Author + information
- George A Beller, MD, FACC*
- ↵*Reprint requests and correspondence: George Beller, MD, FACC, Cardiovascular Division, Department of Internal Medicine, Health System, University of Virginia, P.O. Box 800158, Health Sciences Center, Charlottesville, Virginia 22908-0158
Part of the overall mission of the American College of Cardiology (ACC) is to advocate public policies that best serve the interests of cardiovascular specialists and their patients. Crucial to that mission is working to advance the ACC’s legislative priorities within the U.S. Congress. The country is now under the leadership of a new administration and Congress. The issues and challenges before the country’s elected leadership remain largely the same from one year to the next—the economy, crime, health care, education, defense, taxes, and the environment. How Congress and the administration choose to address those issues depends largely on political dynamics. Because the ACC relies on its membership to help advocate its policies and priorities, it is important that cardiovascular specialists understand the political dynamics of the 107th Congress and what all of it means for the future of health care policy.
Within the 107th Congress, there is a 50/50 split in the Senate, and Republicans control the House by a narrow majority of 221 to 212, with two Independents. As described by political analyst Stuart Rothenburg, “We are a deeply polarized society.”
Not since 1881 has the Senate been evenly divided (1). The last time the Senate had to operate under such a narrow majority was in 1953, when Republican President Dwight D. Eisenhower faced a Senate with 47 Republicans and 48 Democrats that remained under GOP control only because Independent Wayne Morse of Oregon voted with Republicans (2). During that same 83rd Congress (1953 to 1955), the GOP held a narrow majority of 221 to 213 in the House, with one Independent (3).
In 2000, the electorate was evenly divided not only in the congressional races but in the presidential race as well. According to exit polls, half of voters said they were better off financially than they had been four years ago. Even swing voters split their votes, with 47% of self-described Independents voting for George W. Bush and 45% for Al Gore (4).
The general assumption is that narrow majorities produce gridlock in Washington. But history has proved that assumption to be wrong. During the first session of the 83rd Congress, President Eisenhower sent 44 legislative proposals to Congress and won on 32 (5). Will history repeat itself in this Congress?
Eisenhower was elected president with 55% of the popular vote and 442 electoral votes (6). The 1952 election marked the first time since 1933 that a Republican controlled the White House. By contrast, then-Governor Bush won the presidency with 271 electoral votes and did not win the popular vote; and the election was subject to a lengthy and acrimonious contest. Following the 1952 elections, Republicans gained seats in both the House and the Senate to put them in the majority (7). This year, the Senate and the House will experience narrow majorities because of losses of seats, not gains. Republicans have four fewer seats in the Senate than they did in the 106th Congress, and they have two fewer seats in the House. Furthermore, in 1953, Congress was not plagued by the bitter partisanship that has crippled the Congress over the past several years. Although the 83rd Congress proved that narrow majorities do not necessarily mean gridlock, the current circumstances are not analogous to those of 1953.
Achieving a majority
Having won the political trifecta—control of the Senate, the House, and the White House—Republicans are under tremendous pressure to score a legislative victory early in the legislative session. Crucial to that effort is President George W. Bush’s coalition-building ability. Part of President Eisenhower’s legislative success was attributed to the support he received from Democrats early in his presidency. With narrow majorities, President Bush will not be able to afford to ignore Democrats. He must not only reach out to Democrats but also be able to get his own party to come to the table. During the campaign, he did not stump for congressional Republicans and did not mention them in his speech during the GOP convention (8). President Bush’s main problems may be with satisfying the conservative wing of his party, who may push hard for their agenda. Rep. Tom DeLay, R-Texas, and Sen. Trent Lott, R-Miss., may try to prevent compromise legislation proposed by moderates in both parties.
The narrow margin in the House and the equally divided Senate will undoubtedly increase the influence of congressional moderates. The level of influence that both Democratic and Republican moderates will be able to exert will depend greatly on how well congressional leaders can maintain party cohesion. Sen. John Breaux, D-La., has re-established the Senate Centrist Coalition, a group currently composed of 20 Republicans and 16 Democrats. Sen. Breaux has said he believes that the Centrist Coalition will be “more valuable than ever” in the next congressional session, given the 50/50 split (9). Republican and Democratic moderates in the House have also announced the formation of a new coalition, and efforts are under way to start a bicameral centrist movement. For President Bush, the mere defection of conservative Democrats will not be enough to move his agenda forward, especially in the Senate. With a need to develop a filibuster-proof super-majority, President Bush will need to reach beyond conservative Democrats to the heart of the Democratic caucus.
Democrats will also need to reach out to Republicans if they wish to advance their own agenda. Although Senate and House Democrats increased their membership as a result of the November elections, they do not have control over the veto pen. Nevertheless, with the narrow majorities in the House and the Senate and a president elected without a mandate, Democrats could choose to play the role of spoiler and decide not to hand Republicans any major victories in the 107th Congress. Democrats are already looking ahead to the 2002 elections as yet another opportunity to take control of the Senate and the House. In 2002, of the 33 senators up for re-election, 20 are Republicans and only 13 are Democrats. Only three of those 33 senators won their 1996 elections with at least 65% of the vote (10).
Prospects for progress
Already the 107th Congress is being dubbed the “do-over” Congress, as lawmakers failed to reach agreement in the 106th Congress on several issues, including prescription drugs for seniors, tax relief, and a patients’ bill of rights. Some policy experts suggest that President Bush should pick issues with potential for consensus and work to pass those bills first. Education reform is an early candidate for such consensus building.
While Congress operates in an environment of little certainty, it is without doubt that health care matters will remain front and center in the 107th Congress. The two issues most often mentioned on the campaign trail and that will most likely top the health care agenda early in the new Congress are Medicare prescription drugs and a patients’ bill of rights.
Republicans and Democrats agree that congressional action is necessary to make prescription drugs more affordable to senior citizens. However, last year, both sides failed to reach agreement about how that benefit should be provided. Democrats want a prescription drug benefit to be made available to all senior citizens and administered by Medicare, whereas Republicans generally want to make the benefit available to low-income seniors and administered by the private sector. Last year, Sens. Ron Wyden, D-Ore, and Olympia Snowe, R-Maine, introduced legislation to create a Medicare prescription drug benefit, using the Federal Employees Health Benefit Program as a model. Sen. Snowe, who is considered a moderate, has been appointed to the powerful Senate Finance Committee. Her legislation, which is supported by the Pharmaceutical Research and Manufacturers of America, could be a potential starting point for debate by the committee. Action on prescription drugs could become stalled, however, if key lawmakers or the administration insists that a prescription drug benefit be enacted only as part of broader Medicare reform, an issue on which Republicans and Democrats deeply disagree.
Patients’ bill of rights
As a result of the November elections, supporters of a patients’ bill of rights now believe they have the votes necessary to pass a meaningful and comprehensive patients’ bill of rights. Specifically, patients’ rights supporters are hoping for passage of a bill introduced in 1999 by Reps. Charlie Norwood, R-Ga., and John Dingell, D-Mich., and passed by the House with a strong bipartisan majority. Even though President Bush campaigned as a supporter of patients’ rights, because House and Senate Republican leaders generally oppose the Norwood-Dingell bill, it is not clear that he would sign the bill if it passed Congress. Wanting to give President Bush an early legislative victory, Republicans may, however, decide to seek passage of a patients’ rights bill that offers limited health maintenance organization liability. One such alternative could be a bill introduced by Rep. John Shadegg, R-Ariz., late in the last session, which was supported by the ACC.
Like many issues in the 107th Congress, passage of a prescription drug benefit and a patients’ bill of rights will require close cooperation between Republicans and Democrats. Some political insiders are already speculating that Democrats will be unwilling to hand over to Republicans a victory on any health care issues—especially issues as politically popular as prescription drugs and a patients’ bill of rights. The potential for bipartisan cooperation and continued gridlock are both very real.
One issue that is expected to be a topic of much discussion this year is what to do about the 43 million uninsured Americans. In November, the American Hospital Association, Families USA and the Health Insurance Association of America unveiled a proposal that would expand health care coverage to more Americans, starting with those whose incomes are ≤200% of the federal poverty level. Although the ACC and other provider and consumer groups may decide to make health system reform and the uninsured a top priority this year, serious Republican interest in doing something to help the uninsured will be needed to drive the issue. Post-election polling suggests that the public has latent interest in the issue (11). Until the public begins to show greater interest in the issue, it may be difficult to get lawmakers interested in any reforms aside from providing individuals with a tax credit to purchase health insurance or expanding the State Children’s Health Insurance Program to include adults.
Every year, the College’s leadership develops a list of priorities for its advocacy agenda. For 2001, Medicare prescription drug coverage, managed care accountability, health system reform and the uninsured all top the list. Achieving success on any of these issues will be challenging at best. The U.S. electorate is divided, and no clear mandate has been sent to Congress or the president. An environment is now presented in which interested parties, including the physician community, can help shape the policy agenda and influence the development and enactment of important health care legislation. The possibility of gridlock exists, but the physician community must not tolerate it. No longer should health care legislation important to physicians and their patients be held hostage to partisanship. In the spirit of bipartisanship, the ACC remains committed to working with lawmakers on both sides of the aisle to ensure the passage of meaningful health care policy in the 107th Congress.
- American College of Cardiology
- ↵(2000) Searching for the Vital Center. Congressional Quarterly Weekly 58:2645.
- ↵(2000) Searching for the Vital Center. Congressional Quarterly Weekly 58:2641.
- Foley M.,
- Owens J.E.
- Cook C.
- ↵(2000) Searching for the Vital Center. Congressional Quarterly Weekly 58:2650.
- ↵The Internet Public Library: Presidents of the United States. Available at http://www.ipl.org/ref/POTUS/ddeisenhower.html.
- Foley M.,
- Owens J.E.
- Carney E.N.,
- Baumann D.,
- Ghent B.
- ↵Sen. Breaux to revive Centrist Coalition, urges delaying Medicare reform debate. Health News Daily 2000;12:3.
- ↵(2000) The balance of power in 2002 and beyond. Congressional Quarterly Weekly 58:2625.
- ↵Presentation by Robert J. Blendon, ScD, Professor of Health Policy and Political Analysis, Harvard School of Public Health, Kennedy School of Government, before a conference sponsored by the Commonwealth Fund on December 11, 2000, in Washington, D.C.