(Circulation. 2001;103:e9009.)
© 2001 American Heart Association, Inc.
Whither Health Care Under Bush?
In his first few hours in office, President George W. Bush issued directives to suspend a host of last-minute directives from his predecessor—among them >800 pages of new guidelines that provide protections for poor individuals covered under federal and state-funded Medicaid programs. Older regulations, including patient protection regulations for Medicare patients and patients in plans regulated by ERISA (Employee Retirement Income Security Act), remain in place, but they could be under scrutiny by Bush aides.
In his second healthcare-related action, Mr Bush reversed Mr Clinton’s overturning of rules that barred international family planning organizations from receiving US aid if they performed or promoted abortions.
Whether the Bush actions were directed against the regulations themselves or against former President Clinton, who issued a plethora of wide-ranging orders in the final days of his presidency, was as unclear as the direction in which the new president’s healthcare policy will go. Bush has billed himself as the "education president," but the effect that will have on health care is unclear. According to Washington insiders, health care and education are usually lumped into the same money basket, meaning proposals for one inevitably mean fewer funds for the other.
Even the one issue that seemed most clear—abortion—is now muddied by the statement by Attorney General nominee John Ashcroft during attorney-general confirmation hearings that he would be unlikely to seek opportunities to reverse the 1973 Roe v. Wade decision that made abortion legal in the United States. President Bush was said to be seeking means to overturn some of Clinton’s executive orders in favor of abortion rights. During his presidency, Clinton eliminated the 1988 gag rule that barred health professionals in federally supported family planning clinics from counseling patients about abortion. He also overturned the 1988 ban on the use of aborted fetal tissue in research and issued orders that set into motion the process for legally distributing RU-486, the French abortion pill known as mifepristone. Clinton lifted the directive that banned abortions in US military hospitals, even if the woman paid for them herself. All of these orders are also under review, according to Bush aides quoted in the January 16, 2001, issue of the Akron Beacon Journal (Ohio). Bush is also likely to sign the ban on "partial-birth," late-term abortions if the measure is passed again by Congress.
Wisconsin Governor Tommy Thompson, Bush’s new secretary of the Department of Health and Human Services (HHS), is a staunch abortion opponent, but his opposition to stem cell research is not as well defined. Bush has seemed cautiously opposed to the research in the past, according to the online magazine Salon (www.salon.com/politics/feature/2000/12/29/embryo/index1.html). Speculation has surfaced regarding whether the new President could find himself clashing with both his Attorney General and his Health and Human Services Secretary over the issue of abortion in the future.
Secretary Thompson seems a reluctant appointee. Considered a presidential contender early in the recent election, he stumped for George W. Bush during the campaign and then said he wanted to be considered for Secretary of Transportation. He considered the matter carefully before accepting the HHS nomination.
Widely credited with sparking a successful welfare reform effort in his home state, he is also credited with finding ways to allow new workers to retain their federal health insurance while they adjusted to their jobs. An avowed member of the anti-abortion movement, he has also received serious criticism from members of that community because he lauded University of Wisconsin biologist James Thomson, who was among the first to grow embryonic stem cells in the laboratory successfully. Secretary Thompson invited Dr Thomson to his 1999 state-of-the-state address, calling him a "bold pioneer" during his speech. Although some in the anti-abortion community expect President Bush to reverse the National Institute of Health’s (NIH) rules for funding stem cell research (which were endorsed by Clinton), he has not made a definitive statement on the issue yet. Ending the possibility of federal funding for such work would be a blow to the scientific community, which expects the research to enable them to answer crucial questions about the differentiation of cells and ultimately allow them to grow organs and tissues desperately needed by patients with end-stage diseases of all kinds.
Secretary Thompson is also known for opposing new rules on organ donation issued by former HHS Secretary Donna Shalala (who leaves her post to head the University of Miami). Because Wisconsin has an active and successful organ donation plan, he opposed rules that made organs available to the sickest patients on a nationwide basis, rather than allocating them within a specific region first. That issue split the organ donation community while the debate was ongoing, and the rule was delayed for considerable debate and study before Secretary Shalala issued the final rules in March 2000 by publishing a notice in the Federal Register. However, the United Network for Organ Sharing (UNOS) has not yet set up guidelines for putting the new rules into action. UNOS had opposed the change, and Secretary Thompson could simply refuse to make the agency (which is in charge of carrying out organ donation policy nationwide) comply with the requirement for guidelines.
As HHS secretary, Secretary Thompson will also have to come up with some way of alleviating the growing crisis over the high cost of prescription medications, particularly for the elderly population. The plan that President Bush presented during the campaign is not likely to draw Congressional support because it is limited to only very low income Medicare recipients during the first 4 years and it is structured as a block grant to the states. In the long term, President Bush plans an overhaul of Medicare to prepare for the aging of the baby boomers. In Senate hearings, Secretary Thompson said he thought President Bush would offer the plan to Congress because he had promised to during the campaign, but he said he and the President would be flexible.
As the premium rates for managed care begin to rise across the board, Secretary Thompson may find himself having to deal with rising costs in the part of the Medicare program that the previous Administration touted as a cost-saver: the aggressive Medicare HMOs. The report card on the national movement of putting Medicaid recipients in managed care plans will also become public under Thompson’s watch.
Thompson and President Bush will also face the difficult issue of filling the vacancy at the head of the NIH. Although many have pushed for an inside appointee from one of the institutes themselves, other names from major institutions in the nation have been proposed.
No decision has been made as yet, and it may become even more difficult if it seems that funding for research into embryonic stem cells is in jeopardy because of anti-abortion sentiment in the Administration. The push to double the NIH budget is on track, but that was the work of Congress and not the Clinton administration, which proposed lackluster increases for the last 2 budget cycles.
Rep John Porter (R-Ill) retired from his seat, leaving his chair as head of the House appropriations subcommittee that oversees the NIH budget. He was considered a friend of science research. Rep Ralph Regula (R-OH) is scheduled to take that post and, according to Science magazine, "He’ll be under pressure from the Republican leadership to sustain NIH’s budget increases" (Science. 2001;291:222). If the increases at NIH continue, the nation’s research base should be secure for a while.
It is unclear what will happen with the issue of the 43 million uninsured Americans under the Bush administration. Secretary Thompson got high marks in Wisconsin for his enlightened plan to expand insurance coverage to low-income citizens. However, with a massive tax cut proposal on the line, it is unlikely that the Bush administration is going to push for major changes in the area of health insurance that will add to government expenses. President Bush has said that he is adamantly opposed to a national health care plan, but he did propose a tax credit of as much as $2000 to assist in purchasing a basic health plan. How much insurance that will purchase is debatable.
As always, the picture for health care and research changes with the Administration. When Bill Clinton became president, he promised to develop a plan under which everyone would have health care. When that fell through, he began an incremental program that started with children.
It is unclear what priority health care and health research holds in the Bush administration. Until that is decided, most experts fear to hazard a guess about what will or will not happen.
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