Panelists: James C. Capretta, managing director, Wexler-Walker Public Policy Associates and former associate director for human resources, Office of Management and Budget; Elizabeth Fowler, chief health counsel, minority staff, Senate Finance Committee; Sorina Vlaicu, assistant professor of health policy, Department of Political Science, University of Western Ontario; Kate Schuler, health reporter, Congressional Quarterly

The enactment of the Medicare Prescription Drug and Modernization Act in December 2003 was "a miracle" when one considers all the pieces that had to fit together and stay together, and how easily the fragile package of compromises could have blown apart.

That was the conclusion of a panel of first-hand observers who recounted the bill's perilous path through the legislative labyrinth during a Wilson Center seminar on Congress and Healthcare Policy September 13. James C. Capretta, who worked as President George W. Bush's point person on healthcare reform at OMB from 2001 to 2003, credited the president's persistence in getting a bill signed into law as a major factor in the measure's success. In the spring of 2002, Capretta said, Bush as presidential candidate came forward with a package of Medicare reforms that included a prescription drug benefit, and "he made a commitment to hang on to them, no matter what." Capretta added that the key to President Bush's legislative successes during his first term was developing a "short list of high priorities and sticking to them. And the Medicare prescription drug benefit was one of those priorities."

Elizabeth Fowler, the chief healthcare adviser to Senate Finance Committee Democrats, said the close working relationship between the committee chairman, Senator Charles Grassley (R-Ia.), and her boss, the ranking minority member, Senator Max Baucus (D-Mont.) was key in keeping the Medicare package together. They vowed from the outset to work together in developing a workable compromise bill that would have bipartisan support. Another key factor was support for the bill in the Senate by Senator Ted Kennedy (D-Mass.), the Senate's preeminent health policy expert. Kennedy thought it was important to keep the process alive and move the bill forward, but turned against it when it emerged from the House-Senate conference because it leaned too heavily towards privatization of Medicare. Notwithstanding Kennedy's abandonment of the legislation, what probably tipped the balance in its favor, said Fowler, was the endorsement by AARP of the final product. Even then things were so close at the last minute that Fowler said the staff had prepared two speeches for Baucus to deliver-—one in favor of the conference bill and one opposed. Fowler added that the highly charged partisanship of the House, and the Ways and Means Committee chairman's exclusion of all but two Senate Democrats from the conference deliberations (Baucus and Breaux), nearly proved fatal to the bill. Fowler said that among the lessons learned from the prescription drug bill experience is that the more things become polarized and partisan in Congress, the more difficult it is "to find common ground." With such complicated legislation, it is nearly impossible to make everyone happy with the compromises necessary to make it work. As things now stand, hardly anyone is happy with the legislation, she added, especially seniors.

Sorina Vlaicu, a health policy professor at Western Ontario University, compared the 2003 Medicare legislative experience with the 1988 catastrophic health insurance bill, that also included a drug benefit. In that instance, Congress repealed the bill 18 months after it became law because a highly vocal group of senior citizens protested strongly against the additional Medicare premium they would have to pay to receive the catastrophic healthcare coverage. In 2003, Congress was careful to make the new benefit voluntary, and not to put the premium increase into effect before the benefit could be accessed. Moreover, Congress has mandated a public education program about the new benefit to allay confusion or misunderstanding. But thus far, concluded Vlaicu, most seniors (47 percent) still have an unfavorable opinion of the benefit, while only a quarter have a favorable view, and the other fourth are just confused or don't know anything about it. The key question of whether the drug benefit will survive or be repealed, as catastrophic insurance was in 1989, depends on how much better the plan is sold before it takes effect in 2006, and also whether Congress makes necessary adjustments to generate greater confidence in it. "Once it is implemented," concluded Vlaicu, "it is very unlikely Congress would take it away. No one wants to lose their benefits, no matter how imperfect or inadequate they may seem."

Kate Schuler who covers healthcare issues for Congressional Quarterly, gave a journalist's perspective on covering the Medicare saga in 2003. "It was very difficult to get the full story because so many of the negotiations were carried on behind closed doors," she observed. "We had to fight for every little nugget of information we could get from those who were part of the bargaining process, and even then, when we'd compare notes afterwards, we'd realize we hadn't been told anything new." Schuler said the most fascinating part of the process was the House votes on the package, both on its initial passage, and later on the conference report. "In both cases the votes were close, they were held open way beyond the usual 15 minutes, and the leadership had to twist arms and cut all kinds of deals to win narrowly." Schuler recounted how one Republican member hid behind a banister on the Democratic side of the Chamber just to watch the leadership try to turn around the vote on the conference report, even though that member knew she would also be pressured by her leaders to change her vote if they found her. Another member claimed the leadership had attempted to "bribe" him by threatening to withhold support from his son who was running for the retiring member's seat. [The member later recanted, saying it was outside groups that had used the threat of withholding campaign support.]

A final point on which the panelists agreed was that the successful enactment of the bill at the end of 2003 marked a very narrow window of opportunity that could not have remained open in an election year. The budget resources made available for the prescription drug benefit probably would not have been available later as the deficit grew, and it would have been more difficult to hold as many conservative Republicans or moderate Democrats to a bipartisan compromise in a more partisan environment. A variety of interests both inside and outside Congress got enough of value to them, ideologically, regionally, and financially, that they were willing to support the measure on the narrowest of grounds. But that is all it took in the end.