrastructure, and health care quality.