Over•sight n. Supervision; watchful care. –American Heritage Dictionary

This week’s election results mean that the Congress will, for the first time in six years, be giving health programs “supervision” and “watchful care.”
• When the EPA fails to regulate toxic air pollutants, the Congress may soon request a briefing.
• When the CDC fails to update its information on HIV prevention for seven years, the Congress may soon ask why.
• When drug companies appear to be making billions because of the transfer of the low-income dual eligibles from Medicaid to Medicare, the Congress may soon request the records.
• And when CMS tells states to distort the Medicaid rules to disqualify thousands of American-born babies, the Congress may soon hold a hearing.

For anyone who believes in the fundamental American system of checks and balances, the past six years, during which the Congress has become the weakest branch, have been painful to watch. From secret meetings to wild regulatory interpretations to outright lies, the Bush administration has stretched Executive Power to historic levels–and the Congress has quietly stood by. (The exception that has proven the rule has been Sen. Charles Grassley, who has made the Finance Committee, which he chairs, the one congressional venue in which the administration has faced investigation. In the House, Rep. Tom Davis, chair of the Government Reform Committee, has also insisted on some transparency in executive branch actions. The occasional sound of their probing questions has made the other hearing rooms seem particularly quiet.)

There are few areas in which this has been more true than in health policy. All of the above examples are real, and there hasn’t been a hearing on a single one of them. Add to that the headlines over the last few months that have attracted public attention, but not that of the House and Senate committees (e.g., Medicare drug plans, Medicaid waivers, prescription drug marketing, rushed and conflicted FDA drug approval, pesticides tests in humans, collapsing morale within the CDC). All of these merit congressional oversight. With one or two Google and Thomas searches, you and I could name two dozen more.

(My personal hope is for inquiry into the myriad areas in which the administration has let politics override science — areas as diverse as childhood lead poisoning and emergency contraception. These lies, damned lies, and cooked books should have an airing as soon as possible so that policy can be made on the basis of facts, not ideology.)

The oversight in itself will produce corrections. Many of these administrative actions will not bear scrutiny in public. Just asking the questions will begin solving the problems.

Such oversight will have preventive effects, too. Administration officials who feel someone reviewing their work may be a little more cautious in their statutory interpretation or their revision of data. Sunshine — even subpoena-produced sunshine — can stop infections before they start.

That will be the major change in health policy from the election: oversight, supervision, and watchful care for the first time in the twenty-first century. Better late than never.

leg•is•late (lj-slt) v. intr. To create or pass laws. —- American Heritage Dictionary

But after the oversight will come some very tough legislative work. A few bills will be obvious and relatively easy: Lifting the ban on NIH funding of embryonic stem cell research is a major contender. Repealing the prohibition on HHS negotiating discounts for Medicare drugs is another. The president will probably veto both, but the respective positions of the branches will be clear.

Most other health legislation, however, is effectively budget legislation. Medicare and Medicaid are big programs. Even SCHIP is a big program. You can hardly add a comma to them without cutting or spending ten million. One Finance Committee friend of mine (Republican) used to say that she rounded everything under half a billion to zero.

And the budget is in chaos. The turn-of-the-twenty-first-century surplus has long ago been squandered, and now there are big deficits as far as the eye can see.

Moreover, the congressional budget process is in shambles. Its major purpose over the last few years has been to usher through tax cuts in a vehicle that cannot be filibustered. When the budget process has been used for health issues, it has distorted the policy so badly that the authors disown the results. (Ask Mr. Shaw and Ms. Johnson about that doughnut hole now.)

The bellwether for the new Congress on health legislation will be how it deals with the budget, the budget process, and SCHIP. SCHIP expires next year. It’s a very popular program that provides health care to millions of children; everyone will want to renew it. But how?

SCHIP is a budget amalgam: It is capped mandatory spending; the law guarantees that there will be X billion dollars available, but no more. Right now that’s about $5 billion, and it insures about four million children.

Because of health price inflation (which rises faster than the CPI) plus the cost of innovations in technology and drugs, providing the same amount of money next year for SCHIP will not be enough. By 2012, thirty-six states will have insufficient funding for their existing caseloads. According to preliminary estimates from the Center on Budget and Policy Priorities, to insure the same number of children will cost about $14 billion over the next five years above the levels assumed in the budget baseline; if the Congress wants to expand the program to reach other uninsured, low-income children, even more money will be needed. Flat funding of SCHIP will result in almost half the children being dropped from the program.

So there’s the question: Does the Congress want to keep funding the program at only $5 billion a year, or does it want to keep insuring at least four million children (or even more)? It can’t do both.

There is a range of legislative responses to this question.

• They could do what they did with Medicare Part D — i.e., set aside a specified amount of new spending for the specified purpose. (One hopes that they won’t go so far as to play Hide-the-Actuary to make the numbers appear to work out.)
• They could find savings in existing programs to allow them to expand SCHIP. (The repeal of the ban on negotiating discounts for Medicare drugs might save a large chunk of cash. So would the elimination of the Medicare HMO slush fund.)
• They could allow some of the tax-cut giveaways to expire, and use that money to insure kids.
• Or they could make the budget process itself more attentive to savings, recognizing the reduced disability and education costs among insured children or including some private-sector value for children’s insurance in the form of less absenteeism among parents and greater productivity on the job. (Consider, for example, the recent multi-volume IOM study on the “hidden costs and values lost” resulting from the lack of health insurance.)

Or, alternatively, they can keep the funding flat and watch SCHIP’s purchasing power erode and the number of children who are insured relentlessly decline.

Moreover, though first in line, SCHIP funding is relatively small. As the Congress moves toward Medicaid and Medicare, expansion and improvement will be scored as even more expensive.

Whatever they do, this is the kind of calculus that is going to face a new Congress as it tries to achieve its twin goals of expanding health insurance and reducing the deficit. It won’t be easy. But, boy, is it a lot better than where it was headed this year.

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