In Stormy Political Climate, Frist Shifts Focus to Healthcare

Even with the ill-fated Dubai ports deal now sinking out of sight, Senate Majority Leader Bill Frist is bracing for a difficult few months. The Tennessee Republican faces more pressure to post legislative victories because the GOP congressional majority is running out of time to improve the political climate before the November midterm election.

But his ability to produce legislative victories may be diminishing as President Bush’s low poll numbers encourage more Capitol Hill Republicans to demonstrate independence from the White House -- as Frist himself did in denouncing the Dubai takeover.

“With the president right now being down, I expect there will be more separation,” Frist said over breakfast in his Capitol office. “That makes my job a lot harder.”

As he navigates these crosscurrents, Frist wants to steer the Senate agenda toward four issues: lobbying rules, immigration, the federal budget and military spending. But Frist is stepping down from the Senate at year end, fulfilling his pledge in 1994 to serve only two terms. And as he looks beyond the Senate, toward the possibility of a bid for the GOP presidential nomination in 2008, he is shifting his sights toward another issue too long slighted in Washington: a fundamental revision of healthcare.

Frist, a heart surgeon, is one of the few practicing physicians to serve in the Senate. His medical background hasn’t always been a political blessing. It led last year to his lowest moment in elected office, when he challenged the diagnosis of doctors who said Terri Schiavo was in a “persistent vegetative state,” only to see their assessment confirmed by the autopsy performed after the brain-damaged Florida woman died.

But with his interest and expertise on health concerns, Frist has left a mark on issues from the fight against AIDS in Africa to the Medicare prescription drug bill. Often on these projects he’s teamed with Democrats; last year, the Senate approved legislation he sponsored with Sen. Hillary Rodham Clinton (D-N.Y.) to promote greater use of electronic medical records that can follow patients through their lives.

Now Frist is pursuing bigger changes. In a recent speech to the Detroit Economic Club that drew surprisingly little media attention, Frist urged a comprehensive restructuring of Medicare, the federal program that provides healthcare to about 42 million seniors.

Frist started by correctly identifying Medicare as a greater long-term financial problem than Social Security. The nation faces a long-term Social Security squeeze because the number of workers per retiree is shrinking as baby boomers retire. In Medicare, that imbalance is compounded by the unrelenting growth in healthcare costs. The combination points Medicare toward unsustainable growth.

In response, Frist proposed to reshape the program around six basic principles. Three are political apple pie: increasing prevention efforts, improving management of chronic diseases and updating information technology.

His next two ideas are only somewhat more controversial: He wants to apply greater means-testing so that more-affluent seniors pay more for care. And he wants to tie doctors’ compensation to the results they produce for patients. His last idea throws down a gauntlet: Frist wants to allow private insurers to compete more directly with the government in providing healthcare to seniors.

Frist says that approach, which he’s been touting since Bill Clinton’s second term, will increase “choice ... value and quality” while restraining costs. Critics say it would convert Medicare from a program in which Washington guarantees seniors a defined benefit to one in which it only guarantees them a defined contribution that could leave many with inadequate care.

In practice, Washington isn’t likely to provide private insurance companies a larger role in Medicare until they prove they can smooth out their administration of the new prescription drug benefit.

But the sweep of Frist’s Medicare agenda is a sign that he’s thinking big on an issue likely to loom big in 2008. The same is true on the broader problem of covering the nearly 46 million people in America without health insurance.

Frist likes Bush’s emphasis on tax-favored health savings accounts that aim to make patients more careful consumers by encouraging them to pay more routine medical costs out of pocket. But, he says flatly, such accounts are not the answer for the uninsured. “Most people don’t want to make too many choices in healthcare,” Frist says.

Instead, Frist wants to provide tax credits to help the uninsured buy coverage (an idea Bush has played down to focus on the health savings accounts). And to make insurance more affordable, Frist wants Washington, through a government-backed corporation, to assume most of the cost for the most expensive patients -- an idea Bush denounced when Sen. John F. Kerry (D-Mass.) offered a variation on it in his 2004 presidential campaign.

Frist also sensibly says that any healthcare overhaul won’t succeed unless the nation can control costs by “decreasing the burden of disease.” Toward that end, he wants Congress to loosen the restrictions that Bush imposed on stem cell research; the Senate will consider long-delayed legislation to do so by summer, Frist’s aides say.

On healthcare, the challenge for all Republicans is to find solutions that express their faith in the free market without unraveling the collective safety net of public and private social insurance that most Americans have shown that they prize.

Frist has a surgeon’s steady hands, but he will need a politician’s supple touch to thread that needle.

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Ronald Brownstein’s column appears every Sunday. See current and past Brownstein columns on The Times website at latimes.com/Brownstein.