Now comes the really hard part.
With a tentative framework for a new Medicare prescription drug benefit having emerged from behind the closed doors of the House-Senate conference committee, the task of selling the deal to Senate Democrats and a handful of moderate Republicans begins. This may be more than an uphill battle, particularly if several "deal breakers" for those groups remain in the package, as House Republican leaders to date have insisted will be the case.
Despite weeks of all-day (and often all-night) negotiations, the conferees' work could be instantly undone over issues that are as contentious today as they were when the House and Senate passed separate drug bills in June. Those are the provisions calling for traditional Medicare to compete with private health plans, basing premiums on the wealth of the beneficiary and a lack of incentives for employers to continue providing drug benefits to their retirees.
In large part, the selling of this plan is difficult because it's no longer just about a prescription drug benefit. Make no mistake, this is a fundamental restructuring of the Medicare program. It may not be everything that conservative Republicans want, but it still hits the main points: privatization of basic Medicare and cost containment-the latter achieved not through reducing the cost of drugs but through "means testing" on both ends of the socioeconomic scale.
The central theme in every comment from conference leaders and Bush administration officials is that seniors will find themselves in private health plans within a few years. As CMS Administrator Tom Scully put it: "Nobody is going to be forced to change plans or leave traditional Medicare. But once they are presented with these choices, people will vote with their feet" and join a private plan.
It may be that private health plans would be able to offer more attractive packages not just for a stand-alone drug benefit but also for a new "Medicare Advantage" PPO product that would provide hospital and physician services as well. But for many legislators whose older constituents are afraid of losing access to their doctors, that in itself may be one deal breaker.
As Sen. Debbie Stabenow (D-Mich.) put it, "What (Republicans) are talking about is taking away the promise of a Medicare program." She was referring to the idea that beneficiaries would be steered into private plans that have shown a penchant from dropping senior enrollees when they aren't profitable enough.
Making the deal even more tenuous is a provision still under consideration to force the traditional Medicare program to compete with private plans by 2010. If basic Medicare were more expensive, seniors would be forced to pay higher premiums to remain in the program.
Sen. Edward Kennedy (D-Mass.), who supported a Senate-passed bill that contained far more help for low-income beneficiaries, said such an asset test would be "very troubling." "We have a doctrine of do no harm to the Medicare system. This plan does harm to our basic Medicare system and denies to seniors the drugs they need." Kennedy's weighing in against the conferees' plan is especially significant. It was his backing that won over skeptical liberal Democrats to the original Senate legislation. His reasoning was that even though the drug benefit was less than most Democrats wanted, it was a start and the program could be expanded later. Now he rages against caps on Medicare spending in the GOP-led plan.
The Democrats' ire over the legislation and their treatment at the hands of conference committee Chairman Bill Thomas (R-Calif.) spilled over into a letter sent by 40 Democrats and Sen. Olympia Snowe (R-Maine) to President Bush. Four Democrats who didn't sign the letter had already voted against the Senate Medicare bill, bringing the number of senators who might vote against a final bill to 45, easily enough to defeat it, since 60 votes are needed for passage.
The conference committee has included two Democrats, Sens. Max Baucus of Montana and John Breaux of Louisiana-two moderates who have advocated a compromise solution to the prescription drug issue. They did not sign the letter. However, other Democrats, including Senate Minority Leader Tom Daschle of South Dakota and Rep. Charles Rangel of New York, who were named by their caucus to the conference, have not been invited to participate by Thomas. He has reportedly told intimates that Daschle and others weren't asked because they are on record as opposing many of the House Republican provisions that form the basis of much of the conference agreement.
"The system has been extremely unfair and it's very unfortunate when the leader of the Democratic caucus is not included in the conference committee, of which he is a member," Stabenow said. "That does not bode well for coming up with a bipartisan solution."
The developments late last week belied what had seemed like a growing consensus inside the Beltway that a Medicare bill was becoming increasingly likely.
Julie Goon, senior vice president of government affairs at the health insurance group American Association of Health Plans-Health Insurance Association of America, said earlier in the week that "there really seems to be momentum now. I am optimistic there will be a bill. The House language on Medicare+Choice is likely to prevail and there is fully bipartisan support on this."
She may have been especially optimistic given that insurers apparently had been successful in winning additional payments for Medi-care+Choice for 2004 and 2005, and greatly enhanced reimbursements thereafter when a PPO option became standard after 2006.
Also successful at the bargaining table have been pharmaceutical companies, which have fought off most attempts at cost control in the drug benefit program.
However, as House Minority Leader Nancy Pelosi (D-Calif.), put it: "Not everybody in our country is represented at the table. I think what (conferees are) doing is skewed to HMOs and insurance companies and pharmaceutical companies."
The challenge for Thomas and his fellow Republicans, and perhaps for President Bush, is to bring at least some Democrats to the table, which will require further compromises they have so far been unwilling to make.