It was supposed to only take 100 days, but that was eight years ago. When President Bill Clinton took office in January 1993, an air of expectancy permeated Washington, D.C.'s stuffy corridors, and for a moment it seemed as if the world's most developed nation would finally have a national health care policy.
By September, and way beyond the deadline promised by the president, everything was in shambles. In retrospect, the national health care plan hammered out by Hillary Rodham-Clinton and a covey of policy wonks was dead-on-arrival by the time it got to U.S. Congress -- a victim of too much detail and not enough collaboration and compromise.
The Bush administration, however, brings neither hope nor despair, according to informed observers. Nevertheless, there is an anticipation, mostly because no one really knows what he will do next.
"The Bush administration hasn't set forth an agenda that was anything like what we were going to do in 100 days, so it's an altogether different feel" Judith Feder, Ph.D., told Psychiatric Times. Feder is the dean of policy studies at Georgetown University in Washington, D.C. During the halcyon days of health care reform in 1993, Feder was head of the Clinton-Gore health care policy transition team and, as principal deputy assistant secretary for planning and evaluation, was the primary health care policy advisor at the U.S. Department of Health and Human Services.
"The atmosphere is tremendously different now," Feder said. "Not only are we not on a course toward promoting universal coverage, but we are also not focusing on issues of people's need for social supports, such as prescription drug coverage in Medicare."
In February, Bush sent to Congress his "Principles for a Bipartisan Patients' Bill of Rights," which called for comprehensive "patient protections" and a "rapid medical review process for denials of care." That plan also called for assurances that doctors are allowed to make medical decisions. It even supported federal litigation against health care plans if they did not respond to recommendations by an independent reviewer first.
"I want to ensure that all patients receive needed medical care," Bush wrote in a letter to the majority leaders in the House and Senate, "and that doctors are allowed to make medical decisions."
But those promises ring hollow to Feder, who is concerned that the ability to pay for important health care reform measures like universal coverage and drug benefits will be lost to Bush's tax cut plans.
"Improvement of people's coverages takes resources, and I see a concern that those resources will go to tax cuts," Feder said. "I also have a concern that proposals that emphasize 'flexibility' in coverage for low income populations may end up reducing benefits for those covered with programs like Medicaid."
With the states facing rising health care costs, they're eager to cut back benefits, Feder said. "I see an interest in a lot of waiver activity at HCFA [Health Care Financing Administration]. 'Flexibility' can be a euphemism for cutting benefits to poor people."
What is also in play are the interests of big business, both those that sell health-related products and those that buy them. Their influence is widespread according to Common Cause, a Washington, D.C.-based political advocacy group that tracks campaign expenditures. The "soft money" contributions that often go to both the Democratic and Republican national committees should raise eyebrows according to the group's studies.
During the 18-month period from Jan. 1, 1999, to June 30, 2000, Common Cause tracked the top donors ($50,000 or more) of soft money to both parties. The health care industry contributed nearly $4.3 million, while the pharmaceutical and medical supplies industries followed up with nearly $8.7 million.
During 1999, trial lawyers who have an interest in the litigation component of the patients' bill of rights, added $2.75 million to political coffers.
The influence of the political tug-of-war has already been felt. In February, Bush delayed implementation of the medical privacy rules enacted by the Clinton administration just before Clinton left office. This delay came at the behest of the health care and insurance industries and hinted at which interests have Bush's ear. However, according to a statement released on April 12 by Tommy Thompson, Secretary for the Department of Health and Human Services, Bush has now decided, to place strong privacy rules in place.
Daniel Borenstein, M.D., the American Psychiatric Association's outgoing president, told PT that while he is concerned that big-money interests hold sway with the president, there are elements of the privacy regulations that he would still like to see addressed, too.
"It's too soon for me to have an appreciation of what this administration is going to be like," Borenstein said. "We know they've delayed implementation of the HIPAA [Health Insurance Portability and Accountability Act] regs and opened up the comment period, but that may or may not be a bad thing. There's no doubt the administration had some influence from industry, but there are provisions that we would like to see revised as well."
Borenstein said that he is still not sanguine that the medical records privacy provisions offer adequate protection for patients, particularly when it comes to accessibility by the legal system and by marketing forces.
On the other hand, he is concerned that critics of the current rules may take another run at making the regulations pre-empt more vigorous state laws.
"We have to have some experience with this administration to find out how it will react," Borenstein said. "Of course, we don't have the relationships we used to have with other people in the White House. It's a relationship-building period."
Still on the table, according to Borenstein, are the issues that have plagued psychiatry for years, though he is uncertain what the future will hold now that the Bush administration is in place.
"We still have the same issues-which is kind of interesting-that we started with in terms of national politics," Borenstein said. "We still need a good patients' bill of rights, and naturally, there are concerns that it would be watered down or not provide the protections patients need."
For instance, while Bush supported a limited litigation option as long as it followed an appeals process, Borenstein said he was concerned that health care plans may still be able to select the method of oversight.
"It has to be a truly independent appeal panel," Borenstein said. "But to eliminate the possibility of litigation entirely or not to have some way to have a rapid review of health [care] plan decisions that are not dictated by the treating physician would be a bad problem from my perspective."
Getting fair mental health treatment for elderly patients in Medicare is another important issue, though legislative hurdles for more equal benefits must still be overcome.
In March, the APA came out in favor of legislation titled "Medicare Education and Regulatory Fairness Act of 2001," which would alleviate some of the obstacles faced by psychiatrists who treat the elderly.
"Psychiatrists are floundering under Medicare's 100,000 plus pages of regulations," Borenstein said. "There's a substantial and growing need for psychiatric services in Medicare's elderly and disabled population, but HCFA's confusing payment rules and the all-too-adversarial attitude by Medicare bureaucrats are a huge impediment to APA members seeking to provide such care."
Tax policy, however, could also negate much of what health care reformers want to accomplish with Medicare, Feder said. "Of late, any health issue that costs money is essentially at the mercy of the tax cut, and that applies to coverage for pharmaceutical drugs as well as financial security for Medicare.
"The argument is being made that the payroll tax and premiums should be Medicare's only financing and that they should be adequate to pay for all of Medicare's benefits," Feder said. "But Medicare has always had a draw on general revenues. The [faulty premise that only payroll taxes and premiums] should cover Medicare benefits creates a sense of crisis that otherwise doesn't exist."
Jay Cutler, special counsel and director of government relations for the APA, will be responsible for forging new relationships with the incoming administration and the new Congress.
"The politics of health care has become far more complicated since the early '90s," Cutler said. "It's not a matter of a new president with a new agenda, but how do the politics influence the course of the decision making, and no one has the wisdom to answer that yet."
He agrees that implementing the tax cut first and then budget later "is an interesting call."
Part of the problem, said Cutler, is "I hear all the right words, like protecting privacy, but we'll only finally be able to measure it by the results. I don't think anyone can pre-ordain what the outcome will be."
Cutler said that Congress, for instance, could have taken back control over implementing the medical privacy regulations any time it wanted, but it chose not to do that.
"Whether or not there will be a cave-in on privacy I'm not so sure," said Cutler. "But I know medical privacy worries me and I know it worries everyone else a great deal, and I know there's a fair reason to be concerned about it."
As a result there are major issues up for debate again, including the degree of access the health care industry will have to psychotherapy notes. Cutler also said that the ability to protect state privacy laws from federal pre-emption "was quite a coup," but that victory is now also at risk. The rubric of "health plan operations," which allows the use of data without consent for what are essentially business purposes, may also become a trap as the term's definition expands and contracts.
Meanwhile, Cutler says that there are reasons to feel heartened, too. With a Republican administration in place, Sen. Pete Domenici's (R-N.M.) efforts to pass parity legislation could actually receive a boost. In addition, Bush's willingness to sign HMO reform legislation that ultimately included the right to sue in Texas could be a positive sign. It also bodes well for reform of the Employee Retirement Income Security Act (ERISA), which has provided a long-time federally mandated immunity against liability for employer-sponsored health care programs.
Then, the fact that Bush immediately proposed a National Commission on Mental Health as part of his initiative to improve services for the nation's disabled surprised Cutler with its swiftness.
"To see Bush coming down that quickly with a mental health commission was very interesting to me, but we'll see what happens with the commission and what it means," Cutler said. "It is not something I would have thought would have been that fast out of the box for him."
Cutler is not sure yet what the commission means, though he hopes it is something good.
"Nothing is happening on it yet. It hasn't got staff, and there's been no money put up. It's much too early to tell whether it's just window dressing or whether it will accomplish anything.
"But when you can get mental health [mentioned] in this country, it's always good," Cutler added.