The 2008 presidential election comes at a crucial time. Our nation’s financial markets are in turmoil, major investment banks have failed, and the world’s largest insurer remains standing thanks only to a Washington bailout. At the same time, the country remains as divided politically as it was in 2000 when control of the White House was decided by a handful of votes in Florida and the words “hanging chad” slipped into the nation’s consciousness for the first time.

National polls show Senators McCain and Obama running neck-and-neck in a statistical dead heat. The outcome of the election and control of the White House will likely be decided in the same handful of swing states that made up the battlegrounds of recent elections: Michigan, Pennsylvania, Ohio, and Florida, among others. However, while the eyes of the world are focused on the presidential election, some exciting races are unfolding in Senate and House contests across the country.

U.S. Senate

Thirty-five of the 100 Senate seats are being contested in November. Thirty-three of these are regular elections, and the remaining two (Wyoming and Mississippi) are special elections replacing Senators Craig Thomas (R-WY), who died of leukemia on June 4, and Trent Lott (R-MS), who retired in December 2007 to seek opportunities in the private sector.

The Democratic Party is thought to have the upper hand in this year’s Senate elections. After regaining control of the Senate in 2006, the Democrats are now in the fortunate position of defending only 11 of the 35 seats at stake. Republicans previously held all five open seats (Colorado, Idaho, Nebraska, New Mexico, and Virginia), and an additional 19 Republicans are up for reelection.

Top Senate Targets

Virginia – With long-standing Senator John Warner retiring, popular former Governor Mark Warner (no relation) looks increasingly likely to emerge victorious in November and, in doing so, will turn this once Republican stronghold into a “blue state.” (Virginians recently elected Democrat Tim Kaine as governor and Jim Webb as their senator.) Massive population growth in the Northern Virginia suburbs of Washington, DC, accounts, in part, for this perceived political realignment.

New Mexico – With Republican incumbent Pete Domenici retiring and New Mexico Republicans divided after a bruising primary in which Rep. Steve Pearce narrowly defeated Rep. Heather Wilson, Democratic Rep. Tom Udall has shown a lead in the polls. Udall is a popular centrist with strong name recognition and family ties to the area.

Colorado – In another open seat after Republican Senator Wayne Allard’s decision to retire, Rep. Mark Udall (cousin of Tom, running for the Senate in New Mexico) holds the lead against former Rep. Bob Schaffer. Colorado has also seen a dramatic population and demographic shift in recent years; as a result, it is no longer considered a “Republican state.”

Minnesota – Only the very brave would bet money on the outcome of the intriguing battle in Minnesota, where comedian and outspoken critic of the Bush administration Al Franken secured the Democratic nomination to challenge incumbent Republican Senator Norm Coleman. Many Democrats are said to be privately nervous about how Franken’s reputation for being outspoken and sometimes vulgar will affect his chances. However, Coleman’s close association with the Bush administration may count against him in this maverick state, which often leans Democratic.

Alaska – Until recently, Alaskan politics were best known for corruption scandals and pork barrel boondoggles, but the vice presidential nomination of Republican Governor Sarah Palin has thrust the Alaska Senate contest into the limelight. With Republican Ted Stevens under indictment for falsely reporting gifts, Anchorage Mayor Mark Begich (D) is thought to have a real chance of ousting the longest-standing Republican incumbent in the Senate – Stevens has served continuously in the Senate since December 1968. However, Sarah Palin’s presence on the ticket will likely help other Republicans in the largest state of the Union.

Louisiana – Perhaps the only really vulnerable Democratic incumbent is Mary Landrieu of Louisiana. Landrieu only narrowly won reelection in 2002, and Louisianans recently elected a Republican – Bobby Jindal – as governor. In addition, many African American voters – who traditionally support Democrats – left the state after Hurricane Katrina. Landrieu still shows a lead in the polls, however, and her status as incumbent could well carry her in November.

House Races

All 435 seats in the U.S. House of Representatives are being contested in November. Democrats hold 235 seats to the Republicans’ 199 (with one vacancy) after the 2006 elections, and few expect a major reversal this year. According to the Cook Political Report – an independent, non-partisan publication that analyzes elections and campaigns – Democrats currently have 18 seats listed as “lean” or “toss-up” compared with 36 Republican seats listed as “lean” or “toss-up.”

Although continued dissatisfaction with the Republican administration may help the Democrats solidify and build on their majority in the House, there are concerns that traditionally Republican seats that “flipped” in the Democrat sweep of 2006 may now revert to their more natural Republican leaning. Seats vacated by disgraced Rep. Mark Foley (R-FL) and former Majority Leader Tom Delay (R-TX), won by Democrats in 2006, could fall into this category.

Health Care Reform in Congress

Even amid the turmoil of the current economic crisis, health care reform remains a top priority for the 111th Congress to be sworn in on January 19, 2009. The health care platforms of the presidential candidates were discussed in some detail in an earlier Washington Report, but presidents can only propose or veto policy – the real nuts and bolts of health care reform will be decided by Congress. Here are some of the big concepts currently being discussed on Capitol Hill.

Universal Coverage

The subject of universal health care coverage has historically been considered a “lightning rod” issue in Washington that any astute politician would do well to avoid. However, with 47 million uninsured Americans – a figure that continues to grow in the face of double-digit increases in the cost of health care annually – many of whom receive “uncompensated care” in expensive, already overburdened settings such as emergency departments, there seems to be growing support on Capitol Hill for universal coverage.

Among many proposals in Congress that would address access to health coverage, Senator Ron Wyden (D-OR) and Senator Bob Bennett (R-UT) have introduced a bill (S. 334) to ensure health coverage for all Americans by allowing employees to take the money they contribute to employer-sponsored health care plans and use it to purchase their own coverage. The bill’s prospects are looking reasonably positive, partly thanks to a favorable “score” (price tag) calculated by the Congressional Budget Office and the Joint Committee on Taxation. These bodies calculated that the legislation would be roughly budget-neutral in 2014 and would create surpluses after that.

Yet significant obstacles stand in the way. Democrats and their union supporters have suggested that they will not back the bill because it cuts from areas they support, such as employer-provided benefits. Republicans will oppose the legislation because they believe it will create more bureaucracy and lead to a one-size-fits-all government-mandated health care system that they oppose on philosophical grounds. In addition, many lawmakers and lobbyists have serious concerns about the bill’s specifics. First, moving away from employer-based health care coverage “threatens the security of coverage on which millions rely,” said a senior Senate aide. There are also concerns that basing coverage subsidies on the lowest-cost bid in a particular state could lead to a lower standard of care for vulnerable poor populations. But in the face of what threatens to be a full-blown health care crisis, it is clear than Congress will have to act decisively, one way or another, to help modernize our health delivery system.

Health Information Technology

Other industries have lowered costs and improved quality through heavy investments in health information technology (HIT), yet health care has been slow to adopt systems that share important information, monitor compliance with prevention and disease-management guidelines, and measure and improve performance.

Market obstacles – in the form of misaligned incentives and a lack of interoperability between existing systems – have been blamed for the lack of progress in HIT. Action from Congress would likely help accelerate market forces and overcome some of these obstacles. The “Wired for Health Care Quality Act” (S. 1693) is a bipartisan bill that would encourage the adoption of cutting-edge information technologies in health care to improve patient care, reduce medical errors, and cut health care costs. It is hoped that this legislation will lay the foundation for technology and information sharing among doctors, hospitals, and insurers to ensure that patient data, insurance, and medical histories are available wherever and whenever treatment is needed. A Rand Corporation study projected a potential savings of $162 billion per year for the health care industry once the United States achieves widespread adoption of electronic health records.¹

S. 1693 is cosponsored by Senator Mike Enzi (R-WY); Senator Ted Kennedy (D-MA), Chairman of the HELP Committee; Senator Orrin Hatch (R-UT); and Senator Hillary Clinton (D-NY). In the House, Rep. Anna Eshoo (D-CA) and Rep. Mike Rogers (R-MI) have led efforts to enact HIT legislation.

Although IT systems that are linked securely and with strong privacy protections to patients’ medical records can improve the quality and efficiency of care while producing significant cost savings, investment and adoption have been limited, particularly among smaller providers who are most affected by the financial cost of implementing a HIT system. The legislation encourages the development of interoperability standards for HIT by:

• Establishing a public-private partnership known as the Partnership for Health Care Improvement to provide recommendations to the Health and Human Services (HHS) Secretary with regard to technical aspects of interoperability, standards, implementation specifications, and certification criteria for the exchange of health information.
• Requiring that all federal IT purchases conform to the standards recommended by the Partnership and adopted by the President. Adoption of these standards is voluntary for private entities.
• Establishing the American Health Information Community as a body providing recommendations to the Secretary regarding policies to promote the development of a nationwide interoperable HIT infrastructure. These include recommendations regarding patient privacy, information security, and appropriate uses of health information.

Comparative Effectiveness Research

It is well documented that the United States spends far more per capita on health care than any other developed nation yet does not produce correspondingly better health outcomes. This, combined with a growth in health care spending that far outstrips inflation, results in a health delivery system that will ultimately become unsustainable. Comparative effectiveness research has recently been touted as a potential solution to this impending crisis and is considered a “buzz concept” on Capitol Hill and among health policy experts. Comparative effectiveness research compares clinical outcomes, or the “clinical effectiveness,” of alternate therapies for the same condition. By collecting better data on what works and what doesn’t, we can deliver better health care decisions and, ultimately, better quality of care.

Legislation being considered before Congress (S. 3408) would create a private nonprofit corporation called the Health Care Comparative Effectiveness, which would establish a national agenda of research priorities based on the need for better evidence, disease burden, practice variations, the potential for improved care, and expenditures associated with a given health condition or care strategy. Research findings will be peer reviewed and publically disseminated in ways that patients and health care providers can easily understand.

Leadership for Medication Management – Summary of Legislative Principles

With health care reform in mind, ACCP has been working as part of a coalition of seven national pharmacy organizations known as the Leadership for Medication Management (LMM) to advocate for a set of legislative principles aimed at expanding opportunities for pharmacists to provide patient care services to Medicare beneficiaries. (A full version of the principles and supporting documents is available online: http://www.accp.com/advocacy.php.)

1. Medicare Part D Yearly Medication Therapy Review

   Our legislative proposal would enhance the scope of current medication therapy management (MTM) programs by requiring plans to provide a once-yearly medication therapy review and assessment by a pharmacist, with documentation of the encounter and recommendations for improving the outcomes, safety, and cost-effectiveness of the beneficiary’s medication regimen.

   The annual medication therapy review benefit is analogous to the “Welcome to Medicare” medical encounter and would be a covered benefit on an annual basis because of the dynamic nature of beneficiaries’ medication therapy over time.

2. MTM Services Paid for Under Part B

   Of importance, the proposal also requires that MTM services of pharmacists be authorized for payment under Medicare Part B.

   All Medicare beneficiaries, including those not enrolled in Part D, would have access to these services. For beneficiaries not enrolled in Part D, these MTM services could include the annual medication therapy review.

   In addition, Medicare beneficiaries who are enrolled in Medicare Part D but do not meet the eligibility criteria for MTM services required under their Part D plan could be referred for MTM services under a Part B licensed health care professional.

   Documentation and payment for MTM services provided by a pharmacist under this legislation would use the applicable CPT codes for pharmacist-provided MTM services.

3. Comparative Effectiveness Evaluation

   Finally, the proposal calls for a study of the effectiveness of MTM services provided to targeted beneficiaries under the provisions of Medicare Part D compared with MTM services provided under Medicare Part B to the broader Medicare population.

How You Can Get Involved

ACCP is currently holding a series of meetings with key Capitol Hill offices to introduce the proposal and to solicit input and feedback from congressional leaders. Based on the results of these meetings, we will then develop the proposal into a piece of legislation and work to secure congressional sponsors to introduce a bill. At this stage, we strongly encourage all ACCP members to review the legislative proposal and supporting materials (http://localhost/govt/advocacyResources.aspx). In addition, we have prepared a letter on our Legislative Action Center (http://capwiz.com/accp/home/) for all members to send to their federal lawmakers, introducing the legislative principles and offering opportunities for further discussion of the proposal.

We see the remaining months of the 110th Congress as an opportunity to educate lawmakers on these issues, generate support for our proposal, and lay the groundwork for a full legislative campaign beginning in 2009. Please also forward the link to the Legislative Action Center to friends, colleagues, and other clinical pharmacy stakeholders. It is vital that Congress be made aware of the widespread support for this issue throughout the pharmacy profession and that Congress understands the benefits pharmacists can bring to health care delivery and patient care.

Our chances for advancing our agenda depend on your active participation in the political process. For more information on ACCP’s work in Washington, DC, contact John McGlew at (202) 756-2227 or [email protected].

References

1. S. 1693 promotes use of electronic records – Sen. Mike Enzi (R-Wyo.). Posted: July 16, 2008. Accessed 09/30/2008. Available at http://thehill.com/op-eds/s.-1693-promotes-use-of-electronic-records-2008-07-16.html.