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Report from the Washington Office
Report from the Washington Office
WASHINGTON POTPOURRI W i t h the a p p o i n t m e n t b y P r e s i d e n t C a r ter of J o s e p h A. Califano, Jr., as s e c r e t a r y of Health, E d u c a t i o n and Welfare, the stage is a b o u t set for the C a r t e r a d m i n i s t r a t i o n a n d the 95th C o n g r e s s to b e g i n a c t i o n on h e a l t h legislation. S e c r e t a r y - d e s i g n a t e C a l i f a n o was P r e s i d e n t L y n d o n J o h n s o n ' s c hief d o m e s tic a d v i s o r in the m i d - 1 9 6 0 s . As such, he h e l p e d f o r m u l a t e m a n y of the G r e a t So c i e t y p r o g r a m s , i n c l u d i n g the d r a f t ing of the Safe S t r e e t s A c t and the M odel C i t i e s p r ogram. Since 1969, he has p r a c t i c e d l a w in the D i s t r i c t of Columbia, f irst w i t h the f i r m of A r n o l d and Porter, and m o s t r e c e n t l y w i t h W i l liams, C onnolly, and Califano. One of the b i g g e s t issues to be t a c k l e d by P r e s i d e n t C a r t e r and H E W S e c r e t a r y C a l i f a n o is n a t i o n a l h e a l t h insurance. A l t h o u g h it a p p e a r s that n a t i o n a l h e a l t h i n s u r a n c e w i l l be more a "talking" than a "doing" i s s u e - - a t le ast in the f i rst h a l f of the 95th C o n g r e s s - t h e f o l l o w i n g facts are known. Rep. A1 U l l m a n ( D - O r e ) , c h a i r m a n of the H o u s e Ways and M e a n s C o mmittee, will no t r e i n t r o d u c e his NHI p l a n (HR 1) in 1977. Instead, he p l a n s to h o l d h i m se l f o p e n to i n t r o d u c e the C a r t e r n a tional h e a l t h p rop o s a l , w h e n e v e r that m i g h t be sent up to C a p i t o l Hill. There is still litt l e w o r d a v a i l a b l e as to w h a t form P r e s i d e n t C a r t e r ' s NHI p r o g r a m w i l l take. In the e a r l y stages of his bi d for the p r e s i d e n c y , C a r t e r e n dorsed a comprehensive, mandatory, gov ernment oriented national health insur ance p r o g r a m for all people. However, he is n ow a d v o c a t i n g a p r o g r a m w h i c h
w i l l be p h a s e d - i n as r e v e n u e s permit. S p o k e s m e n for the C a r t e r a d m i n i s t r a t i o n h a v e stated that a b i l l is b e i n g d e v e l o p e d and c o u l d b e i n t r o d u c e d w i t h i n t hree m o n t h s of Mr. C a r t e r ' s i n a u g u r a tion. However, g i v e n the d i f f i c u l t i e s f aced by any n e w a d m i n i s t r a t i o n in o r g a n i z i n g itself, it is a l m o s t i m p o s s i b l e to p r e d i c t w h e n a n a t i o n a l h e a l t h i n s u r a n c e p r o p o s a l w i l l b e fort h c o m i n g . Sen. M c I n t y r e (D-NH) a n d Rep. Omar B u r l e s o n (D-Tex) w i l l a g a i n s p o n s o r the NHI bill p r o p o s e d by the H e a l t h I n s u r ance A s s o c i a t i o n of A m e r i c a . In a d d i tion, the A m e r i c a n M e d i c a l A s s o c i a t i o n w i l l r e s u b m i t to C o n g r e s s its NHI p r o posal, c o n t a i n i n g o n l y m i n o r changes. The A M A d e c i s i o n r e g a r d i n g the C o m p r e h e n s i v e H e a l t h Care I n s u r a n c e A c t came a fter a h e a t e d d e b a t e at the 1976 c l i n ical C o n v ention. By a v o t e of 181-57, A M A d e l e g a t e s "decided t h a t p o l i t i c a l r e a l i t i e s d e m a n d e d A M A c o n t i n u e to have a v o i c e in the c o m i n g d e b a t e o v e r NHI, r a t h e r than make an a l l - o u t f ight ag a i n s t any and all f o r m o f NHI." Other Health Legislation A s i d e from n a t i o n a l h e a l t h i n s u r ance, however, a p p r o x i m a t e l y one d o z e n h e a l t h p r o g r a m s are due to e x p i r e in 1977. T h e s e include the m i g r a n t h e a l t h program; the c o m m u n i t y h e a l t h c e n t e r program; the f a m i l y p l a n n i n g prog r a m ; the c o m m u n i t y m e n t a l h e a l t h c e n t e r p r o gram; p r o g r a m s p r o v i d i n g for the N a t i o n al C e n t e r for H e a l t h S e r v i c e s R e s e a r c h and the N a t i o n a l C e n t e r for H e a l t h S t a tistics; and the N a t i o n a l H e a l t h P l a n n i n g and R e s o u r c e s D e v e l o p m e n t Act. It a p p e a r s l i kely that C o n g r e s s w i l l opt for a s i mple o n e - y e a r e x t e n s i o n of t hese p r o g r a m s , in o r d e r to g i v e the C a r t e r a d m i n i s t r a t i o n a m p l e time to f o r m u l a t e t heir p o s i t i o n s . According to the C o n g r e s s i o n a l B u d g e t Act, n e w l e g i s l a t i o n m u s t be a p p r o v e d by the a p p r o p r i a t e c o m m i t t e e by M a y 15 of each year. Thus, this d e a d l i n e w o u l d a l l o w little o p p o r t u n i t y for the a d m i n i s t r a tion to b e c o m e f a m i l i a r w i t h the m a n y and v a r i e d issues involved. It is then a n t i c i p a t e d that g r e a t e r and m o r e f o r mal a t t e n t i o n w i l l be g i v e n t h ese p r o grams in the s p ring of 1977. Of the e x p i r i n g h e a l t h laws, c l e a r
ly th e m o s t c o n t r o v e r s i a l is the N a t i o n al H e a l t h P l a n n i n g and R e s o u r c e s D e v e l o p m e n t Act. A l t h o u g h s t ate and local officials have developed numerous amend m e n t s to the law that they w a n t to see en a cted, some of the m a j o r h e a l t h o r g a n i z a t i o n s m i g h t hold up their e n d o r s e m e n t s , a w a i t i n g the o u t c o m e of the p e n d ing A M A l a w s u i t c h a l l e n g i n g the c o n s t i t u t i o n a l i t y of the h e a l t h p l a n n i n g law. Subcommittee Agenda In a d d i t i o n to the e x p i r i n g h e a l t h p r o g r a m s and, possibly, n a t i o n a l h e a l t h i n s u r a n c e , the S e nate and H o u s e h e a l t h s u b c o m m i t t e e s are l a ying the g r o u n d w o r k for o t h e r l e g i s l a t i v e initiatives. The S e n a t e f i n a n c e h e a l t h s u b c o m m i t t e e will c o n c e n t r a t e on l e g i s l a t i o n d e s i g n e d to r e f o r m the M e d i c a r e and M e d i c a i d r e i m b u r s e m e n t m e c h a n i s m s and will also c o n d u c t f u r t h e r i n v e s t i g a t i o n s into M e d i c a r e a nd M e d i c a i d fraud and abuse. In a s p e e c h this y e a r b e f o r e the P e n n s y l v a n i a H o s p i t a l A s s o c i a t i o n , Sen. H e r m a n T a l m a d g e (D-Ga) said that "Both C o n g r e s s m a n Paul Rogers of the h e a l t h s u b c o m m i t t e e an d C o n g r e s s m a n D a n Rostenk o w s k i of W a y s and M e a n s h a v e p l e d g e d to m a k e t h e s e a n t i - f r a u d and a n t i - a b u s e m e a s u r e s the first o r d e r of b u s i n e s s in the n e w C o n g r e s s . " T h e H o u s e W a y s and M e a n s h e a l t h s u b c o m m i t t e e , c h a i r e d by Rep. Dan R o s tenk o w s k i (D-Ill) has on its l e g i s l a t i v e a g e n d a the p r o m i s e d h e a r i n g s on M e d i c a r e f r a u d and abuse; h e a r i n g s on the M e d i c a r e r e nal d i a l y s i s program; and c o n s i d e r a t i o n of M e d i c a r e r e i m b u r s e m e n t r eform. Rep. Paul Rogers' (D-Fla) C o m m e r c e h e a l t h s u b c o m m i t t e e will hold h e a r i n g s on M e d i c a i d fraud and abuse, and w i l l d e l v e into c l i n i c a l lab r e g u l a t i o n ; d r u g safety a m e n dments; m a t e r nal a n d c h i l d h e a l t h programs; c l ean ai r l e g i s l a t i o n ; food s urveillance; c o s m e t i c safety; and the c o n t i n u i n g in q u i r y into the p r o t e c t i o n of h u m a n s u b jects of b i o m e d i c a l research. S e n a t e and H ouse R e f orms H o w ever, b e f o r e any of this w o r k c a n be started, the S e nate and H ouse of Representatives must organize them selves .
P e n d i n g as the f i rst o r d e r of b u s i ness b e f o r e the S e n a t e is a c o m m i t t e e r e o r g a n i z a t i o n p l a n d e v e l o p e d in the 94th Cong r e s s . Curr e n t l y , the S e n a t e has 32 c o m m i t t e e s and 17 4 s u b c o m m i t t e e s w i t h e a c h s e n a t o r h a v i n g an a v e r a g e of e i g h t c o m m i t t e e and s u b c o m m i t t e e a s s i g n ments. The r e o r g a n i z a t i o n p l a n c alls for c o n s o l i d a t i o n of the e x i s t i n g 32 c o m m i t t e e s into 14 s t a n d i n g c o m m i t t e e s and one s e l e c t comm i t t e e : agriculture and small busi n e s s ; app r o p r i a t i o n s ; armed services; banking, housing, and u r b a n affairs; budget; commerce, s c i ence, and t r a n s p o r t a t i o n ; e n e r g y and n a t u r a l r e sources; e n v i r o n m e n t and p u b lic works; finance; f o r e i g n r e l ations ; g o v e r n m e n t a l affairs; h u m a n resources ; judiciary; rules, a d m i n i s t r a t i o n , and standards; a n d s e l e c t i n t e l l igence. A s e n a t o r c o u l d s erve o n no m o r e than two s t a n d i n g c o m m i t t e e s , and no m e m b e r of an a u t h o r i z i n g c o m m i t t e e could s e r v e as an e x - o f f i c i o m e m b e r of the A p p r o p r i a tions Comm i t t e e . A l t h o u g h the H o u s e of R e p r e s e n t a tives e n a c t e d its o w n c o m m i t t e e r e o r g a n i z a t i o n m e a s u r e in 1974, this y e a r it may well be conducting business under a n e w l e g i s l a t i v e w o r k schedule. De v e l o p e d by a 1 5 - m e m b e r Task F o rce on S c h e duling, the p l a n p r o p o s e s to r e s t r u c t u r e the H o u s e floor s c h e d u l e to pr o v i d e m o r e time for c o m m i t t e e b u s i ness at the b e g i n n i n g of the c o n g r e s sional s e s s i o n and m o r e time for floor b u s i n e s s l a t e r on in the sess i o n as the l e g i s l a t i v e d e a d l i n e s r e q u i r e d b y the C o n g r e s s i o n a l B u d g e t A c t approach. Transition In a d d i t i o n to all the a c t i v i t y on Capi t o l Hill, h e a l t h staf f e r s on P r e s ident C a r t e r ' s t r a n s i t i o n t e a m p r e p a r e d two r a t h e r l e n g t h y docu m e n t s : a'com p i l a t i o n o f f o r t h c o m i n g events, and a list of p r i o r i t y i n i t i a t i v e s that w i l l r e q u i r e e a r l y p o l i c y d i r ection. High on the s e c o n d list is the issue of h e a l t h care c o s t c o n t ainment, i n c l u d i n g M e d i c a r e a n d M e d i c a i d fraud and abuse, and p r o s p e c t i v e r e i m b u r s e m e n t . The d i s c u s s i o n s on this p a r t i c u l a r issue p o i n t up the n e e d to c o n trol h e a l t h care c o s t s if a n a t i o n a l h e a l t h i n s u r ance p r o g r a m is to be enacted.
WASHINGTON POTPOURRI W i t h the a p p o i n t m e n t b y P r e s i d e n t C a r ter of J o s e p h A. Califano, Jr., as s e c r e t a r y of Health, E d u c a t i o n and Welfare, the stage is a b o u t set for the C a r t e r a d m i n i s t r a t i o n a n d the 95th C o n g r e s s to b e g i n a c t i o n on h e a l t h legislation. S e c r e t a r y - d e s i g n a t e C a l i f a n o was P r e s i d e n t L y n d o n J o h n s o n ' s c hief d o m e s tic a d v i s o r in the m i d - 1 9 6 0 s . As such, he h e l p e d f o r m u l a t e m a n y of the G r e a t So c i e t y p r o g r a m s , i n c l u d i n g the d r a f t ing of the Safe S t r e e t s A c t and the M odel C i t i e s p r ogram. Since 1969, he has p r a c t i c e d l a w in the D i s t r i c t of Columbia, f irst w i t h the f i r m of A r n o l d and Porter, and m o s t r e c e n t l y w i t h W i l liams, C onnolly, and Califano. One of the b i g g e s t issues to be t a c k l e d by P r e s i d e n t C a r t e r and H E W S e c r e t a r y C a l i f a n o is n a t i o n a l h e a l t h insurance. A l t h o u g h it a p p e a r s that n a t i o n a l h e a l t h i n s u r a n c e w i l l be more a "talking" than a "doing" i s s u e - - a t le ast in the f i rst h a l f of the 95th C o n g r e s s - t h e f o l l o w i n g facts are known. Rep. A1 U l l m a n ( D - O r e ) , c h a i r m a n of the H o u s e Ways and M e a n s C o mmittee, will no t r e i n t r o d u c e his NHI p l a n (HR 1) in 1977. Instead, he p l a n s to h o l d h i m se l f o p e n to i n t r o d u c e the C a r t e r n a tional h e a l t h p rop o s a l , w h e n e v e r that m i g h t be sent up to C a p i t o l Hill. There is still litt l e w o r d a v a i l a b l e as to w h a t form P r e s i d e n t C a r t e r ' s NHI p r o g r a m w i l l take. In the e a r l y stages of his bi d for the p r e s i d e n c y , C a r t e r e n dorsed a comprehensive, mandatory, gov ernment oriented national health insur ance p r o g r a m for all people. However, he is n ow a d v o c a t i n g a p r o g r a m w h i c h
w i l l be p h a s e d - i n as r e v e n u e s permit. S p o k e s m e n for the C a r t e r a d m i n i s t r a t i o n h a v e stated that a b i l l is b e i n g d e v e l o p e d and c o u l d b e i n t r o d u c e d w i t h i n t hree m o n t h s of Mr. C a r t e r ' s i n a u g u r a tion. However, g i v e n the d i f f i c u l t i e s f aced by any n e w a d m i n i s t r a t i o n in o r g a n i z i n g itself, it is a l m o s t i m p o s s i b l e to p r e d i c t w h e n a n a t i o n a l h e a l t h i n s u r a n c e p r o p o s a l w i l l b e fort h c o m i n g . Sen. M c I n t y r e (D-NH) a n d Rep. Omar B u r l e s o n (D-Tex) w i l l a g a i n s p o n s o r the NHI bill p r o p o s e d by the H e a l t h I n s u r ance A s s o c i a t i o n of A m e r i c a . In a d d i tion, the A m e r i c a n M e d i c a l A s s o c i a t i o n w i l l r e s u b m i t to C o n g r e s s its NHI p r o posal, c o n t a i n i n g o n l y m i n o r changes. The A M A d e c i s i o n r e g a r d i n g the C o m p r e h e n s i v e H e a l t h Care I n s u r a n c e A c t came a fter a h e a t e d d e b a t e at the 1976 c l i n ical C o n v ention. By a v o t e of 181-57, A M A d e l e g a t e s "decided t h a t p o l i t i c a l r e a l i t i e s d e m a n d e d A M A c o n t i n u e to have a v o i c e in the c o m i n g d e b a t e o v e r NHI, r a t h e r than make an a l l - o u t f ight ag a i n s t any and all f o r m o f NHI." Other Health Legislation A s i d e from n a t i o n a l h e a l t h i n s u r ance, however, a p p r o x i m a t e l y one d o z e n h e a l t h p r o g r a m s are due to e x p i r e in 1977. T h e s e include the m i g r a n t h e a l t h program; the c o m m u n i t y h e a l t h c e n t e r program; the f a m i l y p l a n n i n g prog r a m ; the c o m m u n i t y m e n t a l h e a l t h c e n t e r p r o gram; p r o g r a m s p r o v i d i n g for the N a t i o n al C e n t e r for H e a l t h S e r v i c e s R e s e a r c h and the N a t i o n a l C e n t e r for H e a l t h S t a tistics; and the N a t i o n a l H e a l t h P l a n n i n g and R e s o u r c e s D e v e l o p m e n t Act. It a p p e a r s l i kely that C o n g r e s s w i l l opt for a s i mple o n e - y e a r e x t e n s i o n of t hese p r o g r a m s , in o r d e r to g i v e the C a r t e r a d m i n i s t r a t i o n a m p l e time to f o r m u l a t e t heir p o s i t i o n s . According to the C o n g r e s s i o n a l B u d g e t Act, n e w l e g i s l a t i o n m u s t be a p p r o v e d by the a p p r o p r i a t e c o m m i t t e e by M a y 15 of each year. Thus, this d e a d l i n e w o u l d a l l o w little o p p o r t u n i t y for the a d m i n i s t r a tion to b e c o m e f a m i l i a r w i t h the m a n y and v a r i e d issues involved. It is then a n t i c i p a t e d that g r e a t e r and m o r e f o r mal a t t e n t i o n w i l l be g i v e n t h ese p r o grams in the s p ring of 1977. Of the e x p i r i n g h e a l t h laws, c l e a r
ly th e m o s t c o n t r o v e r s i a l is the N a t i o n al H e a l t h P l a n n i n g and R e s o u r c e s D e v e l o p m e n t Act. A l t h o u g h s t ate and local officials have developed numerous amend m e n t s to the law that they w a n t to see en a cted, some of the m a j o r h e a l t h o r g a n i z a t i o n s m i g h t hold up their e n d o r s e m e n t s , a w a i t i n g the o u t c o m e of the p e n d ing A M A l a w s u i t c h a l l e n g i n g the c o n s t i t u t i o n a l i t y of the h e a l t h p l a n n i n g law. Subcommittee Agenda In a d d i t i o n to the e x p i r i n g h e a l t h p r o g r a m s and, possibly, n a t i o n a l h e a l t h i n s u r a n c e , the S e nate and H o u s e h e a l t h s u b c o m m i t t e e s are l a ying the g r o u n d w o r k for o t h e r l e g i s l a t i v e initiatives. The S e n a t e f i n a n c e h e a l t h s u b c o m m i t t e e will c o n c e n t r a t e on l e g i s l a t i o n d e s i g n e d to r e f o r m the M e d i c a r e and M e d i c a i d r e i m b u r s e m e n t m e c h a n i s m s and will also c o n d u c t f u r t h e r i n v e s t i g a t i o n s into M e d i c a r e a nd M e d i c a i d fraud and abuse. In a s p e e c h this y e a r b e f o r e the P e n n s y l v a n i a H o s p i t a l A s s o c i a t i o n , Sen. H e r m a n T a l m a d g e (D-Ga) said that "Both C o n g r e s s m a n Paul Rogers of the h e a l t h s u b c o m m i t t e e an d C o n g r e s s m a n D a n Rostenk o w s k i of W a y s and M e a n s h a v e p l e d g e d to m a k e t h e s e a n t i - f r a u d and a n t i - a b u s e m e a s u r e s the first o r d e r of b u s i n e s s in the n e w C o n g r e s s . " T h e H o u s e W a y s and M e a n s h e a l t h s u b c o m m i t t e e , c h a i r e d by Rep. Dan R o s tenk o w s k i (D-Ill) has on its l e g i s l a t i v e a g e n d a the p r o m i s e d h e a r i n g s on M e d i c a r e f r a u d and abuse; h e a r i n g s on the M e d i c a r e r e nal d i a l y s i s program; and c o n s i d e r a t i o n of M e d i c a r e r e i m b u r s e m e n t r eform. Rep. Paul Rogers' (D-Fla) C o m m e r c e h e a l t h s u b c o m m i t t e e will hold h e a r i n g s on M e d i c a i d fraud and abuse, and w i l l d e l v e into c l i n i c a l lab r e g u l a t i o n ; d r u g safety a m e n dments; m a t e r nal a n d c h i l d h e a l t h programs; c l ean ai r l e g i s l a t i o n ; food s urveillance; c o s m e t i c safety; and the c o n t i n u i n g in q u i r y into the p r o t e c t i o n of h u m a n s u b jects of b i o m e d i c a l research. S e n a t e and H ouse R e f orms H o w ever, b e f o r e any of this w o r k c a n be started, the S e nate and H ouse of Representatives must organize them selves .
P e n d i n g as the f i rst o r d e r of b u s i ness b e f o r e the S e n a t e is a c o m m i t t e e r e o r g a n i z a t i o n p l a n d e v e l o p e d in the 94th Cong r e s s . Curr e n t l y , the S e n a t e has 32 c o m m i t t e e s and 17 4 s u b c o m m i t t e e s w i t h e a c h s e n a t o r h a v i n g an a v e r a g e of e i g h t c o m m i t t e e and s u b c o m m i t t e e a s s i g n ments. The r e o r g a n i z a t i o n p l a n c alls for c o n s o l i d a t i o n of the e x i s t i n g 32 c o m m i t t e e s into 14 s t a n d i n g c o m m i t t e e s and one s e l e c t comm i t t e e : agriculture and small busi n e s s ; app r o p r i a t i o n s ; armed services; banking, housing, and u r b a n affairs; budget; commerce, s c i ence, and t r a n s p o r t a t i o n ; e n e r g y and n a t u r a l r e sources; e n v i r o n m e n t and p u b lic works; finance; f o r e i g n r e l ations ; g o v e r n m e n t a l affairs; h u m a n resources ; judiciary; rules, a d m i n i s t r a t i o n , and standards; a n d s e l e c t i n t e l l igence. A s e n a t o r c o u l d s erve o n no m o r e than two s t a n d i n g c o m m i t t e e s , and no m e m b e r of an a u t h o r i z i n g c o m m i t t e e could s e r v e as an e x - o f f i c i o m e m b e r of the A p p r o p r i a tions Comm i t t e e . A l t h o u g h the H o u s e of R e p r e s e n t a tives e n a c t e d its o w n c o m m i t t e e r e o r g a n i z a t i o n m e a s u r e in 1974, this y e a r it may well be conducting business under a n e w l e g i s l a t i v e w o r k schedule. De v e l o p e d by a 1 5 - m e m b e r Task F o rce on S c h e duling, the p l a n p r o p o s e s to r e s t r u c t u r e the H o u s e floor s c h e d u l e to pr o v i d e m o r e time for c o m m i t t e e b u s i ness at the b e g i n n i n g of the c o n g r e s sional s e s s i o n and m o r e time for floor b u s i n e s s l a t e r on in the sess i o n as the l e g i s l a t i v e d e a d l i n e s r e q u i r e d b y the C o n g r e s s i o n a l B u d g e t A c t approach. Transition In a d d i t i o n to all the a c t i v i t y on Capi t o l Hill, h e a l t h staf f e r s on P r e s ident C a r t e r ' s t r a n s i t i o n t e a m p r e p a r e d two r a t h e r l e n g t h y docu m e n t s : a'com p i l a t i o n o f f o r t h c o m i n g events, and a list of p r i o r i t y i n i t i a t i v e s that w i l l r e q u i r e e a r l y p o l i c y d i r ection. High on the s e c o n d list is the issue of h e a l t h care c o s t c o n t ainment, i n c l u d i n g M e d i c a r e a n d M e d i c a i d fraud and abuse, and p r o s p e c t i v e r e i m b u r s e m e n t . The d i s c u s s i o n s on this p a r t i c u l a r issue p o i n t up the n e e d to c o n trol h e a l t h care c o s t s if a n a t i o n a l h e a l t h i n s u r ance p r o g r a m is to be enacted.