Special Article Washington Odyssey: An Anesthesiologist’s View of the Politics of Health Care

Allen I. Hyman, MD* Department Columbia

of Anesthesiology, University,

In the fall of 1987, as a Robert Wood Johnson Health Policy Fellow, I began a year working for Senator Robert Dole as his health aide. This fellowship program gives academic health professionals a hands-on education in legislation and policy development in Washington, DC, and an insight into the function of government that cannot be obtained simply from written materials or observation. My purpose in this article is to encourage anesthesiologists to learn more about the political process that creates the rules, regulations, and policies shaping and governing their practice and professional lives. Moreover, if upon reading, a few become inclined to spend a year in Washington to learn health policy on the job, I would consider this article successful. Most physicians are uninterested in or uncomfortable with the affairs of government. We tend to hold politics and politicians in low esteem and shun involvement in political activity. At one time, this attitude might have been commendable. Today, however, our


of Anesthesiology

Address reprint requests to Dr. Hyman at the Department of Anesthesiology. College of Physicians and Surgeons, Columbia University, 630 W. 168th Street, New York, NY 10032, USA. Received for publication November 22, 19X9; revised manuscript accepted for publication January 31, 1990. 0

1990 Butterworth-Heinemann

New York,

College of Physicians and Surgeons, NY.

understanding of policy-making and our participation in the political process can affect our practice, research, and training. It seemed to me that health care delivery was being changed by anonymous political forces that had little understanding of patient care and were driven mostly by budget considerations. I went to Washington to learn more about that process. Not only was I interested in procedure-how laws were passed and decisions made-but I also wondered how information was transferred to and from health care providers and health policymakers. I imagined that there must be intensive studies, extensive hearings, and considerable deliberation and debate before voting on crucial issues. Alas, I learned that most lawmakers know little of medical practice and the delivery of health care. I would estimate, for example, that fewer than ten senators understand the Diagnostic Related Groups (DRG) system or appreciate the implications of instituting a change in fee schedule under the Resource Based Relative Value Scale (RBRVS). The Health Policy Fellowship Program was established more than 15 years ago by the Robert Wood *Johnson Foundation to encourage academic health professionals to learn more about health policy in Washington in order to undertake new responsibilities when they return to their institution. Of nearly 50 applicants, 6 fellows were eventually selected. We began an 1 l-week orientation program arranged by the Institute of Medicine and the American Political Science Association. We had four daily conferences and met with White House officials, members of Congress, Department of Health and Human Services J. Clin. Anesth.,

vol. 2, September/October



(DHHS) of‘f’icials, think tank experts, lobbyists, and heads of‘ trade associations and protession;tl societies. During the orientation phase of‘ the program, 1 learned a few important principles that helpctl mea throughout the year. I found that reliable and useful information is a precious arid often rare c.ommodity in Washington. Despite the enormous quantity of‘ciata produced by our government, most helpf‘ul infi)i-mation may not come f‘rom the obvious. direct, oi of’ficial source. Interest groups, lobbyists, and even those opposed lo your own members position often have the best analysis of‘ a particular subject. ‘l‘heir credibility depends on the accuracy of‘ their inf’ormation. One of‘my preconceived notions about Washington was that most people in government work ;I short day, take 2 hours fbr lunch, and have 3-day weekends. In fact Washington is a workaholic’s dre&. People stay late: take their work home, and are constantly up against deadlines. They are dedicated, low paid, loyal to their bosses, and intelligent. Congressional staf’f‘, especially those who work f’or comnittees, have considerable latitude and discretion in writing legislation. Af’ter orientation, 1 accepted an invitation to work with Senator Robert Dole, the Republican leader from Kansas, in the midst of‘ his presidential campaign. I reported to Sheila Burke, who has worked f’or the Senate Republican leader for 12 years, most recently as his chief’ of’ staff. During her assignment on the Senate Finance Committee, Ms. Burke helped write the 1983 Medicare hospital payment reform law. She is a registered nurse and is highly respected f’or her knowledge of health issues and the political process. My typical day began with a breaktast meeting with colleagues in the Senate Dining Room. Reading three daily newspapers and clippings from several more became part of my routine. My day continued with perusing the t;rderul Kq@er, the Con~~e,~.sional Kemd, and the Senator’s mail dealing with health matters. I do not think I have ever been so well inf’ormed; I certainly will miss the morning reading hour. Essentially, my .job was keeping tabs on health activities. Besides responding to questions from the media on Senator Dole’s position on health issues, I attended committee meetings and hearings, wrote “talking points” and a few speeches, and especially enjoyed doing what was called casework. I tried to help health groups and individuals, especially from Kansas, through the bureaucratic maze. Hospitals and insurance carriers f’requently sought help and guidance in their dealings with the Health Care Finance Administration (HCFA). Sometimes the dif’f’erences among professional organizations, trade associations, and special interest groups became blurred. 340

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‘l‘lle Republicarl leader‘s officy could cGl! 1~ ;I SC’I for a vcq good televisioli series. ‘I‘liew LV;I\(lra~~i;~, suspense, tr.diliin, arid tun. .l‘he ofl‘it~ cast 01. c.hai acters is bright, sometimes harassed, highlv conipetitive, occaionally disappointetl, and of’ten tired. ‘I‘heir personal lives and exciting activities becomc~ wondertUlly intermeshed. 1 f‘elt accepted as a member of Senator Dole’s staf’f and en.joyed and appreciated their confidence in allowing me to see firsthand how policy is f’ormulated. Working in a personal office of‘s member of‘(:ongress does not usually allow the fellow to engage in deep analysis of ;I particular subject. ‘l‘hose who choose to work on the committees are likely to have a more detailed understanding of. how a bill is created and moved toward passage. One of my most rewarding experiences was serving as surrogate f’or Senator Dole as co-chairman of‘ the Rural Health C;aucus. I learned about the special economic and health delivery problems of INI-al Amel-ica. I met many Americans who had an entirely different upbringing and experience f’rom my own in New York (;ity. ‘I‘he Kansas Hospital Association arranged for a small plane to take my wif‘e and me around the state to visit rural hospitals, meet theil staf’f‘, and discuss the crisis f’aoing the delivery of‘ health care in our rural areas. We will long remernbe~ the hospitality and kindness of the Kansans we met on that trip. ‘1%~ fellowship year climaxed at the Republican Convention in New Orleans in August 1X-X. I sat near Senator Dole in his sky box in the Super-dome on the last evening as he watched then Vice President George Bush deliver his acceptance speech for the presidential nomination. I could not help but wonder about the senator’s innermost thoughts, perhaps of’ what might have been. When the speech was over, he rose and led the rest of‘ us in a standing ovation for his former political opponent. I felt an extraordinary mix of excitement and disappointment. It is easy to contract Potomac fever and imagine are carrying out earthshaking activities. that you -I-here are always important events whirling about. I remember one morning working at the photocopy machine when one of‘ our staff answered my phone. He called, “Allen, it’s the White House again!” Members of the president’s staf‘f wanted to plan a “photo op” and ceremony with Senator Dole in observance of National Rural Health Awareness Week. “Won’t they let me get my work done?” I lamented. You certainly can get used to this heady stuff. Our nation’s health policy is established in the political arena, which accounts for some of‘ the confusion. -Just as policies in agriculture, taxation, de-

fense, transportation, and social services are shaped and molded by contending partisan and adversarial groups, our health strategy is forged, compressed, and expanded by many separate and diverse forces. Some of these influences are in government, and others are represented by various private associations. Since Lyndon Johnson, none of our presidents has shown leadership in developing health policy. We all know that our health care system is changing rapidly, if not chaotically, in the absence of defined objectives. Annual health care spending now exceeds $600 billion. ‘I’he major buyers of health care-the government, unions, and now businesses-are rebelling. FI’elephone workers and coal miners are fighting to retain health benefits. Industry has awakened like a sleeping giant to force hospitals, doctors, and patients to change their habits. Cost containment, quality, outcome studies, and expanded access are now agenda items. In Washington, I learned that all legislation reallocates and redistributes wealth. I‘he government takes from some and gives to others. (iroups that succeed in the legislative process win; the others lose, pay more taxes, or receive fewer benefits. Back in 1966, Medicare was enacted and promptly changed our national health program forever. When Medicare began, only !50/(# of our gross national product ((GNP) was spent on health care. ‘I‘oday, 12’$, or one dollar in eight, ‘goes to hospitals, doctors, pharmacies, and laboratories. ‘I‘his transfer payment, representing an enormous redistribution of wealth from consumers to providers, has been accepted easily and readily because its impact is imperceptible to the average person. It has been paid by third parties: by government, insurance companies, and big businesses. Until now, industry has not complained much about its cost of health care because health insurance has been a deductible business expense. Workers also have been content, since their health benefits are not taxed as income. Today we know that when consumers pay for their health costs out-of-pocket, they become more prudent and sensitive to price. Consider the defiance of some senior citizens against their elected officials when they learned that they must pay more for catastrophic health insurance. In our political system, organized groups are encouraged to give political and financial support to candidates for public office in order to have more influence and access to lawmakers. Some special interest groups try to achieve their financial goals by swaying legislation rather than doing more in the marketplace; a tax dollar saved is as good as a sales dollar earned. Since Medicare, certain groups have benefited

from the massive distribution of money toward health care delivery. Yhysicians’ incomes have risen more than they might have otherwise. Hospitals, medical and health technology companies have schools, grown. And the elderly receive medical benefits worth more than what they paid into the system. All of these groups succeeded in the political system. But some people now deem 12% of the GNP too much for this purpose. How did we come along this path? Young doctors might be surprised to know that before World War II. the federal government played a minor role in health care. In the 194Os, Washington began to subsidiLe the building of hundreds of new hospitals under the Hill-Burton Act, and in the 19.50s, the government accelerated its commitment to medical research. By 1960, most Americans received their health benefits at work, but most retirees were not covered. ‘I‘he elderly wanted Medicare. ‘I‘he hospitals also supported Medicare. But the doctors objected initially and agreed to Medicare only when promised that they could continue to charge their usual fees and practice without interference from Washington. Anesthesiologists were particularly successful in the political arena, thanks to the American Society of Anesthesiologists (ASA) leadership and their key congressional contacts. ‘rhrough the ASA’s efforts and over the strong objections of the American Hospital Association, anesthesiologists were recognized in Medicare legislation as physicians engaged in the normal practice of medicine. We were reimbursed through Part B with most other doctors and not through Part A’s hospital insurance. This change was a major political achievement and, in large measure, determined our specialty’s successful development. As late as 1972, Congress continued to add major new programs to Medicare. But by the 19XOs, the environment changed from ribbon cutting to cost cutting. Reacting to sharp increases in hospital expenditures under cost reimbursement despite costcontainment programs, Congress passed a prospective payment system. This important legislation was enacted in only 2 weeks, without much consideration of the impact of DRGs OII the quality of or access to health care. Congress’s only concern was cutting the federal expenditures for Medicare. On the last day of the 1972 session, Congress fundamentally changed the budget process. The new system was a response not only to a budgetary crisis but also to a worsening economy. The stock market plummeted, unemployment rose, and we were in a recession. The so-called peace dividend from the winding down of the Vietnam War vanished. Then came OPEC’s $40~a-barrel oil and stagflation. Jimmy Carter J. Clin. Anesth., vol. 2, SeptemberiOctot)e~ 1990


was Oul; KOnald Keagan roared in. ‘l’he politics of tlit Keagan revolution created a paradox in health policy. While President Keagan and Office of Managemenr of Budget (OMH) d irector Stockman encouraged deregulation and competition in most sectors of. our economy, they clamped down hard on health (‘are programs and tried an assortment of new policies to contain costs. ‘I-he politics of the Keagan era led to cost cutting by hospitals and contraction throughout the health care system. Hospitals were forced to merge or close, bed census and length of stay fell, and doctors squabbled for a piece of the diminishing economic pie. President Keagan sought to control inflation, bring down interest rates, lower taxes, increase the defense budget, and lower social program spending all at the same time. He completed all of these policies, but the costs were not offset by the expanding economy. ‘I‘he legacy is our $1.50 billion budget deficit. How is our health policy established? The president articulates our national health policy through the office of the secretary of the DHHS. The health branch of this agency is divided between the Public Health Sector and HCFA, the agency that distributes more than $100 billion annually to doctors and hospitals. Nearly half of the money collected by the federal government is returned to the people by the DHHS through legislatively ‘Those individuals who meet mandated expenditures. the statutory standards are automatically entitled to the benefits. Medicare and Social Security are virtually inviolate entitlements because few politicians would risk reelection by tampering with these programs dear to the elderly. Balancing the power of HCFA in the executive branch is the OMB, which sits like a greeneyeshaded monolith behind the walls of the New EXecutive Office Building, fending off and balancing the budget requests from more than a dozen competing agencies. FI’hree committees of Congress oversee and appropriate funding for Medicare. ‘I-he Senate Finance Committee, led by Lloyd Bentsen Texas, authorizes spending for more than 90% of the total health dollar through Medicare and Medicaid legislation. In the House, the Health Subcommittees of Ways and Means and Energy and Commerce have complementary and, sometimes, overriding jurisdiction over health care financing. In the final analysis, it is the chairpersons of these three committees, together with their staff, that craft the final legislation achieved through consensus and compromise for enactment by Congress. Before the budget system was changed in 1972, Congress enacted health policy one bill at a time, just as we were taught in high school civics class. Lawmakers introduced legislation, hearings were held, the



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nieasure w;is tleba~eti, and finally (he Ijill $1;IS \ otc*(I up or docv11. But ~otlay, nearly all changes in O~II. health policy are made ill the budget I-~~corlc.ili~rtiorl process it1 omnibus legislation. Keconcilia~iorl CL’;IS illtended to ensure that the final budget met targccs or priorities set up by C;ongress earlier in (he )wr iti t Ire Budget Kesolution. Since the process failetl to l)revent huge deficits, Clongress passed the (;r-anl~ll-K~ldnl;~nHoldings law in 1985. ‘I‘he law forces (Congress to rerevenue to meer deficit duce spending or increase targets or else face automatic cuts called sequestration. Lawmakers can be highly creative in coming up with accounting gimmicks euphemistically called “smoke and mirrors.” Every budget item comes with a price tag; even a small change in the way anesthrsiologists clock their time for charging Medicare patients has ;I predicted dollar value. Politically, reconciliation allows menibe~3 of (:ongress to cut programs dear to the hearts 01‘ thcil constituents without ever taking the blame. ‘[‘he reconciliation process leads to short-term thinking and narrow planning. ‘I‘here is no time to look at the broad picture-no discussion of’ quality or priorities. ‘l‘ht final conference is usually held behind doors closecI to those most interested in the outcome; ever1 the lobbyists remain outside in crowded corridors. ‘I‘he tinished bill, of several thousand pages, goes back to Congress for a yea or nay \,ote on the entire package and is sent to the president for his signature. His veto is unlikelc. Membkrs of Congress do not go to Washington to save money. Legislators enjoy promoting new programs and new projects, especially those bills named for them. ‘I-hey like to‘ vote for highways, hospitals, or a nlanned Martian landing. 13ut Congress behaves schizophrenically when it comes to health policy basically because the public is also of two opinions. Most Americans say they want mow money spent on health care, even if we must cut into other programs. At the same time, they say that it costs them too much. They want more but also want to pay less. (;ongress, listening and responding to public opinion, cut spending for health care but continued the benefits. Despite freezes and cost-corltainlnerlt measures, llot one entitlement was ever withcirawn, until the catastrophic health law was repealed in late 1989. ‘I-his law, aptly named, is an example of how Congress errs when it overtly and conspicuously reallocates money and benefits. In the fall of’ 19X8, lawmakers went home happy, having passed the first major health bill since Medicare. They told the American people not to worry about going bankrupt if they had the misfortune of a catastrophic illness or an in-

jury. No longer would families be wiped out by extended hospitalization. But Congress misread public opinion. Catastrophic health coverage was President Reagan’s only new Medicare proposal. Despite strong opposition from the insurance and pharmaceutical industries, he supported the bill as long as it was financed by the senior citizens themselves. Because the monthly premium would be more than most elderly persons could afford, Congress proposed a means test. All the elderly would get the same new benefit, but the wealthier ones would pay an additional supplementary tax. The American Association of Retired Persons (AARP), representing the elderly, agreed to support the new benefit and its unique method of financing. But Congress failed to see the power of a determined, organized, single-minded, well-funded group. Tons of mail and threats to cut political support alarmed the lawmakers. In less than a year, Congress completely reversed its position. Today, doctors and hospitals feel the pressure of government, business, and insurance companies. The health care system, like our health policy, seems chaotic. The hidden effects of all the cutbacks over the past few years must eventually catch up. So many factors are changing simultaneously that no one can tell if and when the whole process will unravel. Will AIDS deplete our health care resources? Do we have a doctor glut or a doctor shortage? What will we do about the uninsured, our high infant mortality, the drug crisis, and long-term care for the elderly? Will anyone care about anesthesiology research and resident training? What are our national priorities? All of our social and health problems have begun to touch one another. Although George Bush said, “Read my lips: no new taxes,” he may have to find new revenue to solve the deficit crisis. Many in Congress covet the expanding Social Security trust fund, likely to exceed a trillion dollars; others would like to increase the payroll tax by eliminating the cap. Until now, few thought either initiative would be politically possible. Senator Patrick Moynihan’s recent preaching has stirred up the pot. ‘rhree years ago, most people said national health insurance was a dead issue. But today, the directors of some of our largest corporations call for government help to reduce their health care expenses. Many of these capitalists are considering, even supporting, socialized medicine rather than stay the present course, which reduces their profits. Others suggest we copy Canada’s approach to universal health coverage to slow the growth of spending on health care. Some analysts say that the cost of our health care system is out of control. They argue that only two

options can check rising health care costs and provide more care to those in need: regulation and competition. Those who favor regulation say that the government should set limits on total spending and the hospitals and doctors must learn to live within these established expenditure targets. Other experts want more competition among hospitals and doctors. They consider that health care, as any other economic enterprise, operates most efficiently in a free market. ‘I’he health financing problem at this time is so large and so constrained by budget and economic forces that the Bush administration and Congress seem impotent, with no lasting solutions. We must be wary of the quick fix in times of crisis. We must be mindful of sudden shifts in public opinion that can cause important changes in programs that are politically expedient but hastily and poorly conceived. We must be informed and involved in order to influence health policy fbr the best interest of our patients, our profession, and our practice. My year in Washington was a \vonderful adventure-not quite “Allen in Wonderland” but a splendid opportunity to participate in the political system. I hope this report will induce other anesthesiologists to catch a case of‘Potomac fever, an exhilarating but not necessarily fatal disease.




A Glossary of Terms

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is in the details

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vol. 2, September/October


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I am most grateful to Senator Robert Dole :mtl his wonderlul staff for their grxious hospitality and genel-ous ;Gsr;mc-c. I am especi;~lly indebted LOSheila Burke for her enc-ourxgement, advice, and good cheer. I also wish to th;tnk Alycia Rhinehart I&- typing the manuscript.

Washington odyssey: an anesthesiologist's view of the politics of health care.

Special Article Washington Odyssey: An Anesthesiologist’s View of the Politics of Health Care Allen I. Hyman, MD* Department Columbia of Anesthesiol...
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