Why Washington ignores you.

Historians already are describing the presidential term now ending as having the smallest domestic policy agenda of the past 50 years. Whether you supported or opposed the Bush administration, there is no question that the federal government established only a handful of new programs during its first four years. Instead, most of its domestic initiatives consisted of rolling back regulations and reducing taxes. The single most sweeping domestic achievement--the "No Child Left Behind" act--actually involved limiting federal grant programs for education by imposing new requirements on school districts that applied for federal aid.

Nursing home administrators are painfully aware of the limited impact of the administration's domestic agenda on their industry's well-being. Four years ago, nursing homes were struggling with reduced public-sector reimbursement, burdensome regulations, and shortages of qualified staff. Bankruptcies were commonplace. Innovative public-private financing reforms were stalled. Today, the situation is almost unchanged, despite the apparent early successes of CMS's Nursing Home Quality Initiative.

Trying to explain Washington's lack of progress in addressing the needs of long-term care (including in this indictment not just the Buch administration but Congress, as well) is difficult. Federal legislation adopted during the previous 40 years has equipped our government with the means to tackle many of the problems facing nursing homes. The National Health Service Corps (NHSC), for example, could recruit skilled nurses and nursing assistants in areas with staffing shortages to help ease that situation today. The NHSC, however, has never had even close to the funding needed to accomplish this. Meanwhile, the repeal of the Boren Amendment under President Clinton--and never remedied under President Bush--has deprived the federal government of much of its influence on state Medicaid reimbursement rates through federal court appeal.

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During the past four years, a late 1990s recession and tax cuts vaguely intended to attack it have transformed a large federal surplus into a huge federal deficit. Today, much of the federal treasury is used to pay interest on loans. In 2004 alone, Washington spent more than $1 billion per day on interest payments--more than the total available for job training, veterans' healthcare, and healthcare research combined.

Appropriate attention to the needs of nursing homes requires, for starters, a rational budget process. Under normal conditions, the White House is expected to develop a detailed budget every January; traditionally, the President's congressional allies then introduce in March or April the 14 spending bills required by federal agencies and programs. This process allows Congress approximately six months to debate or amend the spending bills before the end of the federal fiscal year on September 30.

This process has not been followed, however, during the past three years. Recent January budget proposals have lacked sufficient detail to indicate the administration's spending preferences for most federal programs. Meanwhile, Congress has typically not received appropriation bills for health and human services, housing, and education until late July. Without appropriations legislation, federal agencies limp along at reduced levels of activity until some type of generic spending legislation is enacted. This generic legislation has taken several forms over the years, including spending resolutions and omnibus appropriations, but the net effect remains the same: The Department of Health and Human Services operates without a normal budget, and has done so for years.

On paper, even stopgap measures could release hundreds of millions of dollars in grants, loans, and specific programs that could benefit nursing homes. Instead, the adoption of those generic spending bills for health and human services, education, and housing has posed an opportunity for a handful of influential congressmen and senators to divert this money for their own specific "earmarked" projects. An edition of this column published earlier this year (see "You're Not Invited to the Pork Fest," February 2004, p. 10) described how a few legislators on the House-Senate joint committee that prepares the final version of the generic spending bill use their position to direct grants and loans to individual companies and organizations.

The term "pork barrel project" was first used a century ago to describe the practice of diverting federal funds to help individual constituents. Never before in legislative history, however, has Washington's pork barrel budget been so large that it virtually eliminates competition for congressionally enacted grants and loans. In the healthcare field, almost without exception, the beneficiaries of "earmarks" are hospitals, outpatient programs, and universities; nursing homes are a rare, perhaps unique, exception.

The biggest mystery is why congressmen and federal administrators tolerate this state of affairs. It might come as a surprise to some readers to learn that people in Washington who focus on long-term care issues generally are aware of the challenges facing nursing homes. In dozens of conversations with political appointees and congressional staff members since 2002, I have repeatedly encountered this acknowledgment coupled with a sense of resignation concerning the federal government's failure to act.

Nursing homes and long-term care providers face an enormous disadvantage in this policy environment. Legislators view hospitals and doctors as institutions whose good work must be strengthened and supported for the benefit of all. No doubt this image is reinforced by televised portrayals of doctors and hospital staffs as harried, flawed, but nevertheless sacrificing humanitarians. Rational observers might recognize that hospitals and doctors' groups are often, in fact, quite wealthy and profitable, while long-term care providers are more generally in need--but, as we've seen, rational decision making has not exactly characterized Washington's domestic spending approach during the past four years.

Perhaps the most honest response I ever received to the question of why Washington has avoided nursing home issues came from a press assistant to a Midwestern congressman. Explaining why scheduling an interview with his boss was not a major priority for his office, he said, "Our [constituents] aren't interested in better nursing homes ... they want to stay out of nursing homes. The congressman has a very crowded agenda; it's very hard to fit in time for a subject that doesn't matter to the district."

To sum up, although existing federal programs and legislation could make a major difference in how nursing homes operate in the United States, they don't because:

1. The federal deficit diverts billions of your tax dollars to interest payments.

2. The loss of a budget process leading to a health and human service appropriations bill prevents the available money from being spent rationally.

3. A handful of congressmen use this situation to earmark grant funds designed to help healthcare providers other than nursing homes for political benefit.

4. A widely held perception of nursing home care as a potentially avoidable result of families' poor planning and bad luck places nursing homes at the bottom of the whatever domestic agenda survives in Washington.

Other factors contribute to this situation--the growth of party-line voting, making it nearly impossible for legislators to oppose their leadership, and the focus of news coverage on issues such as terrorism and sensational political/entertainment scandals rather than substantive issues. In the end, the cure for the neglect of nursing home issues will begin with a return to rational decision making in setting the domestic policy agenda. Unfortunately, that's one thing neither political party promised during the recent election.

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