The House headed for a historic vote Friday night on a bill that would a prescription drug benefit to Medicare, marking the biggest expansion of the politically popular entitlement program in its 38-year history.
"The moon and the stars have lined up in our favor," House Speaker Dennis Hastert said at a rally-style press conference in the Capitol. "The time is upon us. It's now or never."
Republican leaders were still pressing wavering GOP conservatives to vote for the bill, which carries a 10-year price tag of $395 billion. Conservatives have balked at the price tag, arguing that the measure offers too little in the way of private competition and other measures designed to hold down future costs.
"I predict right now it will come out double that," Sen. Don Nickles, R-Okla., told fellow House-Senate negotiators on Thursday, referring to the cost estimate.
Top House Democrats, meanwhile, were pressuring rank-and-file members to hold the line against the package, setting the stage for a close vote in the late-night or early-morning hours.
Democrats contend the competition and other cost-containment provisions that accompany the outpatient drug benefit will undermine the traditional Medicare over the long run, hurting seniors and enriching pharmaceutical companies and HMOs.
"We were shut out of these negotiations ... and what we have here now is an evisceration of Medicare," said Rep. Alcee Hastings, D-Fla.
The House and Senate each passed their own versions of a Medicare drug bill earlier this year -- the House by one vote. Republican House and Senate negotiators and two Democrats -- Sens. Max Baucus of Montana and John Breaux of Louisiana -- reached agreement on a final bill last Saturday.
Negotiators, with the cooperation of Hastert and Senate Majority Leader Bill Frist, have tweaked the compromise in recent days in an effort to build support among dissatisfied Senate Democrats and House Republicans who threaten prospects for passage in either chamber.
Frist predicted the Senate may vote on the proposal Monday.
As initially drafted, the compromise came in at $395 billion over the next decade, $5 billion less than the amount set aside for the package under the fiscal 2004 budget outline, according to a Congressional Budget Office analysis.
That gave the plan's drafters room to sweeten the proposed drug benefit in a bid to further build support. Among the changes, the proposed deductible for drug coverage was lowered from $275 to $250.
That means the drug bill would cover 75 percent of drug costs between $250 and $2,250. The earlier draft had cut off coverage at $2,200.
Catastrophic coverage would kick in once out-of-pocket spending exceeded $3,600, covering 95 percent of costs.
The drug benefit would become available in 2006. Meanwhile, prescription drug discount cards would be available to all Medicare beneficiaries beginning in April 2004.
Beneficiaries who opt to participate in the plan would pay a monthly premium of $35. The drug plan is voluntary. Seniors would be able to buy prescriptions through a private drug plan or could leave Medicare and join a preferred-provider organization. In either case, premiums, coverage levels and deductible would be the same.
House and Senate Democrats, who complained they were kept out of the talks, have attacked provisions that would establish a test project requiring the traditional Medicare fee-for-service program to compete with private plans in six metropolitan areas and one region of the country beginning in 2010.
That proposal has also drawn criticism from conservative House Republicans, who say it doesn't go far enough.
The original House bill called for Medicare to compete directly with private health plans beginning in 2010.
The Senate bill contained no such provision, known as "premium support." Such proposals faced stiff opposition in the Senate from Democrats and moderate Republicans who fear the competition provisions would allow private health plans to siphon off the healthiest seniors while leaving the oldest and sickest seniors in the traditional Medicare program, where they would pay higher premiums.
It also includes provisions designed to partially protect patients who remain in the original program from higher costs.