Bush's long-term care agenda

President Bush will be a less zealous regulator in chief with the nursing home industry than President Bill Clinton was, according to long-term care experts.

"I think you're going to have fewer armed raids of healthcare company headquarters with guns drawn and flak jackets on under a Bush administration," says Steve Monroe, a healthcare analyst and partner with Irving Levin Associates, New Canaan, CT. The Clinton administration had a confrontational attitude toward for-profit healthcare providers, he says.

The Clinton legacy

President Bill Clinton left the White House with a reputation as an unflinching regulator, especially when it came to the nursing home industry. He toughened nursing home enforcement regulations in 1995, 1998 and up to the time he left office.

Clinton increased the Health Care Finance Administration's budget for survey and certification from $158 million in fiscal year 1997 to $210 million in fiscal year 2000.

In July 1998, the HCFA started requiring states to impose immediate fines against nursing homes that caused harm to residents on consecutive surveys. State inspectors had to stagger surveys and conduct visits on weekends, early mornings and evenings. And states were ordered to conduct more frequent inspections of nursing homes providing poor care.

Nursing homes now face fines of up to $10,000 for each serious incident that threatens residents' health and safety. Previously, fines had been linked to the number of days nursing homes did not comply with federal requirements.

Now, enter George W. Bush. Industry experts agree that nursing home care is not a priority on Bush's healthcare agenda, and as a result they feel the nursing home industry can expect a period of regulatory calm during the Bush years.

Paul R. Willging, director of seniors' housing programs at Johns Hopkins University, Baltimore, and former head of the Washington-based American Health Care Association, says a Bush administration is both good and bad for nursing home providers.

The good news: Bush will champion states' rights, he says. "I don't think in the area of survey and certification he will allow the Health Care Financing Administration to run rampant with no consideration given to the particular realities in the states."

With Tommy Thompson heading the Department of Health and Human Services, "there's going to be less of a concern to make a federal statement and more of a concern to recognize that things can be best dealt with at the local level," Willging says.

The bad news: Willging says a Bush administration will favor Medicaid waivers and increasing the use of home- and community-based alternatives to nursing home care. "So the issue of market share, which is one of the biggest issues facing nursing homes, is going to be to some extent, if anything, exacerbated."

Nursing homes not a priority

Monroe, the analyst from Irving Levin Associates, says the nursing home industry is not a Bush priority. Monroe says that Bush didn't focus on nursing homes when he was governor of Texas, "a state with a God-awful track record in the nursing home industry," and, therefore, will not do so as president.

"He's got a much bigger agenda nationally, so I don't think he's really going to give it two thoughts."

However, Monroe expects that a Bush White House will be "neutral to positive" for the long-term care industry because, he says, Republican administrations typically support business.

"I think we'll have a kinder, gentler White House in regard to Justice Department and HCFA oversight. Bush is just not a big regulations guy. I think it will be less anti-provider."

Andy Bressler, senior vice president of healthcare industry research with Bank of America, Bethesda, MD, agrees with Monroe that nursing homes are not on Bush's radar.

Under Clinton, the HCFA, the Department of Justice and the Department of Health and Human Services' Office of Inspector General cracked down on substandard nursing home care, targeted fraud and abuse violations, increased inspections and toughened surveys, he says.

"Obviously, Bush is not going to scrap all of it, but he's not going to go after it with the same fervor that Clinton had."

Texas nursing homes

One week before the presidential election, democrats on the House Government Reform Committee released a scathing report on substandard care in Texas nursing homes.

Using state inspection reports from March 1998 to August 2000, the committee found that 1,044 of Texas's 1,230 nursing homes had at least one violation that could cause "more than minimal harm" to residents. In addition, 680 nursing homes had violations that caused harm to residents or placed them at risk of death or serious injury. These violations, according to the report, included untreated bedsores, preventable accidents, and nutrition and dehydration problems.

But industry officials have noted that states differ on what they consider a deficiency, thereby making comparisons of quality care among states problematic.

The report also pointed out that "one of the underlying causes of the poor conditions in Texas nursing homes appears to be the low level of reimbursement paid by the state under the Medicaid program and the low level of staffing that the nursing homes are able to afford."

The average Medicaid payment in Texas is $81 a day, the report noted, making the state 44th among the 50 states in reimbursement levels. Nationwide, state Medicaid programs paid an average of $103 a day in 1999.

The report also found that 90% of Texas nursing homes did not meet preferred minimum staffing levels set by the Department of Health and Human Services.

The Grassley factor

Joshua M. Wiener, principal research associate at the Urban Institute, Washington, says although long-term care was not the centerpiece of the Bush presidential campaign - Bush had said he favored increased Medicare funding for providers and tax incentives to encourage the purchase of long-term care insurance - some lawmakers could lead him to it.

Who would they be? Sen. Charles Grassley (R-IA), the former chairperson of the Special Committee on Aging and now head of the Finance Committee, and Sen. Larry Craig (R-ID), the new chairperson of the Special Committee on Aging, Wiener says.

Nursing homes became an issue for the Clinton administration because Grassley made them an issue, Wiener says. "It's a question of whether Grassley or the new Aging chairman will continue to push.

"Either [Grassley] will find his plate too filled with other things to pay attention [to nursing homes] or he's in a much better position to press his point," he says.

New faces at labor board

Stephen J. Cabot, management labor lawyer and partner with Harvey, Pennington, Cabot, Griffith & Renneisen Ltd., Philadelphia, says that, unlike Clinton, Bush will not favor unions over employers.

"Bush was a businessperson before becoming governor, and as a consequence he understands the issues and challenges that face businesspeople, one of them being labor unions. One of Clinton's constituencies was the AFL-CIO, and he rewarded labor with many laws."

Cabot says that within the next 15 months, Bush may have the potential to appoint three members to the five-member National Labor Relations Board, which under Clinton, the lawyer says, had been "working overtime trying to assist unions."

The National Labor Relations Board oversees union elections and ensures that employers and unions treat workers lawfully.

Says Cabot, "I believe Bush's appointments to the National Labor Relations Board will be more business-friendly." PR