Congressional Leaders Research Articles

The President and the Environment: A Reinterpretation of Neustadt's Theory of Presidential Leadership

Neustadt's theory of presidential leadership is conventionally viewed as based on a model of the Bargaining President, in which presidents focus on twisting arms and trading favors rather than on making public appeals. However, Neustadt's theory has a deeper logic—the logic of strategic choice, in which both effective bargaining and rhetorical appeals are techniques of presidential persuasion enabled by a President's choices. This reinterpretation of Neustadt's theory is supported by an original case study of President George H.W. Bush's leadership on the 1990 Clean Air Act. The President presented an initiative in a manner that capitalized on the public mood and he made key strategic choices aimed at persuading congressional leaders to engage with his administration in a non-zero sum game to enact a law that served their mutual policy and political interests. Rhetorical appeals were few in number. Quid pro quo bargaining played a limited role.

Medicaid Funding Boost May Rescue At-Risk MH Services

Back to table of contents Previous article Next article Government NewsFull AccessMedicaid Funding Boost May Rescue At-Risk MH ServicesRich DalyRich DalySearch for more papers by this authorPublished Online:3 Sep 2010https://doi.org/10.1176/pn.45.17.psychnews_45_17_019AbstractMany states whose revenues have plunged due to the recession will be able to avoid implementing massive reductions in their Medicaid programs following congressional passage of a bill that extends federal financial assistance to those programs.About $16 billion in Medicaid assistance was included in a $26 billion measure (HR 1586) passed in August and signed by President Obama that will also provide states with funds to rehire public-school teachers and other state and local government workers who lost their jobs due to funding cuts resulting from budget shortfalls.The Medicaid appropriation will extend by an additional six months—to June 30, 2011—an increase in federal Medicaid payments to the states, known as the Federal Medical Assistance Percentage, that was enacted as part of the federal stimulus measure (PL 111-5).About 60 percent of states had already passed budgets that assumed the federal government would provide the additional Medicaid assistance in the wake of falling tax revenues during the recession. If the added federal funding had fallen through, those state legislatures would have had to scramble to find sufficient cuts or tax increases to make up the difference.The National Governors Association, in a letter to congressional leaders, said that the states' total estimated budget shortfall for the 2010-2012 period is expected to be $116 billion. The letter described the extended Medicaid payments as “the best way to help states bridge the gap between their worst fiscal year and the beginning of recovery.” Medicaid is dually funded by states and the federal government. The measure provides a 6.2 percent across-the-board increase to each state's Medicaid program and extra funding for states with the highest unemployment rates.The federal Medicaid boost was urged by mental health advocates, who were alarmed that many states had already sought budget savings through cuts in their mental health programs and that more such cuts could result from a lack of additional federal assistance.For instance, Michigan Gov. Jennifer Granholm (D) said in July that her state would cut mental health and prescription drug coverage under its Medicaid program if the state didn't receive the full $560 million it needed in federal Medicaid assistance, according to local media reports.“Medicaid is the primary funder of community-based mental health services and supports, including psychiatric rehabilitation and intensive case management,” said Laurel Stine, director of federal relations at the Bazelon Center for Mental Health Law. “The passage of this extension will help ensure that states can continue providing vital health care and recovery-oriented services and help fulfill community integration efforts for many individuals with disabilities.”Those who urged Congress to increase Medicaid funding highlighted the program's expansive coverage—compared with many private insurance plans—of treatment for psychiatric illnesses. Medicaid is already the largest single payer for mental health care in the United States, funding about 25 percent of such care. Advocates link the current number of Americans who have recently turned to Medicaid for their mental health care to their difficulties finding jobs that offer health insurance while struggling with the challenges of psychiatric illness.But funding mental health treatment could actually save states money by avoiding other costly medical and criminal-justice spending on people whose untreated mental illness results in deterioration of their condition. For instance, the New England Healthcare Institute estimated that the cost of poor medication adherence—linked to increased hospitalizations and worsening of illnesses—already reaches $290 billion annually, or 13 percent of all health care expenditures.Republicans in Congress objected to the Medicaid measure because of the way it is to be paid for, which is in part through raising $10 billion in taxes from U.S.-based multinational companies, while antipoverty activists complained that other offsets would phase out an increase in food-stamp payments implemented through the stimulus measure.More information on the state aid package is posted at <http://dpc.senate.gov/dpcdoc.cfm?doc_name=lb-111-2-133>. ISSUES NewArchived

Debating the Great Emancipator: Abraham Lincoln and our Public Memory

Abstract In this essay I analyze the debate over Abraham Lincoln’s role in the emancipation of African American slaves. Speaking both to contemporary public memory and the evidence of history, I contend that when Lincoln discussed or wrote about emancipation between 1860 and 1863, his rhetoric exhibited a dialogic form that shifted responsibility from the president to congressional leaders and common citizens. I conclude that Lincoln’s dialogic rhetoric does not signal his opposition to emancipation but rather his deep belief that emancipation would become meaningful only after the considered deliberation and action of the American people.

Independence or Not? Paul V. McNutt, Manuel L. Quezon, and the Re-examination of Philippine Independence, 1937–9

In 1934 the United States set the Philippines on a new course, one that was to begin with autonomy for the archipelago as a ‘commonwealth’ - not a colony - and end with the Islands gaining independ...

Are Congressional Leaders Middlepersons or Extremists? Yes

Infuential theories of legislative organization predict that congressional leaders will be selected from the center of their parties. Yet previous research has generally rejected the “middleperson hypothesis,” finding leaders to be extremists. We challenged these findings by testing more‐appropriate null hypotheses via Monte Carlo simulation. We found that congressional leaders (and leadership candidates as a whole) tend to be closer to their party's median than would occur by chance, but leaders also tend to be selected from the left of the median for Democrats and to the right for Republicans. Compared to the pool of announced candidates for leadership positions, winners are not ideologically distinctive. This result suggests that factors affecting the ideology of leaders tend to operate more at the candidate emergence stage.

The Patient Protection and Affordable Care Act, Cost Control, and the Battle for Health Care Reform

For many social workers, March 2010 enactment of Patient Protection and Affordable Care Act (PPACA) (EL. 111-148)--later amended to include EL. 111-152, Health Care and Education Reconciliation Act of 2010--was bittersweet moment. Bitter because was less than many of us had wanted. For years, NASW had advocated single-payer system, which president and congressional leaders rejected from beginning. During debate over reform, NASW supported strong public option, which was not included in final legislation. Yet, despite this, bill's enactment was, as NASW (2010b) put (in response to enactment of House bills, H.R. 3590 and H.R. 4872), a monumental legislative achievement of our time and a significant step toward comprehensive and universal care system for our nation. Although this battle was successful, war over care reform is far from over (Aaron & Reischauer, 2010). Polls have found mixed support for legislation and confusion about its content and potential effects on various groups (Kaiser Family Foundation, 2010a). In several states, legislators have introduced bills challenging aspects of legislation, particularly mandate requiring individuals to buy insurance, and others have scheduled ballot referendums to determine whether citizens can refuse to comply with legislation (Cauchi, 2010). In addition, several state attorneys general have brought suit against law (Lazarus & Morrison, 2010). Opponents of reform pledged to and the procedures used to enact it an issue in 2010 elections (Aaron & Reischauer, 2010). Supporters of reform hoped that once legislation became law, opposition would dissipate; however, middle of May 2010, this had not happened (Pollster.com, 2010). The complexity of law, critical role of states in carrying out, and legislation's implementation schedule make likely that reform will be an arduous process (Aaron & Reischauer, 2010). Aaron and Reischauer (2010) warned that unless supporters of reform face up to challenges, health care reform could go way of Medicare Catastrophic Coverage Act of 1988, which was enacted with almost self-congratulatory enthusiasm but, due to strong opposition from consumers, was repealed year and half later (p. 1260). A critical issue facing supporters of PPACA is whether can succeed in reducing care inflation. Although latter has slowed in recent years, remains serious concern. Between 1999 and 2009, employer-based insurance premiums increased 131 percent, more than three times worker wages and four times general inflation (Kaiser Family Foundation, 2009). Health care inflation, in form of increased Medicare expenditures, also lies at root of our much discussed budget and crisis (Orszag, 2009). Opponents of PPACA argue that will worsen care inflation. At President Obama's summit, Representative Paul Ryan (R-WI), ranking Republican on House Budget Committee, warned that Senate bill, which was similar to final version, failed to control costs or [the] deficit and engaged in double-counting and other gimmicks (Rep. Paul Ryan on Health Inflation, 2010). After enactment of final bill, Ryan stated that these bills would exacerbate our fiscal crisis adding trillions of dollars to our debt burden (Ryan: 'This Heavy-Handed Overhaul', 2010). What is reality? The Congressional Budget Office (CBO) and staff of Senate's Joint Committee on Taxation estimated that health-related sections of bill (the legislation also included education provisions) would reduce budget $124 billion between 2010 and 2019 and by ... around one-half percent of gross domestic product during following decade (Elmendorf, 2010b). …

Analysis &amp; commentary Health Reform: Only A Cease-Fire In A Political Hundred Years’ War

Four dominant political forces drove the process and product of national health reform during the past two years: federal budget constraints; public concerns about the size and reach of the federal government; the time pressure of the congressional calendar; and the political parties' high-stakes, all-or-nothing bets on what became President Barack Obama's defining policy priority. Republican congressional leaders saw little advantage in offering more detailed alternatives. Congressional Democrats calculated that they had even more to lose politically by abandoning health reform legislation than by pushing it through Congress. This essay argues that passage of the legislation merely represents a cease-fire in a long-standing war and that more battles between forces for "implementation" and those for "repeal and replace" are to come.

Communicating and advocating for science and medicine: rules of engagement

A challenging issue in research and medicine is one of communication with others who are neither researchers nor medical professionalsda persistent concern between science or medicine and policy or politics or the media. I believe that there is no natural communication framework among these several areas, and I admonish researchers and physicians to learn new skills and work at communicating with other stakeholders, be they politicians, policy makers, the media, or patients. As stated by Alvan Feinstein [1] several decades ago, ‘‘Since few human ideas are truly original, a scientist’s creative thoughts generally represent the conquest of his own ignorance.to get his mind through to a liberating concept that is often obvious to an untutored observer, the scientist may have to overcome many intellectual restrictionsdthe boundaries of his specialized focus, the incrustations of his previous training, and fashions of his current preoccupations.’’ A recent Congressional hearing derides the Department of Veterans Affairs (VA) for knowingly providing ‘‘dangerous’’ medications to their patients without informing them of risks associated with taking the targeted medication. With the hearing entitled ‘‘Why does the US Department of Veterans Affairs continue to give a suicide-inducing drug to veterans with post traumatic stress disorder?’’, one might ask how our Congressional leaders could get it so wrong. In my opinion, the answer is simpledfrom a political perspective, they will never think it was wrong! In this specific case, the politics of the situation prevails, and there is no miscommunication, only a different agenda. This particular hearing was initiated in the House of Representatives, Committee on Veterans Affairs (http:// veterans.house.gov/hearings/OpeningStatement). The opening statement of the committee chairman is informative and should be read if you are interested in advocacy activities or the workings of our government. Chairman Filner began, ‘‘I

Medicare Cut in M.D. Payments Awaiting Permanent SGR Fix

Back to table of contents Previous article Next article Government NewsFull AccessMedicare Cut in M.D. Payments Awaiting Permanent SGR FixRich DalyRich DalySearch for more papers by this authorPublished Online:21 May 2010https://doi.org/10.1176/pn.45.10.psychnews_45_10_017AbstractMore temporary postponements of steep cuts to Medicare's physician pay schedule are likely in coming months, even as some congressional leaders propose longer-term fixes.A confluence of political realities is likely to result in continued short-term delays of a pending 21 percent cut required under Medicare's often-criticized physician payment formula, instead of a long-term overhaul favored by physicians. One such factor in the near-term outlook for the Medicare fee system is the law (PL 111-157) signed by President Obama in April to postpone the cut until June 1. Prior to that law, the cut was scheduled to take effect on April 1.Such short-term approaches to the Medicare physician-payment problem sow confusion and concern among clinicians who can't plan for the income they will receive from treating Medicare beneficiaries, said physician advocates.“Congress must now turn toward solving this problem once and for all through repeal of the broken payment formula that will hurt seniors, military families, and the physicians who care for them,” said AMA President J. James Rohack, M.D., in an April 16 statement. “It is impossible for physicians to continue to care for all seniors when Medicare payments fall so far below the cost of providing care.”The ongoing game of political brinksmanship over delaying the scheduled cuts versus enacting a permanent overhaul of the reimbursement system has led to a standoff that finds Republicans demanding that Democrats offset with new revenue or spending reductions any fix that eliminates the planned 21 percent cut. House Democrats have largely ignored this demand and passed a bill (HR 3961) last November that would replace Medicare's sustainable growth rate (SGR) formula—a congressionally created cost-control measure that offsets increases in Medicare volume with decreases in physician payments—with a payment system that was designed to automatically keep pace with the costs of running a practice. However, moderate Democrats joined Republicans in the Senate to vote in October 2009 against taking up similar legislation (S 1776), based on concerns that it would use deficit spending to cover its estimated $245 billion 10-year cost.In recent months, some Democratic leaders such as Rep. Chris Van Hollen (D-Md.) have suggested a five-year “fix” as an alternative to short-term delays in the payment cuts required by the SGR. Such an approach would theoretically give Congress time to devise a comprehensive overhaul of the physician payment system that could garner wide political support. However, a five-year approach is likely to draw Republican opposition because it is not expected to include offsetting spending cuts.An effort to extend a delay in the physician fee cuts until October 1 was included in a $138 billion package of legislation (HR 4213) that aimed to spur the nation's economy, which the Senate passed on March 10. That legislation, however, has to be reconciled with another version of the same bill that the House passed last December. But once again, progress on those measures is expected to become mired in concerns of fiscal conservatives about offsetting spending cuts. Calls for fiscal prudence will likely become stronger as the November elections approach, and other congressional and White House legislative priorities squeeze out time needed to reconcile the bills that contain the October extension.Ultimately, continued delays in addressing the strong objections of physicians to a Medicare cost-control system based on cuts in their payments will complicate any solution because such delays will add to the cost of such a fix.“Fixing the Medicare physician payment problem is essential to the security and stability of Medicare. If the formula is not repealed, the problem will continue to grow,” Rohack said.Information on the various bills containing physician payment changes can be accessed by searching on the bill number at <http://thomas.loc.gov>. ISSUES NewArchived

Dreams, Teachers, and Legislation

When I accepted the James D. Mills Award from The American College of Emergency Physicians, I had three goals in mind, which I wanted to share with those attending the commemorative dinner meeting. My first goal was to remind those in attendance that each of us must make our academic dreams come true. My next goal was to acknowledge two of my empowering teachers at the dinner, Dr. Peter Rosen and Dr. William Sacco, who have made revolutionary advances in health care; and finally, I wished to remind the membership of the need to work with Congressional leaders to pass the Access to Emergency Medical Services Act of 2009. I warned the leaders in emergency medicine of the necessity to pass the Access to Emergency Medical Services Act of 2009 to ensure that our emergency medical patients receive prompt and responsible care. This has been our quest.

Parties, Preferences, and Petitions: Discharge Behavior in the Modern House

Although discharge petitions lie at the confluence of personal preferences, committee prerogatives, and party leadership in Congress, these procedures have received little scholarly scrutiny. We capitalize on the public nature of petition signatures since 1993 to examine the behavior of the most cross‐pressured members in discharge battles: bill sponsors and cosponsors belonging to the majority party who personally prefer the bills they have sponsored but who face party pressure not to sign the petitions that threaten the leadership's control of the legislative agenda. After controlling for personal preferences, we find a statistically significant partisan effect in the U.S. House, which further illuminates the “Where's the party?” debate.

Medicare Focuses on Hospital Readmissions

Joyce Frieden is a contributing writer with Elsevier Global Medical News. NATIONAL HARBOR, MD. — Medicare wants to save money and improve quality of care by reducing the number of patients readmitted to the hospital within 30 days after their initial stay, according to Michael Rapp, MD. Readmission is a problem within Medicare, said Dr. Rapp, director of the Quality Measurement and Health Assessment Group at the Centers for Medicare and Medicaid Services. In a recent study, nearly 20% of Medicare fee-for-service patients discharged from the hospital were readmitted within 30 days; 34% were readmitted within 90 days (N. Engl. J. Med. 2009;360:1418-28). The estimated cost to Medicare was $17.4 billion. There is “quite a bit of variability” in the 30-day readmission rate, depending on the patient's diagnosis, Dr. Rapp said at the World Health Care Congress Leadership Summit on Hospital Readmissions. For example, 25% of heart failure patients were readmitted within 30 days, compared with 20% of acute myocardial infarction patients and 18% of pneumonia patients. Part of the problem stems from continuity of care issues, he continued. One study looked at 366 patients discharged from the hospital with a follow-up primary care appointment scheduled within 2 months. The researchers found that 42% of those patients had a medication continuity error, 12% had a workup error, and 8% had a test follow-up error (J. Gen. Intern. Med. 2003;18:646-51). Subjects with workup errors were six times more likely to be readmitted than were other subjects, Dr. Rapp noted. Unplanned rehospitalizations often signal a failure of transition from the hospital to another source of care. Because any hospital admission is a source of revenue for a hospital, new incentives for reducing readmissions need to be worked out, he said. “One of the ways we've sought to [get hospitals engaged] is by publishing readmission rates,” Dr. Rapp said. “We published them for the first time on the Hospital Compare Web site last July. It got quite a bit of interest.” Another way the CMS is trying to reduce readmissions is through the Care Transitions Intervention, a way of “coaching” patients during and after discharge. Under a pilot program, the CMS is paying 14 of Medicare's quality improvement organizations to implement this program in some locations. One QIO implementing the program with 130 patients achieved a 7.7% decrease in hospital readmissions, Dr. Rapp said. And 96% of patients said they had a good understanding of how to manage their health after the program was finished, compared with 63% at the start. Of the 14 communities involved in the pilot program, 9 have seen at least a 2% reduction in readmissions after instituting the program, he added. Dr. Rapp said the CMS had learned several things from the project: ▸Community meetings are a catalytic point in the process.▸Community recruitment and engagement can take longer than anticipated.▸Increased time and resources are required to engage outpatient physicians and specialists.▸Each patient should be assigned a coach before discharge. To improve the discharge procedure and reduce hospital readmissions, Dr. Rapp suggested several measures, including creating a collaborative forum that includes patients and families, exchanging quality data routinely, identifying the sickest patients and reviewing the way they get care, and implementing personal health records.

Be Not Afraid

Voters are angry and distrustful of Washington. Democrats have lost their nerve. Republicans, sensing weakness, are closing in for the kill. We have seen this health care reform horror movie before. Our leaders in Congress and the White House face a fateful fork in the road. They can follow the public's fear and confusion down the path of perpetual inaction. Or they can lead. They can let the confusion fester or they can leverage the support of health care innovators who can explain the benefits of reform to all. This movie can have a happier ending, one that is good . . .

The Complexity That Killed Health Care Reform (Again)

Even if the Democrats had kept their supermajority by retaining the Senate seat in Massachusetts, final passage of a health care reform bill would have seemed far from certain, given the major differences between the Senate and House bills. Congressional leaders and the administration seem to have acknowledged this reality. So what went wrong? A major cause for the failure of health care reform this time around — as with the Clintons' attempt in the 1990s — is the complexity of the bills. President Barack Obama and the drafting committees in Congress reached too far, tried to accomplish too much . . .

Was Vital Component Omitted From Health Care Reform?

Back to table of contents Previous article Next article Government NewsFull AccessWas Vital Component Omitted From Health Care Reform?Rich DalyRich DalySearch for more papers by this authorPublished Online:5 Feb 2010https://doi.org/10.1176/pn.45.3.psychnews_45_3_010AbstractThe use of defensive medicine—long dismissed as a myth by some lawyer groups—is a major driver of medical costs, and efforts to reduce the practice through tort reform could yield billions of dollars in health care savings, a recent analysis by the nonpartisan Congressional Budget Office (CBO) concluded.The report was released last December in follow-up to an initial report in October 2009 on tort-reform legislative proposals. Although the report did not use the term “defensive medicine,” it described the impact of clinicians ordering more tests or procedures than are necessary solely to protect themselves from lawsuits.The CBO researchers concluded that medical-liability reform proposals at the federal level would save at least $54 billion over 10 years, in part by reducing the need for physicians to use defensive medicine.Lisa Rickard, president of the U.S. Chamber Institute for Legal Reform, called the finding on cost savings “momentous.”“Neglecting to include medical liability reform [in the health care overhaul] benefits only the plaintiffs' lawyers,” stated Pickard in a written statement. “Including it benefits every American participating in our health care system.”Advocates for tort reform contend that the CBO estimate of cost savings from such legislation is likely an underestimate. Previous studies have concluded that the real cost of defensive medicine is between $151 billion and $210 billion annually. That cost could be reduced or eliminated, they maintain, through reforms such as caps on noneconomic damages and the creation of protections from lawsuits for physicians who utilize best medical practices.President Obama spoke positively in the summer of 2009 about the incorporation of legal protections for physicians who adhere to best-practice guidelines within health care reform, although he rejected caps on noneconomic damages that former President George W. Bush supported. However, Democratic leaders in Congress have kept nearly all tort-reform proposals out of the health care reform legislation. For example, Democrats in the Senate rejected an amendment to the health reform bill by Sen. John Ensign (R-Nev.) that would have established caps on noneconomic damages.“The whole premise of a medical malpractice ‘crisis’ is unfounded,” said Senate Majority Leader Harry Reid (D-Nev.) in a frequently cited Senate floor speech on tort reform in 2006.Likewise, trial-lawyer advocates have minimized the impact and even the existence of defensive medicine as a response to the threat of lawsuits.“To the extent that defensive medicine does exist, research has found that the motivation behind it is not liability but rather a desire to simply help a patient or, in some cases, boost physician income,” according to a statement by the American Association for Justice, a national attorney advocacy group.Conversely, physician groups—including APA—have advocated for the inclusion of tort-reform provisions within the health care overhaul effort as an important way to reduce the rise of ever-increasing health care costs.While the cost of malpractice insurance for psychiatrists ranks among the lowest in medicine, the price is still high: the average psychiatrist malpractice policy costs over $6,000 each year, according to a leading psychiatrist insurer.The CBO tort reform analysis is posted at <www.cbo.gov/ftpdocs/108xx/doc10872/12-29-Tort_Reform-Braley.pdf>. ISSUES NewArchived

Press Ahead or Scale Back? The Reform Effort after the GOP Victory in Massachusetts

For almost a century, U.S. presidents have tried and failed to enact comprehensive health care reform featuring expanded coverage.1 In a development never imagined by most Democrats, President Barack Obama's name may be added to this list because his party lost its filibuster-proof 60-vote Senate majority on January 19, thereby imperiling its ambitious reform package. In the wake of Republican Scott Brown's upset victory in the race to fill the seat long held by the late Senator Edward M. Kennedy (D-MA), congressional Democratic leaders and the White House are discussing how to proceed on reform, but no early consensus has . . .

A Need for Reorganization of the Food and Drug Administration

The associate director for science and medicine in the Office of Drug Safety at the Food and Drug Administration (FDA), Dr. David Graham, reported that the FDA was incapable of protecting Americans from unsafe drugs. In testimony to the Senate Finance Committee, he stated that the FDA has let the American people down and betrayed public trust. Drastic changes and measures within the FDA must be made to ensure the safety of American consumers of drugs, products, and medical devices. Efforts such as the introduction of the Grassley-Dodd Bill, allowing the FDA to order immediate drug recall or increased risk warnings, followed by the FDA Safety Act of 2007, are still not enough to ensure the safety and efficacy of drugs, biological products, and medical devices that the American public use every day. In this report, we describe past and present efforts by congressional leaders, FDA representatives, and American citizens to effect changes within the FDA in order to protect America from unsafe drugs and medical devices. We describe our own struggles in passing a citizen’s petition to ban cornstarch in medical gloves, and the lack of response and responsibility that the FDA has displayed.

Mentally Ill People May Gain Benefits of Coordinated Care

Mentally Ill People May Gain Benefits of Coordinated Care

The American Public and the Next Phase of the Health Care Reform Debate

Congressional leaders and President Barack Obama are moving ahead to develop a single piece of major health care legislation, which will be debated, voted on by both houses of Congress, and, if enacted, sent to the President for his approval and signature. Previous research suggests that public opinion will play an important role in the outcome of this process. Experience suggests that although the final legislation is likely to be complex, the public will form an overall view leading it either to support or to oppose enactment, but this view can change substantially over time. Multiple factors may contribute to . . .

The D&amp;T Report

The D&amp;T Report