Washington Watch

President Bush and Health Care - Just What Are His Health Care Priorities?

by James L. Thorne, Esq.

Introduction
Former President Clinton actively worked to bring the Democratic Party back to the political center and President Bush campaigned for the presidency on a centrist platform of Republican "compassionate conservatism." Both men clearly believed the country is in a centrist era and to govern you must "govern from the center outward." Further, both men won the presidency based on a centrist approach to government.

Yet, with each passing day, we are beginning to see the clear operational and policy differences between President Bush and former President Clinton. For one, President Bush has a different management style. He is a proponent of the "corporate management" model-tighter control; working from a specific agenda; speaking with one voice. His predecessor was more inclined to operate using a "graduate school seminar" model, in my opinion-less structured; several policy "voices;" but overflowing with ideas.

For another, former President Clinton was a strong proponent of increased health care for Americans. As you will recall, early in his administration he invested considerable political "capital" in a plan to totally revise the health care system in the United States. It failed because the proposed system revision was far more encompassing than the Congress or the country could understand and support. President Clinton (and Mrs. Clinton) learned the hard way that a proposal to totally change health care has less chance for success in Congress than a series of incremental health program changes.

Now that we have a new administration, what will President Bush do? Will he advocate broad change, incremental health care change or no change at all? What health care issues does he care about and how will it affect the member physicians of AAEM?

President Bush's "Blueprint for New Beginnings" (2002 Budget)
In February 2001, President Bush issued his "Blueprint for New Beginnings." The blueprint is his governance budget document. It states what is important to him and it states what he desires to spend on the items listed. Yet, what proposals and funding Congress finally agrees to may be another matter! The president's blueprint contains seven "Major Policy Initiatives" and an additional eight "Other Key Policy Priorities."

Two of President Bush's seven "Major Policy Initiatives" involve programs that vitally affect the provision of health care. One is to Modernize and Reform Social Security. The other is to Modernize and Reform Medicare. One of the president's remaining "Other Key Policy Priorities" contained in the blueprint is to Invest in Health Care.

It is also becoming clear that President Bush prefers to articulate his government policy preferences with a statement of general principles rather than specific legislative proposals; leaving the legislative specifics to Congress. There may be wisdom in this approach, given the near-equal split in the House and the even Republican/Democrat split in the Senate. President Bush followed this preference for general principles, rather than proposing specific legislation, with regard to his effort to Modernize and Reform Social Security and with regard to his effort to Modernize and Reform Medicare.

Bush's Plan to Modernize and Reform Social Security
In order to Modernize and Reform Social Security, President Bush's principles for reform include (a) no change in existing benefits for current retirees or near-retirees, (b) any Social Security surplus must be preserved only for Social Security, (c) Social Security payroll taxes must not be increased, (d) the Government itself must not invest Social Security funds in the private economy and (e) Social Security reform must be built upon a core of individually controlled, voluntary personal retirement accounts. Personal, voluntary retirement accounts appear to be the core of President Bush's approach to reforming Social Security. According to the Blueprint for New Beginnings, "personal accounts invested in safe private financial markets will earn higher rates of return than the traditional system."

President Bush's Plan to Reform Medicare
President Bush's plan to reform Medicare is based on six principles. They include (a) a continued guarantee of access to Medicare for seniors, (b) Medicare recipients must have a choice of health plans, including the option of purchasing a plan that covers prescription drugs, (c) Medicare must cover expenses for low-income seniors, (d) streamlined access to the latest medical technologies, (e) Medicare payroll taxes must not be increased and (f) reform must establish an accurate measure of Medicare solvency.

In his blueprint, the President cites several demographic changes including the growth of persons age 65 and older-from 39.7 million to 69.1 million-during the years between 2010 and 2030. Further, a permanent shift in the ratio of workers to Medicare beneficiaries is expected to decrease from 4.0 workers today to 2.3 workers in 2030 and to 2.0 workers in 2070. According to the president, Medicare's spending exceeds the total of tax receipts and premiums dedicated to Medicare today and the "financing gap" is projected to widen dramatically. In his blueprint, the President states that the gap is $51 billion today, growing to $216 billion in 2020, and to $368 billion in 2030. Yet, until Medicare reform is enacted by Congress, President Bush only proposes a modest program to give immediate prescription drug help to the country's neediest seniors. This immediate prescription drug help (Immediate Helping Hand funds) was submitted in legislative form to Congress but it was declared "dead on arrival" by a member of President Bush's own political party last month.

President Bush's Planned Investment in Health Care
As previously stated, President Bush's Investment in Health Care is important but it is not listed as one of his seven Major Policy Initiatives. The President's 2002 budget includes targeted investments in key presidential priority areas such as improving biomedical research, strengthening community-based health care, enhancing drug treatment, and providing an immediate prescription drug benefit to those who are considered in the greatest need.

Politicians (and the new president is no exception) are prone to highlight the programs they favor by proudly listing the desired funding for these programs. Programs that are not favored usually do not show their specific funding reductions. Again, the new president is no exception.

Thus, President Bush's 2002 budget provides (and highlights) spending $156 billion over ten years for Medicare reform, including his integrated prescription drug plan, and the Immediate Helping Hand program. Further, President Bush intends to provide $ 23.1 billion in 2002 to fund the National Institutes of Health, a stated increase of $2.8 billion over 2001. In order to expand the delivery of primary health care services to communities that lack health care access, the President has proposed $1.29 billion, a $124 million increase. In order to increase access to substance abuse funding, the President's budget provides $111 million, with $100 million of it going to the Substance Abuse and Mental Health Services Administration. Finally, the President's budget targets areas of health risk by including approximately $400 million for existing activities for innovative health care improvement projects in state and local communities.

On the other hand, President Bush's 2002 budget does include three specific areas for targeted reductions in health care funding. The three areas are: Health Professions, the Community Access Program, and Medicaid Integrity. The following statement on the reduction in health care funding for Health Professions is restated, verbatim, from the President's budget:

"Health Professions: The budget recommends a reduction to Health Professions' funding, which provides training grants to institutions. These training grants were created almost forty years ago when a physician shortage was looming. Today a physician shortage no longer exists. Moreover, the Federal role is questionable in this area given that these professions are well paid and that market forces are much more influential in determining supply. To reflect changing priorities, the budget will recommend focusing resources on the Health Professions' grants that address current health workforce supply challenges, such as the impending nursing shortage and improving diversity in the health professions." These are chilling but probably not surprising words to AAEM members and medical training institutions.

Bush's (and Secretary Thompson's) Initiatives for HHS
As previously stated, President Bush has a marked preference for using a corporate management model and "speaking with one voice." In keeping with this approach, the enumerated health care investments targeted in his budget are, in turn, restated by Secretary Thompson as the Health and Human Services Department's priority initiatives.

Yet, Secretary Thompson's priority initiatives do highlight some items (listed in the President' s budget) that were not highlighted by President Bush. Several of the Health and Human Services Department's priority initiatives are programs that highlight state-level action, a preferred Republican governmental approach. Further, HHS will seek to fund these state-level action items, where possible, through block grants, education and training vouchers, and state tax credits.

For example, HHS' priority initiatives include: (a) possible block grants to states totaling $400 million to assist parents in obtaining after-school childcare, (b) $500 million in 2002 to help states keep children with their biological families, if safe and appropriate, or to place children with adoptive parents, (c) $64 million in 2002 to strengthen the role of fathers in the lives of families. This initiative will provide competitive grants to faith-based and community organizations that help unemployed or low-income fathers and their families avoid or leave cash welfare-a proposal that has been met with some controversy and (d) to encourage states to create state tax credits for contributions to designated charities, the Administration will propose legislation to allow states to use Federal Temporary Assistance for Needy Families funds to offset revenue losses.

President Bush's Principles for a Patient's Bill of Rights
When the President moves from advocating his tax cut plan and tolerating the campaign finance reform debate (which was not his priority but a Senate debate he agreed to rather than see Senator McCain lead with) on which health care measure will he spend his political capital? The answer is, most likely, a patients' bill of rights and, again, Senator McCain played a prominent role in "forcing" the president to act quicker than he wanted.

As you may recall, Senator McCain, Senator Kennedy, Senator Edwards, and others, introduced S. 283, the "Bipartisan Patient Protection Act of 2001," early this session. The bill is based on and closely follows the Norwood/Dingell patients' bill of rights that passed the House last year but languished in the conference committee.

Concerned that S. 283 might gain momentum, President Bush countered with a statement of principles letter to friendly senators then-in a March 21, 2001 speech to the American College of Cardiology-he provided a more exacting statement of principles for a patients' bill of rights that he would sign into law. The president also pointedly stated in his speech "I cannot sign any one (bill) that is now before the Congress."

AAEM, as almost all medical associations, supported last year's Norwood/Dingell bill and supports this year's McCain/Kennedy/Edwards bill. Yet, President Bush has the power to veto any bill that is placed on his desk for signature. Realistically, it may serve little purpose for Congress to pass patients' bill of rights legislation that does not adhere to the president's principles stated in his March 21, 2001 speech. Therefore, the principles are worth restating and remembering.

First, according to President Bush, "a federal patients' bill of rights must cover everyone, all patients in all private health plans.yet flexible enough to preserve the good work that has already been done in many states."

Second, "we must guarantee all patients important rights.the right to get emergency treatment at the nearest emergency room.women should be able to visit their gynecologist and parents their children's pediatrician without going through a gatekeeper.the right to participate in potentially life-saving clinical trials."

Third, "if medical care is denied, .the right to a fair and immediate review.a strong and binding independent review process.you should be able to appeal immediately to an independent, impartial review panel of medical doctors."

Fourth, "a patients' bill of rights should offer patients who have been harmed a meaningful remedy, without inviting frivolous lawsuits. with a strong, independent review process, most disagreements should not wind up in court.with strong independent review, doctors make medical decisions; not the lawyers."

Fifth, ".ensure that Americans will have access to affordable health care coverage.improve medical care, not make it impossible for patients to afford it. excess and frivolous litigation does harm to our health care system.I will insist any federal bill have reasonable caps on damage awards.I will not support a federal law that subjects employers to new multiple lawsuits in 50 different states."

Conclusion
Does President Bush care about health care? The answer is, of course, yes. However, he does have a different approach to health care than his predecessor. It is really a matter of degree but President Bush is more wedded to market-based and state-administered programs than former President Clinton.

Does this matter to AAEM and its members? As most government policy issues, it is in the eyes of the beholder and AAEM members are not monolithic in their beliefs. Yet, all members can be unanimous in their belief to advance the practice of Emergency Medicine and to provide the best care possible for their patients. In Washington, we will be working to advance these interests irrespective of who is president.

James L. Thorne is Washington government relations counsel for AAEM. He can be reached jnlt@erols.com.