With a new Administration and a close split in both the House and Senate, Hill-watchers expect that the health care legislative agenda will be generally non-controversial and predictable. Based on last year's congressional activities, one can anticipate that items such as Medicare prescription drugs and Balanced Budget Act givebacks will be on Congress' agenda. End-of-life care, which was a major topic of discussion during the last Congress, will almost certainly be considered either as part of other health care bills or, as it did last year, separately.
Building on Last Year
The 106th Congress passed the Benefits Improvement and Protection Act (BIPA), legislation designed to provide limited Medicare and Medicaid relief to hospitals, home health agencies, skilled nursing facilities, hospices, managed care plans and other providers, as well as beneficiaries. This legislation include a hospice rate increase (5% increase in the hospice payment base rates) and changes in the certification of hospice eligibility. The certification changes, which require study by the Department of Health and Human Services, specify that the physician's or hospice medical director 's certification of terminal illness would be based on his/her clinical judgment regarding the normal course of an illness. In addition, MedPAC is required to examine the factors affecting the use of Medicare hospice benefits, including delay of entry into hospice and differences in utilization rates in urban and rural areas.
Under BIPA, the Medicare definition of homebound has been changed to increase access to adult day care facilities for Alzheimer's patients; it also increases rates for skilled nursing facilities and home health agencies. Equally important to those involved in improving end-of-life care are items that Congress reviewed but did not pass. Both House and Senate considered the Pain Relief Promotion Act (PRPA), legislation designed primarily to prohibit Oregon's use of physician-assisted suicide by amending the Controlled Substances Act. PPRA would have also authorized limited pain management benefits, e.g., training grants to entities and dissemination of guidelines. While the House passed PRPA, the Senate did not consider the bill because of parliamentary maneuvering involving a filibuster threat.
The 107th Congress
The new Congress is likely to come back to the PRPA. At the same time, the new Administration could choose to resolve this issue itself through regulatory actions in addition to or instead of congressional action. In brief, the Attorney General could choose to issue a new opinion regarding the legality of the Oregon state law governing the use of physician assisted suicide and, thus, Congressional action to overturn the state action would be unnecessary.
The debate is not likely to focus on physician-assisted suicide. In fact, Congress is beginning to recognize that improved pain management research and treatment are essential. Several comprehensive pain management bills should be reintroduced or introduced for the first time this year. The Conquering Pain Act, which includes comprehensive pain legislation, is likely to be reintroduced. This measure requires a Surgeon General report regarding pain management in the United States and authorizes $18 million for six family support networks for pain management to serve as national models. The Advance Planning and Compassionate Care Act, which provides for Medicare end-of-life demonstrations and makes advance directives portable across states, should also be reintroduced.
As the policy focus on end of life continues, the scope may expand to include related issues, such as care for people with serious and complex illness. Care for chronic illness is quite different from acute care; patients have diverse needs and goals. Such patients usually need to learn to live well despite disease; prevent increased disability; seek spiritual support and social connections, as well as to prepare for death; and to receive comprehensive and continuous care from a range of health care providers. Possible legislative actions might focus on funding research regarding this population and demonstrations that evaluate how to deliver improved care.
Although the health care legislative agenda is just unfolding, the combination of a new Administration and a narrowly divided Congress means that policymakers will look for issues that appeal to many individuals and that cut through party divides. End-of-life care may be just what the doctor ordered.
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