It may be that the 1990s will be a kinder, gentler decade after all. While everybody's attention was focused on the deficit and the crisis in the Persian Gulf, it turns out that Congress passed the greatest expansion of health programs in recent years, setting the stage for even more comprehensive reforms in the next legislative session.
"One of the lessons of the elections is that while the American people are concerned about the situation in Iraq, they are much more desperate about their national security at home," said Sen. John D. Rockefeller IV (D-W.Va.) at a conference last week in Washington on health-care issues. "That means the domestic agenda, and there is nothing more complex -- or that affects people more directly -- than health care." ANALYSIS
The ink was scarcely dry on the budget when consumers got a look at the surprising array of new benefits. These include:
Expanded Medicaid coverage for infants and children. Medicaid, the federal-state health program for the poor, will now cover infants for one year without requiring their mothers to re-apply for coverage every 60 days. The program will also be expanded so that by the year 2002, children who live in families below the poverty line will be covered by Medicaid up through age 18.
Medicaid, a notoriously flawed program, covers less than half of those below the poverty line and its payments to doctors and hospitals are often too low to guarantee access to care. The new budget initiatives suggest that Medicaid is going to get more attention from both Congress and the administration.
Home care for the elderly. This new program under Medicaid provides "assisted living" services such as help with meals and visits by nurses and social workers to enable people to remain in their homes instead of being placed in institutions.
Although a relatively modest initiative ($580 million over five years), it represents a step by Congress toward a federal role in long-term care in a person's home. Until now, Medicare and Medicaid reimbursement has been weighted in favor of acute illness and hospital and nursing home care.
Breast screening benefit. Medicare will now cover routine mammograms every two years for women age 65 and over to detect breast cancers at an early stage. This program will help the 18.7 million women in Medicare. It also represents a victory for politicians like Rep. Mary Rose Oakar (D-Ohio) who have worked hard to reduce sexism in health care and to expand research studies to include women, who traditionally have been excluded.
Potpourri of subsidies and regulations. Medicaid, for example, will pick up out-of-pocket expenses for doctors' bills for elderly beneficiaries on Medicare who also fall below the poverty line. And the federal government will strengthen regulation of private supplemental insurance policies sold to the elderly.
To be sure, the budget package is hardly a medical bonanza. It also contains an array of unkind cuts -- $44.2 billion from Medicare over five years -- a hardship that will be borne largely by doctors and hospitals, especially suburban community hospitals.
But the new benefits reflect a growing consensus in Congress that parts of the health care system need emergency treatment. Earlier this year, a bipartisan congressional study, called the Pepper Commission after the late Rep. Claude Pepper (D-Fla.), released a series of recommendations designed to guarantee medical coverage for all Americans.
The plan was immediately ridiculed by many health experts as too radical and too expensive. Yet some of the initiatives recommended by the Pepper Commission -- home-care services for the elderly, coverage of infants and children -- have now become law.
Congress in turn found a financing gimmick: requiring drug companies to give discounts on prescription drugs for Medicaid patients will save almost $2 billion, which will go toward paying for the new programs.
If the momentum for reform continues, the next target is to clean up the mess in the health insurance industry that leaves more than 30 million Americans uninsured and many more without the coverage they need when they get sick.
One reason there is more optimism about health care reforms stems from a change within the administration. Until now, Congress has taken the lead in setting health policy, with the White House dragging its feet. But significant in the budget process was the role of Gail Wilensky, who recently took charge of the Health Care Financing Administration (HCFA), the agency that runs Medicare and Medicaid.
During the 1980s, the budget cutters from the Office of Management and Budget represented the administration on health policy. This time, Wilensky worked closely with Congress, attending all the meetings and standing in the hallway ready to debate the details of the bill.
"That's a sea change," says one Capitol Hill lobbyist for hospitals. "Congress is looking to HCFA and HHS for leadership rather than to OMB."