In eight years in the Senate, Bill Frist has drawn on his surgical experience and free-market beliefs to establish himself as a potent spokesman for GOP views on health care. But with the Tennessee Republican's sudden ascent to the Senate majority leadership, and with the overhaul of Medicare one of the main items on the domestic policy agenda, his advocacy on health issues is coming under fresh scrutiny.

Frist has repeatedly vowed to put the interests of patients before those of others in reshaping the delivery of health care for Americans. At the same time, he has consistently said the private, for-profit health institutions that have captured a much larger share of the market in the past decade are more efficient than the nonprofit ones that predominated earlier.

But in health care generally, and on Medicare specifically, patient and profit-making interests can clash in deliberations about who should have access and what they must pay. An examination of Frist's campaign and legislative records shows that in this collision, he has sometimes promoted consumer interests but has shown more consistent support for for-profit interests with powerful Washington lobbies.

This pattern has attracted criticism from consumer advocates as Congress begins to wrestle with the reform of Medicare, a fast-growing, $265 billion program that provides health care reimbursements for 40 million elderly and disabled people. Frist has said he favors expanding Medicare benefits while shifting more of the program's business to private insurers, a reform that he says will offer more choice while keeping costs down.

Frist's critics assert that his personal history has given him blinders on this issue, because his father and brother founded a company that made millions of dollars by converting nonprofit hospitals into for-profit institutions, and because he has drawn extensive campaign contributions from profit-making health care and related industries.

"Frist is incapable of thinking about a health care system that would reduce the number of for-profit health providers," including nursing homes, managed-care companies and hospitals, said Sidney Wolfe, director of the Health Research Group, an arm of the consumer advocacy group Public Citizen. Wolfe's colleague Frank Clemente, director of Public Citizen's Congress Watch, said that Frist "represents the medical-industrial complex."

Frist spokesman Nick Smith contested that characterization. "As a doctor and now a senator, Frist is bound to the fundamental ideal of improving people's health," Smith said. "He always votes his conscience, and quality patient care has been his priority. His full record testifies to that." His record also makes plain how he prefers to achieve that ideal.

Family Ties

Frist's political activism is barely a decade old. He did not vote until 1988, when he was 36, and former Tennessee newspaper editor John Siegenthaler said that before Frist's first Senate race, it was unclear whether he was a Republican or a Democrat.

He was, however, well-known as a heart transplant surgeon and as a multimillionaire scion of the man who founded the Hospital Corporation of America, the nation's largest for-profit hospital company. In a relationship that links Frist more directly to the health care industry than any other senator, Frist's holdings in HCA stock provided the most significant source of his wealth and helped launch his political career: In 1994, he lent his first Senate campaign $6.24 million, secured partly by HCA stock.

Frist has never been employed by HCA or one of its 258 hospitals and outpatient centers; the company was run mostly by his father, Thomas Frist, and brother Thomas Frist Jr., who was HCA's chairman for 15 years and remains on its board of directors. During his first campaign, Frist valued his holdings in the company at more than $13 million; a year later, in 1995, he placed them in a blind trust, out of his direct control, and he says today that he no longer knows how much the stock is worth.

As Frist was entering politics, House and Senate committees -- including one chaired by the senator whom Frist would defeat in 1994, James Sasser (D-Tenn.) -- were conducting hearings about Medicare fraud by health care providers, including HCA. In 1993, a General Accounting Office audit alleged specifically that HCA had improperly billed Medicare for partial reimbursement of its spending on items such as liquor, flowers, symphony tickets, a sailing regatta, scholarships for its employees' children, a costly corporate reorganization and a public relations firm to counter its negative image.

Since then, the company has paid at least $1.47 billion in fines to settle federal lawsuits for improper billing and other regulatory violations. Frist did not make any comment about HCA's business practices during either of his campaigns and, through a spokesman, declined to do so for this article.

Frist has avoided public appearances with HCA employees and has not attended several hearings at which the trade association representing for-profit hospitals provided its views. But the company's employees have strongly backed his campaigns, contributing $171,350 since 1993, according to the Center for Responsive Politics, an independent group that tracks the role of money in politics. That was part of the $1.44 million the company and its employees have given to politicians in the past decade, including roughly $1 million to Republicans.

Frist's political action committee, which donated to other political candidates, further benefited from contributions of $20,000 by his brother Thomas and sister-in-law Patricia. Another donor was HCA's registered Washington lobbying firm, the Smith-Free Group, which gave $5,000.

Lobbyists from that firm, representing HCA's interests, contacted Congress regarding four of the health care bills that Frist has sponsored in the past two years, according to lobbying disclosures filed on Capitol Hill. One promoted the career of nursing, and another promoted defenses against bioterrorism. A third bill, still pending, would increase hospital Medicare reimbursements, and another would shift some Medicare patients to private insurance plans.

A lobbyist with the group, W. Timothy Locke, recently told an Internet journal published by Legal Times that he counted himself in the "small circle of folks" around Frist on a regular basis. In response to an inquiry from The Washington Post, Locke said, "We've never talked to Bill about anything related to HCA, or [talked] to his staff" about HCA matters.

The Senate Select Committee on Ethics has twice sent Frist private advisories about his links to HCA and involvement in health care policymaking, once at Frist's request and once in response to a complaint from Rep. Harold E. Ford Jr. (D-Tenn.). Frist's office declined to release the texts, which are not public documents, but said the committee had assured him there was no bar on his role as long as the policies at issue affected multiple companies, not only HCA.

Frist summarized his policy views at a 1995 Tennessee fundraiser, saying, "I believe that we can make government a helpmate . . . in many cases, simply by getting out of the way." This free-market approach has drawn considerable support from the health care and insurance industries, which are among the most heavily regulated in the United States.

Campaign Contributions

In his 1994 campaign, Frist received $634,081 in health industry contributions, more than any other Senate candidate that year, according to data compiled by the Center for Responsive Politics. Frist's financial records over the past decade show that health professionals have consistently been his largest contributors, with the pharmaceutical and insurance industries and their employees not far behind. Together, they have contributed $1.8 million to his campaigns out of the $17.9 million he has received from all donors.

Frist's links to the health industry have also been strengthened by the movement of his staff to and from the lobbying industry. His staff director on the Senate public health subcommittee, Dean Rosen, is a former general counsel of the Health Insurance Association of America, a group of 290 insurance companies that has lobbied aggressively for an expanded share of Medicare business. In addition, Frist's former health policy analyst and his former legislative assistant are now working for Washington law firms or industry associations that lobby on health care and other policy issues.

Over the past two years, when Frist headed the National Republican Senatorial Committee, he came into contact with big-money donors from around the country, not only those with headquarters in Tennessee. The committee raised $124.5 million for the party's successful effort to regain Senate control from the Democrats. Thomas Frist Jr. contributed $10,000 to that total.

The largest chunk of the committee's money -- $4.67 million -- came from retirees, while the second-largest was from political action committees and employees affiliated with "pharmaceuticals and health products" companies, which contributed $3.9 million, according to the Center for Responsive Politics. The insurance industry, which has a huge stake in changes made to Medicare, was the third-largest contributor, providing $3.7 million.

Eli Lilly & Co. and its employees were among those contributors, giving $30,000 to Frist's political action committee in the past two years as well as $425,000 to the Senate campaign committee Frist headed and $2.5 million to Republicans overall. Eli Lilly has also contributed $10,000 directly to Frist's campaigns since 1994.

In December, it was discovered that Frist included a provision in a health care bill that limited Eli Lilly's liability in pending litigation over the safety of its vaccines in which mercury was used as a preservative. The provision was subsequently shifted to another bill -- with no one acknowledging responsibility -- and enacted. Frist has said a federal advisory group backed the provision, but he has since promised to bring it to a second vote after "strong patient protections" are added.

The episode was something of an aberration for Frist, because the provision was so narrowly tailored. His legislative record suggests wider health interests.

Patients and Providers

Since his 1994 election, Frist has helped draft bills with bipartisan support, promoting organ donation, strengthening community health centers, expanding minority health studies, and encouraging the use of defibrillators and the development of new vaccines against bioterrorism agents. He also voted for a compromise bill expanding mental health benefits -- a bill the insurance industry opposed.

More often, he has supported bills that have reflected the interests of large donors.

In 1997, for example, Frist sponsored a bill that would allow new doctor-hospital alliances to begin serving Medicare patients under federal supervision, a bill supported by HCA. He is one of 29 Senate sponsors of a bill introduced in 2001 that would loosen regulation of Medicare contracts and force faster federal adjudication of billing disputes with hospitals and doctors.

Frist has also been an outspoken critic of consumer-backed proposals for mandatory reporting of medical errors at hospitals, introducing a bill backed by the American Hospital Association that would keep such data confidential unless disclosure is necessary for litigation.

In addition, he has attacked the Democratic-sponsored version of the "patients' bill of rights" as a bill that would "do more to promote the . . . wealth of our nation's trial lawyers than to" protect patients, supporting instead a bill preferred by the managed-care industry it would regulate. The industry favors the bill partly because it offers fewer legal remedies for disgruntled patients.

Frist helped gain Senate approval of a bill, backed by the pharmaceutical industry, that would allow companies to send scientific information to doctors about unapproved uses of their drugs, boosting prescription sales to new categories of patients.

But Frist's main health care initiative so far is the Medicare bill broadly supported by the White House and a coalition of the nation's largest business, drug, hospital and private insurance groups, known as the Alliance to Improve Medicare. If the legislation is approved, insurers stand to gain as much as $25 billion in new business, independent analysts say, nearly doubling their current Medicare business.

Rep. Jim McDermott (D-Wash.) served with Frist in 1999 on a bipartisan panel that examined Medicare's shortcomings but deadlocked over any solutions, mostly along party lines. McDermott criticized Frist for taking a "doctrinaire" position in arguing for industry-backed changes, which McDermott said would put the elderly at risk of paying higher premiums they may not be able to afford.

Frist has said the bill would provide more efficient medical care, reduce government regulation and give the elderly a larger menu of health care options by offering drug reimbursement they currently lack and rewarding health care providers with higher reimbursement rates. Speaking in 1999 about the agency that implements Medicare, he said, "It is so huge, so big, so inflexible, that we really don't any longer . . . want it at the top overseeing" patient care.

Staff researchers Lucy Shackelford and Madonna Lebling contributed to this report.

Senate Majority Leader Bill Frist (R-Tenn.), flanked by Sen. Mitch McConnell (R-Ky.), left, and Rick Santorum (R-Pa.).