MANAGED CARE February 2001. ©MediMedia USA
State medical associations, hospital associations, health plan associations, and legislators on opposite sides of the political aisle seldom see eye to eye — except when you ask them about term limits. There seems to be an overwhelming consensus that in the 18 states that have them, term limits have done health care policy more harm than good.
"You wouldn't say to a brain surgeon, 'I hope you haven't been working in this field too long. I want somebody who's fresh,'" says former Maine Senate Majority Leader Chellie Pingree, whose fourth and final two-year term ended in December. She wrote Maine's prescription drug-price legislation that is now being tested in court, and is running for governor in 2002.
The point Pingree and others make is that when legislators are term-limited out, they take with them the expertise, experience, and relationships that took years to develop. For interest groups across the health care spectrum, that makes it even more difficult to keep this complex industry from spinning out of control.
Back in the early '90s, when state legislative term limits were on the front burner, these unintended consequences were overshadowed by a powerful national animus against "career" politicians. Now that term limits have been around a while, those longer tenures are looking better every day.
"I wouldn't be surprised to see a proposal emerge in California to have a limit of something like 14 years in the state legislature," says California Association of Health Plans Executive Director Walter Zelman. "That would be better, because then you'd get some career politicians."
Too much upheaval
One of the first states to enact term limits, California limits assemblymen to three two-year terms and senators to two four-year terms.
Steve Thompson, vice president for governmental relations with the California Medical Association, lays much of the blame for the upheavals in the state's health care marketplace on term limits. Like Zelman, he's persuaded that term limits have hindered needed structural change in California, because legislators are reluctant to tackle complex, long-term issues when they may not be around for the payoff.
"When your chairman of the lower house health committee changes every two years, and every two or four years in the Senate — and when one of those years has been devoted to raising money for the next election — you simply don't have the appropriate attention span to deal with long-term structural change in the managed care market," says Thompson. "Most large problems in the context of legislation simply are not amenable to one- or even two-year solutions. It takes a period of fact finding, public hearings, oversight, research, and analysis."
Before joining the CMA, Thompson was research director for the state assembly and chief of staff for then-speaker Willie Brown. He notes that California's current electricity debacle is partly the result of deregulation legislation drafted by legislators who didn't have enough time on the job.
Another insider with a dim view of term limits is John Schwarz, M.D., a practicing head-and-neck surgeon in Battle Creek, Mich., and president pro tem of the state Senate. Michigan enacted term limits through a ballot initiative in 1992. The House lost 64 members to term limits in 1998 and the Senate will lose 29 members next year.
"These new people may or may not be bright, but they'll never have time to learn how lawmaking works, especially in populous states where state government is a very complex operation," says Schwarz, who himself will be out of a job after 16 years in 2002 thanks to term limits. "Basically, term limits marginalize the legislature, which should be that branch of government closest to the people — but will be that branch of government with really no effect on anything anymore because people are running through it so rapidly."
Schwarz, who serves on the health policy and appropriations committees, says Michigan's $8.5 billion community health budget, which includes all spending on public health, mental health, and Medicaid, is a good example of what he's talking about. This enormous budget is so complex that even two four-year senate terms aren't enough time to understand it, in context, completely. The danger is that legislative oversight may be lost. Money may not be going to programs for which it was intended, or may be going to programs for which it was not intended.
"With term limits, there is no institutional memory of budget history, what works and what doesn't," says Schwarz. "You can be in and out of the legislature before you realize that you have been flummoxed."
Medicaid, typically a state's biggest appropriation, turns out to be a recurring theme in discussions about term limits. With increasing competition in many states between Medicaid expenditures and primary and secondary education budgets, legislators who don't know how the program works tend to look to Medicaid as a source of dollars for education. That's been the experience of former state Medicaid director Bill Ryan, now vice president for government affairs at the Ohio Hospital Association.
Power shift
Ryan and others also point to a shift in the way interest groups do their work in the capitols of term-limit states. With long-term relationships curtailed, lobbyists are more likely to emphasize substance. Lobbyists talking substance sounds like progress, but a term-limited legislator spending proportionately more time running for re-election may still find it expedient to put political considerations foremost when voting. Ambitious freshman legislators who sense that time is short may be tempted to make a splash — requiring that they get a speedy education from lobbyists. Ironically, that increases the effect of special-interest money on the political process.
What's clear is that term-limited legislators and legislative leadership are perceived to be less powerful and influential, so some power is shifting to the executive branch, to lobbyists, and even to legislative staff. The National Conference of State Legislatures On-line Term Limits Poll of state legislators, staffers, and state government officials supports these conclusions.
NCSL says many legislatures are taking proactive steps to mitigate negative effects — steps that include legislator and staff training, and such new-member orientation programs as training on the legislative process, history of the legislature, policy briefings, consensus building, and conflict management.
What's less clear, however, is how term limits have affected specific pieces of health care legislation.
"I accept the premise, but it's awfully hard to look at the performance of the states at this point and see a measurable difference in legislative outcomes," says John McDonough, former representative in the Massachusetts House and now associate professor of health policy at the Heller School of Brandeis University. "The smoking gun has yet to emerge."
Second-term California assembly member Marco Firebaugh, himself a beneficiary of term limits, sees them as a double-edged sword. He bemoans the loss of institutional memory and of legislators who were "policy giants." On the other hand, he says term limits gave him a chance to serve.
"In a perfect world, I suppose I'd like to see term limits extended to give folks enough time to become experts," says Firebaugh. "But I think turnover is a good thing."