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108th Congress, Vote 332; House of Representatives #1

Medicare Prescription Drug, Improvement, and Modernization Act of 2003

Official Title: An act to amend title XVIII of the Social Security Act to provide for a voluntary prescription drug benefit under the medicare program and to strengthen and improve the medicare program, and for other purposes.

HR1, S1 Medicare Prescription Drug Benefit Bill
House bill passed 216-215, 4 not voting June 27, 2003.
Senate bill passed 76-21, 3 not voting June 26, 2003.
After the two bills were unified in Conference, the legislation came back to the House, where it passed 220-214, November 22, 2003.
Three days later, Senate passed this final version, 54-44, November 25, 2003.

Synopsis: The Medicare Prescription Drug, Improvement, and Modernization Act provided prescription drug coverage for the elderly and gave private health plans (a.k.a., "Medicare Advantage" plans) a much larger role in the Medicare program.

This was not the first time that Washington tried to nudge seniors into private-sector plans, hoping that that free-market competition would bring down the cost of care. In 1997, Medicare began giving beneficiaries a choice between traditional Medicare (with the government paying medical bills directly) and "Medicare + Choice," a program that paid HMOs to provide Medicare benefits to seniors. The theory was that the private sector would do a better job of finding innovative ways to trim costs while enhancing benefits.

Unfortunately, things didn't work out that way. First, many HMOs found ways to shun the sickest seniors by charging high co-pays for items like chemotherapy, hospital care, oxygen and dialysis. As a result, they wound up with a relatively healthy pool of customers. Meanwhile, Medicare paid the HMOs a lump sum per enrollee, without adjusting for the fact that private insurers had winnowed out so many of the most expensive patients. Thus, in 2003, Medicare shelled out roughly 4 percent more for Medicare + Choice enrollees than it would have spent if these same healthy seniors had stayed in traditional Medicare where they would have used fewer services.

Even so, insurers soon began to grouse that Medicare's payments were not high enough to keep up with the soaring cost of care, and they began bailing out of the Medicare + Choice. From 1998 to 2003 the number of Private M +C plans fell by 50 percent. Other private Medicare + Choice insurers raised co-pays and deductibles. As a result, over the five years ending in 2003, the list of beneficiaries enrolled in M+C plunged from 6.2 million to 4.6 million.

Enter the Medicare Modernization Act of 2003. This time around Congress hiked payments to private insurers. These payments varied in different parts of the country, reflecting differences in health care costs in different regions. In some places insurers enjoyed enormous increases: for instance, in Long Island's Nassau Country, Medicare lifted payments to private insurers by over 24 percent.

It seemed that Congress had given up on the theory that private sector insurers could provide better care for less. But some still believed that if private insurers were given enough time to let market forces kick in, the cost of care would, in fact, fall.

But the Medicare Modernization Act also greatly expanded coverage–and costs– by providing prescription drug coverage to seniors under Medicare Part D. The legislation explicitly barred the federal government from negotiating directly with drug companies to lower prices.

The Votes

The Medicare Modernization Act would roil Congress, and the roller-coaster votes on this bill would set history.

The legislation was supported by President George W. Bush. But in 2003, not all Republicans were willing to vote along party lines. As a result, the political pressure was intense when the bill came up for a vote in the House in June 2003. A dramatic roll-call lasted more than 40 minutes, with the ''nays'' outnumbering the ''yeas,'' while House Republican leaders feverishly pressured legislators to vote for the bill.

Three Republican representatives then changed their votes. One opponent of the bill, Ernest J. Istook, Jr. (R-OK-5), changed his vote to "present" upon being told that C.W. Bill Young (R-FL-10), who was absent due to a death in the family, would have voted "aye" if he had been present. Next, Republicans Butch Otter (ID-1) and Jo Ann Emerson (MO-8) switched their votes to "aye." At 2:30 a.m. the bill passed by one vote, 216-215.

A day earlier, the Senate had cleared its version of the bill by an overwhelmingly bipartisan vote of 76 to 21 http://www.nytimes.com/2003/06/27/us/house-and-senate-pass-measures-for-broad-overhaul-of-medicare.html?pagewanted=3&src=pm Although the House and the Senate had now each passed their versions of the legislation, the two bills had to be reconciled in "Conference" – the place where the House and Senate compromise

A final version of the bill did not come back to the House until November 21. At that point, one of the most contentious votes in the history of Congress began to unfold. The legislation didn't come to a vote until 3 a.m. on November 22. After 45 minutes, the bill was losing, 219-215. Speaker Dennis Hastert and Majority Leader Tom DeLay began working to convince some of the dissenting Republicans to switch their votes, as they had in June. Ernest J. Istook, Jr. (R-OK-5), who had always been a wavering vote, consented quickly. The tally was now 218 to 216. In a highly unusual move, the House leadership held the vote open for hours as they sought two more votes.

Representative Nick Smith (R-Mich.) would claim that he was offered campaign funds for his son, who was running to replace him, in return for a change in his vote from "nay" to "yea." Smith later said that no explicit offer of campaign funds was made, but that he was offered "substantial and aggressive campaign support" which he had assumed included financial support.

About 5:50 a.m., the leadership convinced Butch Otter (ID-1) and Trent Franks (AZ-2) to switch their votes. With passage assured, Democrats Calvin M. Dooley (CA-20), Jim Marshall (GA-3) and David Scott (GA-13) changed their votes to the affirmative. But Brad Miller (D-NC-13), and then, Republican John Culberson (TX-7), reversed their votes from "yea" to "nay." The bill ultimately passed 220-215.

The Senate's consideration of the compromise "Conference" bill was somewhat less heated–until Tom Daschle raised a budget point of order. Since 60 votes were necessary to override this challenge, some observers thought he had a credible chance of blocking the legislation.

For several minutes, the vote total was stuck at 58-39 – until Senators Lindsey Graham (R-S.C.), Trent Lott (R-Miss.), and Ron Wyden (D-Ore.) voted in quick succession, bringing the tally to 61-39. The bill itself was finally passed 54-44 on November 25, 2003. It was signed into law by President Bush on Dec. 8.

Why supporters pushed for this bill

  • Seniors had long complained that prescription drugs were becoming unaffordable. Some said they had to choose between buying medication and buying groceries.
  • During his 2000 presidential campaign, George W. Bush promised to make prescription drug coverage for seniors one of his top priorities. With Republicans controlling both houses of Congress, many GOP lawmakers also felt the pressure to deliver on a promise before the 2004 election campaigns got underway.
  • Conservatives also had long believed that if Medicare became a private sector program, market competition would lower costs. They hoped that if they created "Medicare Advantage" and paid private insurers more, those insurers would be able to offer extra benefits that would draw seniors into the private insurance programs, and that ultimately, most would join private sector Advantage plans.

Why opponents tried to stop the bill

  • Those who refused to vote for the bill saw it as a sweetheart deal for drug-makers and insurers. Medicare wouldn't be able to bargain for better prices with pharmaceutical companies, but would be sending many more customers their way. Meanwhile, insurance companies would be paid far more to take on Medicare patients than they had been under Medicare + Choice.
  • Detractors pointed out that under the bill, seniors would receive limited prescription drug coverage. In addition to paying a premium pegged at $35 a month and satisfying a $250 deductible, most seniors who signed up for the prescription benefit would have to pay 25 percent of their annual drug costs up to $2,250 but 100 percent of additional costs up to $5,100. The plan would then covers 95 percent of drug costs above $5,100. (Low-income seniors would receive more generous benefits.
  • Others suggested that by paying Medicare Advantage so much, the legislation was designed to turn Medicare into a private sector program. If wealthier, healthier seniors gravitated toward Medicare Advantage (because it offered benefits that would appeal to this group, such as discounts on gym membership), traditional Medicare would become much like Medicaid – a "poor program for the poor."
  • Many believed the $400 billion bill was just too expensive. This is why conservative Republicans in the House joined Democrats in fighting the bill. In fact, a month after President Bush signed the Medicare Modernization Act, administration officials and congressional aides acknowledged that the legislation would cost at least $134 billion more than expected, or a total of $534 billion over ten years. "The news on the Republican Medicare bill gets better and better for drug company profits and HMOs, and worse and worse for seniors and the Medicare program," said Sen. Edward M. Kennedy (D-Mass.), one of the law's strongest opponents.
06/27/2003 Status: House passed

More: select a member to see his or her other key Medicare votes.

Yes (216)
R Don Young AK
R Robert Aderholt AL
R Spencer Bachus AL
R Jo Bonner AL
D Robert Cramer AL
R Terry Everett AL
R Mike Rogers AL
R John Boozman AR
R Trent Franks AZ
R John Hayworth AZ
R James Kolbe AZ
R Rick Renzi AZ
R Mary Bono Mack CA
R Ken Calvert CA
R C. Cox CA
R Randall Cunningham CA
R John Doolittle CA
R David Dreier CA
R Elton Gallegly CA
R Walter Herger CA
R Duncan Hunter CA
R Darrell Issa CA
R Jerry Lewis CA
R Howard McKeon CA
R Gary Miller CA
R Devin Nunes CA
R Doug Ose CA
R Richard Pombo CA
R George Radanovich CA
R Dana Rohrabacher CA
R Edward Royce CA
R William Thomas CA
R Bob Beauprez CO
R Joel Hefley CO
R Nancy Johnson CT
R Christopher Shays CT
R Robert Simmons CT
R Michael Castle DE
R Michael Bilirakis FL
R Virginia Brown-Waite FL
R Ander Crenshaw FL
R Lincoln Diaz-Balart FL
R Mario Diaz-Balart FL
R Tom Feeney FL
R Mark Foley FL
R Porter Goss FL
R Katherine Harris FL
R Ric Keller FL
R John Mica FL
R Adam Putnam FL
R Ileana Ros-Lehtinen FL
R E. Shaw FL
R Clifford Stearns FL
R David Weldon FL
R Max Burns GA
R Michael Collins GA
R Nathan Deal GA
R Phil Gingrey GA
R John Isakson GA
R Jack Kingston GA
R John Linder GA
D Leonard Boswell IA
R Steve King IA
R Tom Latham IA
R James Leach IA
R James Nussle IA
R C.L. Otter ID
R Michael Simpson ID
R Judy Biggert IL
R Philip Crane IL
R J. Hastert IL
R Henry Hyde IL
R Timothy Johnson IL
R Mark Kirk IL
R Ray LaHood IL
R Donald Manzullo IL
R John Shimkus IL
R Gerald Weller IL
R Chris Chocola IN
R Mark Souder IN
R Todd Tiahrt KS
R Ernest Fletcher KY
R Ron Lewis KY
D Kenneth Lucas KY
R Anne Northup KY
R Harold Rogers KY
R Ed Whitfield KY
R Rodney Alexander LA
R Richard Baker LA
R James McCrery LA
R William Tauzin LA
R David Vitter LA
R Roscoe Bartlett MD
R Wayne Gilchrest MD
R Dave Camp MI
R Vernon Ehlers MI
R Peter Hoekstra MI
R Joseph Knollenberg MI
R Thaddeus McCotter MI
R Candice Miller MI
R Mike Rogers MI
R Fred Upton MI
R Mark Kennedy MN
R John Kline MN
D Collin Peterson MN
R James Ramstad MN
R W. Akin MO
R Roy Blunt MO
R Jo Ann Emerson MO
R Sam Graves MO
R Kenny Hulshof MO
R Charles Pickering MS
R Roger Wicker MS
R Dennis Rehberg MT
R Cass Ballenger NC
R Howard Coble NC
R Robin Hayes NC
R Sue Myrick NC
R Charles Taylor NC
D Earl Pomeroy ND
R Douglas Bereuter NE
R Thomas Osborne NE
R Lee Terry NE
R Charles Bass NH
R Jeb Bradley NH
R Michael Ferguson NJ
R Rodney Frelinghuysen NJ
R Scott Garrett NJ
R Frank LoBiondo NJ
R H. Saxton NJ
R Christopher Smith NJ
R Stevan Pearce NM
R Heather Wilson NM
R James Gibbons NV
R Jon Porter NV
R Sherwood Boehlert NY
R Vito Fossella NY
R Amory Houghton NY
D Steve Israel NY
R Sue Kelly NY
R Peter King NY
R John McHugh NY
R Jack Quinn NY
R Thomas Reynolds NY
R John Sweeney NY
R James Walsh NY
R John Boehner OH
R Steve Chabot OH
R Paul Gillmor OH
R David Hobson OH
R Steven LaTourette OH
R Robert Ney OH
R Michael Oxley OH
R Robert Portman OH
R Deborah Pryce OH
R Ralph Regula OH
R Patrick Tiberi OH
R Michael Turner OH
R Tom Cole OK
R Frank Lucas OK
R John Sullivan OK
R Greg Walden OR
R Philip English PA
R Jim Gerlach PA
R James Greenwood PA
R Melissa Hart PA
R Tim Murphy PA
R John Peterson PA
R Joseph Pitts PA
R Todd Platts PA
R Donald Sherwood PA
R Bill Shuster PA
R Patrick Toomey PA
R W. Weldon PA
R James Barrett SC
R Henry Brown SC
R Joe Wilson SC
R William Janklow SD
R Marsha Blackburn TN
R John Duncan TN
R William Jenkins TN
R Zach Wamp TN
R Joe Barton TX
R Henry Bonilla TX
R Kevin Brady TX
R Michael Burgess TX
R John Carter TX
R John Culberson TX
R Thomas DeLay TX
R Kay Granger TX
R Ralph Hall TX
R Jeb Hensarling TX
R Sam Johnson TX
R Randy Neugebauer TX
R Pete Sessions TX
R Lamar Smith TX
R Mac Thornberry TX
R Rob Bishop UT
R Christopher Cannon UT
D Jim Matheson UT
R Eric Cantor VA
R Jo Ann Davis VA
R Thomas Davis VA
R J. Forbes VA
R Virgil Goode VA
R Bob Goodlatte VA
R Edward Schrock VA
R Frank Wolf VA
R Jennifer Dunn WA
R Doc Hastings WA
R George Nethercutt WA
R Mark Green WI
R Thomas Petri WI
R Paul Ryan WI
R Shelley Capito WV
R Barbara Cubin WY
No (215)
Our pick
D Artur Davis AL
D Robert Berry AR
D Mike Ross AR
D Victor Snyder AR
R Jeff Flake AZ
D Raúl Grijalva AZ
D Ed Pastor AZ
R John Shadegg AZ
D Joe Baca CA
D Xavier Becerra CA
D Howard Berman CA
D Lois Capps CA
D Dennis Cardoza CA
D Susan Davis CA
D Calvin Dooley CA
D Anna Eshoo CA
D Sam Farr CA
D Bob Filner CA
D Jane Harman CA
D Michael Honda CA
D Tom Lantos CA
D Barbara Lee CA
D Zoe Lofgren CA
D Robert Matsui CA
D J. Millender-McDonald CA
D George Miller CA
D Grace Napolitano CA
D Nancy Pelosi CA
D L. Roybal-Allard CA
D Linda Sánchez CA
D Loretta Sanchez CA
D Adam Schiff CA
D Brad Sherman CA
D Hilda Solis CA
D Fortney Stark CA
D Ellen Tauscher CA
D Mike Thompson CA
D Maxine Waters CA
D Diane Watson CA
D Henry Waxman CA
D Lynn Woolsey CA
D Diana DeGette CO
R Marilyn Musgrave CO
R Thomas Tancredo CO
D Mark Udall CO
D Rosa DeLauro CT
D John Larson CT
D Allen Boyd FL
D Corrine Brown FL
D James Davis FL
D Peter Deutsch FL
D Alcee Hastings FL
D Kendrick Meek FL
R Jeff Miller FL
D Robert Wexler FL
D Sanford Bishop GA
D John Lewis GA
D Denise Majette GA
D James Marshall GA
R Charles Norwood GA
D David Scott GA
D Neil Abercrombie HI
D Ed Case HI
D Jerry Costello IL
D Danny Davis IL
D Rahm Emanuel IL
D Lane Evans IL
D Luis Gutiérrez IL
D Jesse Jackson IL
D William Lipinski IL
D Bobby Rush IL
D Janice Schakowsky IL
R Dan Burton IN
R Stephen Buyer IN
D Julia Carson IN
D Baron Hill IN
R John Hostettler IN
R Mike Pence IN
D Peter Visclosky IN
D Dennis Moore KS
R Jerry Moran KS
R Jim Ryun KS
D William Jefferson LA
D Christopher John LA
D Michael Capuano MA
D William Delahunt MA
D Barney Frank MA
D Stephen Lynch MA
D Edward Markey MA
D James McGovern MA
D Martin Meehan MA
D Richard Neal MA
D John Olver MA
D John Tierney MA
D Benjamin Cardin MD
D Elijah Cummings MD
D Steny Hoyer MD
D C. Ruppersberger MD
D Chris Van Hollen MD
D Albert Wynn MD
D Thomas Allen ME
D Michael Michaud ME
D John Conyers MI
D John Dingell MI
D Dale Kildee MI
D Carolyn Kilpatrick MI
D Sander Levin MI
R Nick Smith MI
D Bart Stupak MI
R Gilbert Gutknecht MN
D Betty McCollum MN
D James Oberstar MN
D Martin Sabo MN
D Wm. Clay MO
D Richard Gephardt MO
D Karen McCarthy MO
D Ike Skelton MO
D Gene Taylor MS
D Bennie Thompson MS
D Frank Ballance NC
R Richard Burr NC
D Bob Etheridge NC
R Walter Jones NC
D Mike McIntyre NC
D R. Miller NC
D David Price NC
D Melvin Watt NC
D Robert Andrews NJ
D Rush Holt NJ
D Robert Menendez NJ
D Frank Pallone NJ
D Bill Pascrell NJ
D Donald Payne NJ
D Steven Rothman NJ
D Tom Udall NM
D Shelley Berkley NV
D Gary Ackerman NY
D Timothy Bishop NY
D Joseph Crowley NY
D Eliot Engel NY
D Maurice Hinchey NY
D Nita Lowey NY
D Carolyn Maloney NY
D Carolyn McCarthy NY
D Michael McNulty NY
D Gregory Meeks NY
D Jerrold Nadler NY
D Major Owens NY
D Charles Rangel NY
D José Serrano NY
D Louise Slaughter NY
D Edolphus Towns NY
D Nydia Velázquez NY
D Anthony Weiner NY
D Sherrod Brown OH
D Stephanie Jones OH
D Marcy Kaptur OH
D Dennis Kucinich OH
D Tim Ryan OH
D Ted Strickland OH
D Brad Carson OK
D Earl Blumenauer OR
D Peter DeFazio OR
D Darlene Hooley OR
D David Wu OR
D Robert Brady PA
D Michael Doyle PA
D Chaka Fattah PA
D Joseph Hoeffel PA
D Tim Holden PA
D Paul Kanjorski PA
D John Murtha PA
D Patrick Kennedy RI
D James Langevin RI
D James Clyburn SC
R Jim DeMint SC
D John Spratt SC
D Jim Cooper TN
D Lincoln Davis TN
D Harold Ford TN
D Barton Gordon TN
D John Tanner TN
D Chris Bell TX
D Lloyd Doggett TX
D Thomas Edwards TX
D Jonas Frost TX
D Charles Gonzalez TX
D Gene Green TX
D Rubén Hinojosa TX
D Sheila Jackson Lee TX
D Eddie Johnson TX
D Nicholas Lampson TX
D Solomon Ortiz TX
R Ronald Paul TX
D Silvestre Reyes TX
D Ciro Rodriguez TX
D Max Sandlin TX
D Charles Stenholm TX
D James Turner TX
D Frederick Boucher VA
D James Moran VA
D Robert Scott VA
I Bernard Sanders VT
D Brian Baird WA
D Norman Dicks WA
D Jay Inslee WA
D Rick Larsen WA
D Jim McDermott WA
D Tammy Baldwin WI
D Ron Kind WI
D Gerald Kleczka WI
D David Obey WI
R F. Sensenbrenner WI
D Alan Mollohan WV
D Nick Rahall WV
Not Voting (3)
R Scott McInnis CO
R C. Young FL
D Adam Smith WA
Present (1)
R Ernest Istook OK