House Passes Medicare Bill

By Amy Goldstein, Helen Dewar and David Broder
Washington Post Staff Writers
Sunday, November 23, 2003; 7:48 AM

A divided House, in a dramatic vote before dawn, approved the most fundamental transformation of Medicare in the program's history, adopting legislation that would add a prescription drug benefit and create a large new role for private health plans in caring for the nation's elderly.

The measure had appeared destined for defeat, but passed on a vote of 220 to 215 after the House's GOP leaders kept the roll call open for nearly three hours until shortly before 6 a.m. as they scoured for extra votes. Knots of senior House Republicans and Health and Human Services Secretary Tommy G. Thompson huddled repeatedly around several of the two dozen skeptical members who had initially voted against the bill -- with little apparent effect -- while their colleagues milled the floor and a few napped.

Through most of that time, the red lights on the voting board in the House chamber showed the tally at 216 for the measure and 218 against it. Finally, moments before 6 a.m., two Republican members, Rep. C.L. "Butch" Otter (Idaho) and Rep.Trent Franks (Ariz.) changed their minds, then another few colleagues followed suit.

Several longtime lawmakers said the roll call was the longest in their memory. The cliff-hanger vote, and the arduous efforts to pry a victory from an apparent defeat, reflected the enormous political significance of the Medicare issue and the philosophical differences -- between the political parties and among factions of Republicans who hold the majority in both houses of Congress -- over the changes the legislation would bring to the program.

The bill's passage, rocky as it was, vastly increases the chances that, after years of legislative struggle, the federal government will begin to offer the help in paying for medicine that has been a rallying cry among older Americans.It handed a substantial victory to the White House, which has sought to champion Medicare changes as a major domestic accomplishment for President Bush in his reelection campaign next year.

Congressional Republicans and Democrats, however, were deeply divided over whether the legislation would prove helpful to the 40 million older and disabled Americans who get health insurance through the program.

The slender margin resembled another cliff-hanger vote when the House passed a more conservative version of the Medicare legislation by a one-vote margin in June, following similar pressure by GOP leaders to win over skeptics. In that earlier vote, the GOP leadership extended the roll call by more than an hour to secure the final "yes" vote. Throughout Friday and until voting began at 3 a.m., Republicans leaders scurried to overcome resistance from Democrats and some GOP conservatives who objected to elements of the biggest proposed change to the program since it began in 1965.

The House took up the legislation one day after congressional negotiators completed work on a hard-fought compromise, produced largely by Republicans, that would inject heavy new market competition into the government health insurance program for the elderly and disabled. The compromise emerged from four months of negotiations over separate Medicare bills that the two chambers had passed.

Many Republicans called the bill an unprecedented opportunity to help older Americans with drug costs. "This is one of those times for great change," said House Speaker J. Dennis Hastert (R-Ill.)

Most Democrats condemned it as a handout to pharmaceutical and insurance companies and a threat to the program's existence. House Minority Leader Nancy Pelosi (D-Calif.) said the bill would offer too little help with drug costs and lead to "the end of Medicare as we know it."

In the end, just 16 Democrats joined with the Republican majority to pass the bill. Twenty-five Republicans and one Independent voted with the rest of the Democrats against the measure.

The conservative Republicans who switched their votes at the end said they did so because they were told that if this bill failed, Democrats planned to bring up an earlier, more liberal Senate version.

Otter said he and Franks were among a group of seven conservatives who met with party leaders off the House floor. About an hour before the switch they were told the House Democrats were planning to introduce the Senate version of the Medicare prescription drug bill and bring it to the floor through a seldom used discharge petition that requires the signature of a majority of the members. The Senate bill was far more expensive and contained fewer reform elements, so Otter said he and Franks decided to change their votes.

Otter said he received a call from Bush earlier urging him to vote for the bill but he told the president "I can't help you" because the bill would increase the national debt.

After the vote, Rep. Steny Hoyer (D-Md.) blasted the GOP for forcing a rejection into a win. "Arms have been twisted and votes have been changed," said Hoyer, who said the process had been anti-democratic.

The House vote is to be followed by action in the Senate, which planned to debate the legislation today and Sunday, with a vote possible by Monday. Yesterday, the bill continued to pick up support from senators of both parties. Democratic leader Thomas A. Daschle (S.D.), who has sharply criticized the bill, said he would not support a filibuster to block its passage because Democrats are split on the issue.

Starting in 2006, the bill would allow everyone in Medicare to obtain federally subsidized drug coverage by buying a separate insurance policy or by joining a private health plan that also provided the rest of their care. Before those subsidies began, the government would, starting next spring, organize a network of drug discount cards sold by private companies that proponents predict could shave about 15 percent from the price of pharmaceuticals.

The drug assistance, the most widely publicized part of the 678-page legislation, is less controversial than several other provisions. Some of those would try to nudge Medicare patients to join preferred provider organizations (PPOs), HMOs, and other private health plans. Nearly nine in 10 people on Medicare belong to the original "fee-for-service" version in which patients choose their doctors and essentially can get the care they request.

Under a central compromise reached a week ago, the program would begin an experiment in which the traditional program would have to enter direct price competition for patients against private health plans. That six-year experiment in several metropolitan areas, to start in 2010, has drawn fire both from Democrats, who say it would begin to undermine Medicare, and from conservatives, who favor such competition permanently and nationwide.

For the first time, the plan calls for wealthier Medicare patients to pay more for doctors visits and other outpatient care. It provides for extra drug subsidies to low-income beneficiaries, although not to as many as many Democrats would like.

To get the drug benefit, patients would pay an average premium of $35 a month and a $250 annual deductible. After that, the government would pick up 75 percent of their drug expenses up to $2,250 a year. At that point, coverage would stop, except for a small number of patients wth extremely large pharmaceutical expenses who incur $3,600 in out-of-pocket costs. At that point, the government would pay 95 percent of the rest.

Before last night's debate began, GOP House leaders spent the day racing to cajole a skeptical core of conservatives and other party members who reluctantly supported the original Medicare legislation that passed the chamber. The White House, hoping to tout a new Medicare law in President Bush's campaign next year, applied similar pressure. Bush telephoned "more than a handful" of House members from Air Force One as he returned from Britain, a White House spokesman said. And Friday night, Health and Human Services Secretary Thompson came to the Capitol to lobby in person for the measure's passage.

The House debate's intensely partisan tone, escalating all week, was vivid. Early in the day, Pelosi (D-Calif.) made a rare appearance at the Rules Committee and complained that the bill was being brought to the floor without a standard three-day waiting period for such agreements between the House and Senate. Rep. John D. Dingell (D-Mich.) called the measure "an unfair improper dangerous piece of legislation, conceived in darkness and . . . slipped through over the heads of our senior citizens." In a frequent theme, one Democrat denounced it as "a GOP drug company bonanza." And Many Democrats criticized the AARP, the nation's largest organization of older Americans, for endorsing the plan.

Rep. Gene Taylor (D-Miss), said: "This is nothing but an auction to the insurance companies and the pharmaceutical companies in this nation for campaign contributions to the Republican Party."

Republicans, trying to court skeptics in their own party, emphasized parts of the bill that embrace conservative goals. They include the expanded market competition in Medicare, steps toward limiting overall spending on the program, and new tax breaks for Americans of all ages who open special savings accounts for medical expenses.

"This bill is really all about a fair deal," said Ways and Means Committee Chairman Bill Thomas (R-Calif.), one of its main architects. "Modernize Medicare with prescription drugs, but put Medicare back on a sound financial basis, as well."

Thomas also countered Democratic efforts to demonize the AARP for its surprise decision to side with the GOP in support of the bill. "The AARP has not abandoned you. You've abandoned seniors," he told the Democrats.

In the 100-member Senate, Democratic foes of the Medicare bill may use parliamentary maneuvers to force Republicans to muster 60 votes to block a filibuster. But after a 90-minute Democratic caucus on the issue, Daschle said party members were "passionately" divided over the filibuster strategy.

"I don't believe a filibuster reflects the consensus of our caucus," he said, adding that he would vote against such a delaying tactic.

Despite some defections from their ranks, Senate Republicans said they believed they had enough votes for passage, even if they have to clear a 60-vote hurdle. During the past few days, wavering Democratic Sens. Kent Conrad (N.D.), Mary Landrieu (La.) and Blanche Lincoln (Ark.) said they would vote for the bill, as did a Republican skeptic, Sen. Olympia J. Snowe (R-Maine). Sen. John Cornyn (R-Tex.), who voted against an earlier Senate version of the legislation in June, said he supports the new version.