Reshaping Medicare, Rural Roots in Mind

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Reshaping Medicare, Rural Roots in Mind

By Robin Toner

New York Times, June 2, 2003

RESTON, Iowa, - When it comes to running the all-powerful Senate Finance Committee, geography is often destiny.

As the committee begins an overhaul of Medicare, it matters that the chairman is from Iowa: Senator Charles E. Grassley, Republican, farmer, a man who says he spends, on average, two nights a week in his bed on his 710-acre corn and soybean farm in New Hartford.

If Mr. Grassley has his way, the interests of rural America will loom large in the push to enact a Medicare law. And that could make life complicated for the Bush administration and its conservative allies, who want to transform Medicare from a traditional government health insurance program for the elderly to a new marketplace of competing private health plans.

Mr. Grassley, 69 and fresh from a brutal battle over tax cuts, in which his committee also played a central role, describes his challenge on Medicare as twofold: getting enough Democratic support for a bill to prevent a filibuster, and holding onto the more conservative Republicans that he describes as "the purists."

Along the way, he wants to raise the reimbursements for doctors and hospitals in rural areas and look after the interests of elderly beneficiaries in places like Iowa. They are overwhelmingly reliant on traditional Medicare and skeptical that health maintenance organizations and other private plans will ever really be accessible to them. And not without reason.

Until now, H.M.O.'s have not been available to Medicare beneficiaries in many rural areas.

"I don't have any quibbling with the desires of my colleagues who are more purist," Mr. Grassley said one night recently, over an Iowa pork chop. "But the practical thing is, you've got to sell it here at the grass-roots, not only in Iowa but all over the country."

That means promising people, he said, that they can stay with the traditional program, where they have free choice of doctors and hospitals, and still get a comprehensive new drug benefit. In contrast, the Bush administration and many of its conservative allies would prefer to use drug benefits as an incentive to entice people into the private plans; as a result, they have proposed offering far less generous drug coverage in the traditional program.

As Mr. Grassley made the rounds of town meetings in southwestern Iowa this week, he said that he disagreed with that approach. Asked by a skeptical doctor at a meeting in Atlantic whether Mr. Grassley would not, in the end, push the Bush plan, the senator replied: "No. Well, some elements of it would be."

"But let me explain," he added, while about 75 Iowans hung on his words. "When it finally got said and done, Bush never had a bill to present to Congress, because they didn't really know what they were doing. Not that their ideas were wrong, but they didn't have them well thought out, or put together in a perfect piece of legislation. So they ended up just establishing some principles.

"Now, those of us who have been working on Medicare and prescription drugs for the last two or three years, we feel like we know how to do it. So what we finally talked the president into, back in probably February or early March, was, `We ain't going to wait for a bill; we're going to go ahead.' "

Mr. Grassley added, very plainly and carefully, his words highlighting the political risk of this issue: "We're going to give seniors a maximum of choice. If they want to keep their current Medicare, they can get it with prescription drugs. And if they want to go into a new Medicare, they can get that with prescription drugs, too."

Mr. Grassley is hardly the only member of the Finance Committee who is sensitive to rural America. In fact, the 21-member committee also includes senators from Montana, West Virginia, South Dakota, North Dakota, Maine, Vermont and Wyoming. It makes a difference, Mr. Grassley said, and he added, with a smile, that New York did well on Medicare issues when Senators Daniel Patrick Moynihan and Alfonse M. D'Amato of New York were on the Finance Committee.

The committee is expected to begin voting on a Medicare bill in early June, and Republican leaders in the House and Senate hope to act on the legislation before the July Fourth recess.

It will require Mr. Grassley once again to work closely with his counterpart in the House, the chairman of the Ways and Means Committee, Representative Bill Thomas, Republican of California. The tension between the men was apparent, repeatedly, in the battle over tax cuts.

Mr. Grassley said he assumed the relationship had healed, but added, "Have you ever seen him explode?"

"I just say the reality of it," said Mr. Grassley, who struggled to hold together his party's one-vote majority on the committee. At one point, Mr. Grassley said with some amusement, he told Mr. Thomas that more changes were needed in the tax bill to hold the Republican Senate moderates, and Mr. Thomas stormed from the room — even though it was his own office.

"They don't understand us," Mr. Grassley said of the House. "I can understand them. I served in the House. What it amounts to is, the majority party can get anything done they want to get done there."

Not so in the Senate, where some say Mr. Grassley will need significant Democratic support to get a bill passed.

"If this proposal significantly moves toward privatizing Medicare, I think there's a reasonable chance that Democrats will feel so strongly about defending the program that 60 votes will be needed to overcome a filibuster," said Ron Pollack, executive director of Families USA, a liberal advocacy group.

Mr. Grassley, who grew up on a farm but has spent the last 44 years in the state Legislature, the House and the Senate, carries himself modestly, happy to stay at economy motels on his round of town meetings, stopping by Wal-Mart at the end of the day. He is up for re-election next year and says he expects to raise "a massive amount of money" to meet what he expects to be a stiff challenge from the Democrats. He won 68 percent of the vote in 1998 and 70 percent in 1992.

Even after 23 years in the Senate and becoming chairman of a powerful committee, Mr. Grassley seems determined to present himself as an Iowan, first and foremost.

Doug Sickler, a retired banker active in economic development in Corning, told Mr. Grassley this week: "This is the heartland of America. Don't forget about us."

Mr. Grassley replied: "I come home every weekend. It's not easy to forget Iowa when you come home every weekend."