Hard pill to swallow: The art of the possible

December 13, 2003

The landmark Medicare drug bill passed by Congress last month has something in it for almost everyone to complain about. Senator Edward Kennedy (D., Mass.), who led the Democratic opposition to the bill, thinks it moves too much toward privatization. It relies on private companies to implement the drug benefit, includes significant new fees for most people, and requires Medicare in some areas to compete with private health maintenance organizations. Kennedy, justifiably angry that most Democrats were shut out of the legislative process, termed the bill “the first step toward dismantling Medicare.”

The bill also prohibits the government from using its clout to negotiate lower drug prices from the pharmaceutical companies—a clear victory for the drug industry, and an “outrageous” omission, according to Senator John McCain (R., Ariz.), one of three Republican senators to vote against the bill. Meanwhile, some conservatives complained about the bill for a familiar reason: it will cost a lot. The drug provision, which doesn’t go into effect until 2006, is expected to cost at least $400 billion over ten years. But others think the bill is too stingy: it offers most middle-class seniors very little relief from their drug expenses. In fact, counting the deductible and the monthly fees, the standard plan will cover only $1,080 of the first $5,100 in prescription expenses.

The politics of the bill is complicated as well. One might think the bill is a huge victory for liberal Democrats. After all, it institutes the biggest expansion of the government’s health program for seniors since Medicare was created 65 years ago. Low-income seniors stand to gain the most from the bill. It will make prescription drugs more affordable for 10 million people who have no prescription drug coverage at all and will assist 14 million other low-income seniors.

In immediate political terms, however, the bill’s passage is a clear victory for the Republicans and President Bush. They can claim credit for addressing the problem and thereby can deprive the Democrats of one of their key campaign issues with seniors—a crucial bloc of voters.

Some observers predict that seniors will soon be expressing outrage over the patchwork quality of the bill and the limits of the coverage. Its provisions will surely be up for intense scrutiny and debate by both parties.

An old adage says that politics is the art of the possible. What is politically possible is usually not coherent legislation. Nevertheless, given widespread suspicions of big government in this era, it is significant that legislators could agree, in however clumsy a fashion, that Americans have a responsibility to assist the elderly among them with one of their main financial problems. There is no guarantee that political forces will coalesce behind such a principle in any future Congress. The possibility needed to be seized. As Senator Kent Conrad (D., N.D.), one of 11 Democrats who supported the bill, put it: the only thing worse than the bill itself would have been not passing it.