Ten days ago, Richard S. Schweiker stunned those who keep an eye on his Health and Human Services Department by announcing that he was calling off plans to revise health and safety rules for the 8,500 skilled nursing facilities that get money from Medicaid and Medicare.
Had rising political opposition forced Schweiker to stand up to the White House and its Task Force on Regulatory Relief, which had included nursing home rules on its regulatory hit list?
Well, not exactly.
While criticism from senior citizen and other groups led Schweiker and his senior staff to take a hard look at the proposals that were working their way through HHS, the proposals that he halted are not the rules that the White House regulatory reformers are most concerned about.
The changes that Schweiker pulled back would have relaxed requirements for staff training, for having medical directors and dental consultants and the like on staff, and monitoring infection control and communicable diseases.
As drafts of the revisions and revisions of the revisions began appearing in the press, Schweiker's senior staff became concerned that the changes would be viewed by the elderly as a case of the Reagan administration "beating up" on old folks.
That might be a political risk worth taking if the changes drafted by HHS's Health Care Financing Administration really achieved effective regulation. But at least one senior staffer reportedly told Schweiker that, in his opinion, the proposed regs wouldn't give nursing home operators genuine flexibility to achieve real economies and efficiencies. At the same time, though, the staffer said, they would drive opponents of the changes, like the National Citizens' Coalition for Nursing Home Reform, into a frenzy. The game isn't worth the candle, he told the secretary.
So Schweiker called off the effort, declaring, "I will not imperil senior citizens in nursing homes, our most vulnerable population, by removing essential federal protections. I will not turn back the clock."
But still to come are the regs that the White House does care about: a related set of regulations involving inspections of nursing homes to see how well they are complying with health, safety and other rules.
Right now, skilled nursing homes with Medicare and Medicaid patients must be inspected annually. Much of the nursing home industry, represented by such groups as the American Health Care Association, believes that the paper work and other requirements associated with inspection are too burdensome for homes with a good record of compliance. They would prefer inspections every three years for homes with good records.
Schweiker is getting ready to look at a number of options, including one that would set biennial inspections at homes with good records and at least once a year--more if required--for those with poor records. That would target inspections on substandard homes, according to HHS officials.
According to Peter Teeley, press aide to Vice President Bush, who chairs the task force, and Ed Dale, spokesman for the Office of Management and Budget (which provides most of the task force personnel), as well as sources in HHS, the White House isn't angry with Schweiker's decision to pull back the first set of regs. All three sources said that those were never targeted.
Since the health and safety rules had never been targeted, Teeley said, it was Schweiker's call to decide whether to change them, as he saw fit. "So we have no disagreement with the announcement he made" and foresee no attempt to reverse his decision.
But Teeley and Dale both said that the task force is very interested in what Schweiker does on the inspection regulations.
Teeley, Dale and HHS also denied yet another interpretation of Schweiker's announcement that had been gaining some currency: that the White House actually connived with the secretary to take the action he did because it feared the adverse reaction of advocacy groups for the aging in the November elections. They said Schweiker made the decision, and Edwin Meese III, counselor to the president, confirmed it.
The confusion over the two sets of regulations goes back a year, when the vice president's office first announced that nursing home "certifications and surveys" (a term that means inspections) had been placed on the list of burdensome regulations that it wanted departments to review. Its supporting documents never referred to "conditions of participation," the term of art for health and safety standards.
Neverthless, as part of its own regulatory review, a special HCFA study group began examining both the health and safety rules and the inspection issue.
At the time there was a widespread impression, which many nursing home spokesmen still believe was actually correct, that the task force had wanted HHS to study both issues. In fact, the HCFA study group put out a number of internal memos and announcements implying that, as well as letters to members of Congress.
The HCFA study group drew up a plan for revising some of the health and safety standards and it was eventually sent to Schweiker by Carolyne K. Davis, the administrator of HCFA.
Meanwhile, the nursing home reform coalition was waging a vigorous campaign against what it called proposals to "weaken" the "federal protections for nursing home residents."
The matter came to a head early this January when a copy of the HCFA plan was leaked to the press. It created a storm among groups representing the aged. At that time, Schweiker told The Washington Post, through an intermediary, that he would "never approve anything in the guise of regulatory reform that will detract from any of these rights or health or safety." Some people viewed that as rhetoric, but when it came to a final decision, Schweiker turned down the changes.