How GOP is subverting Medicare

This effort is being pursued despite the fact that it is capable of derailing yet again the decade-long effort to add a desperately needed prescription drug benefit to Medicare -- something both President Bush and his congressional leadership have pledged to do. Cooler heads in both political parties could still prevail, but for the moment, the House Republican leadership is driving the Medicare and prescription drug debate and Bush has not lifted a finger to push sensitive House-Senate negotiations toward an agreement -- in marked contrast to his dispatch of Vice President Cheney last week to resolve an intra-party fight that threatened more government subsidies for their buddies in the energy business.

The House Republican effort is leadership driven -- by Speaker Dennis Hastert and Majority Leader Tom DeLay, with Ways and Means Committee chairman Bill Thomas of California doing the dirty work -- and involves the changes in Medicare supposedly necessary to help fund a limited prescription drug benefit. The House Republicans have decided to interpret change to mean an attempt to force more Medicare beneficiaries into the tender arms of insurance companies.

Senate Republicans have told their House friends privately, and Senate Democrats (led by Edward Kennedy) have told them publicly, that this is a sure route to gridlock and another year without promised action. They have also pleaded with the president to get involved.

The "mandate" behind the House Republicans' behavior is a one-vote majority that five months ago passed a business-tilted prescription drug bill. As an example of their good faith, consider what they did to the Republican member, JoAnn Emerson of Missouri, who supplied that last vote.

On the floor at the last moment, Emerson voted for the GOP package after being promised a separate vote on the volatile issue of permitting the importation of cheaper prescription drugs from other countries, which she favors. The vote was held, the proposal passed 243-186, and now the leadership is in the process of making sure it never happens.

Their Medicare "reforms" are a joke. Already, there is nothing in current law to prevent a beneficiary from joining a health maintenance organization. In fact, many of the growing number of active, healthy, older people find HMOs an attractive choice; unfortunately, HMOs have often found they don't make high enough profits off them and have dumped them by the tens of thousands in recent years.

Already, the government subsidizes use of HMOs through Part B of Medicare, which involves outpatient care and for which beneficiaries pay premiums if they choose to enroll. Indeed, the subsidies to the private providers, called premium support, exceed the average cost of providing the care. The House Republicans want to make these subsidies even more lavish.

They also want to do something more outrageous. To the extent subsidized private insurance is cheaper than the care beneficiaries get by visiting a doctor of their choice under a traditional fee-for-service system, they want to force beneficiaries to make up the difference through higher premiums under Part B. It is one thing to advocate more choice through Medicare and to watch costs, but it is quite another to in effect dictate the choice and try to "cap" the drug costs (which House Republicans always want to do) in a way that directly undermines the already limited benefit.

By contrast, the Senate bill (primarily a delicate compromise overseen by Kennedy and Senate Majority Leader Bill Frist) passed by an overwhelming, bipartisan, 76-21 vote. The drug benefit has openly acknowledged holes in its coverage which proved too large for several Senate liberals. However, it does constitute a very large foot in the door of drug coverage and includes a careful maintenance of public-private balance in Medicare itself. It also provides for the delivery of the drug benefit through existing, private business networks. Both sides recognized in the deal that they would live to fight another day over more generous benefits and deeper changes in Medicare itself.

All that is threatened by the House Republicans; at this late date only Bush's intervention can restrain his own troops. He might want to remember that he was the one who promised to get something done this year and that his party controls both the House and the Senate.

Thomas Oliphant's e-mail address is oliphant@globe.com.