WASHINGTON — In a suspenseful and controversial pre-dawn vote, a sharply divided House on Saturday approved and sent to the Senate the most sweeping revision of Medicare since its creation in 1965, as lawmakers from both parties said the nearly $400 billion bill represented only the start of a long-term political battle over the shape of the health care program.
"This is just the beginning of trying to reform Medicare," said House Speaker Dennis Hastert, R-Ill., referring to the legislation that not only would provide a long-sought prescription drug benefit but is supposed to promote competition by giving private insurance companies billions of dollars to entice seniors and the disabled into managed care plans.
The Senate opened debate, expected to last three days, within hours of the bill’s 220-215 passage in the House.
If it is passed by the Senate, as many believe is likely, and signed into law, the legislation would do more to change how the elderly and disabled receive and pay for their health care than any development since Medicare’s creation 38 years ago.
And that’s exactly what worries Sen. Edward Kennedy, D-Mass.
Outraged by the action in the House, where Republican leaders held the Medicare vote open for almost three hours — instead of the usual 15 minutes — until pressure from President Bush and other lawmakers convinced two Republicans to switch their votes, Kennedy announced that he would seek to prevent a vote in the Senate.
"What happened in the House of Representatives in the dead of night was Florida 2000 all over again," Kennedy said. "It was a rigged vote."
Although several Democrats are expected to join Kennedy’s filibuster, Congress’ longtime leader on health care issues acknowledged that he would not have the 41 votes needed to prevent a Senate vote on the Medicare bill.
"This is not the end of this battle, no matter what happens on Monday or Tuesday or Wednesday. This is just the beginning," Kennedy said Saturday. "Anybody who thinks it’s all over … is absolutely mistaken."
Within hours of Kennedy’s announcement, Senate Majority Leader Bill Frist, R-Tenn., filed a motion setting up a vote to force an end to debate on Monday. But he said he regretted that the Senate’s consideration of the bill had come to that.
"Those who would support a cruel filibuster of this bill would hold our parents and grandparents — 40 million American seniors — hostage to Washington’s politics," Frist said. "Our seniors deserve better."
When the House began debating the Medicare bill late Friday, lawmakers from both parties expected the vote to be close. But no one anticipated the historic drama of the vote being held open longer than any in memory, which gripped the 435-member chamber for the three hours when Democrats appeared to have defeated the legislation.
President Bush, just back from four days in Britain, was awakened so he could call dissident Republicans, but in the end it was the suggestion by GOP leaders that Democrats would bring a much more moderate Senate version to the House that convinced two conservative Republicans who opposed the bill to change their minds.
"There was a buzz going around on the floor that if we lost this package, we weren’t going to like what we ended up with," said Rep. C.L. "Butch" Otter, R-Idaho, one of the two whose switch led to passage.
"I did not want to vote for this bill," he said. "I had already told the president I couldn’t help him."
Democrats accused Republicans of stealing the vote, which for two hours and 50 minutes — from 3 a.m. to 5:50 a.m. — stood frozen at 216 votes for the bill, 218 votes against and one lawmaker not voting. After Otter and Rep. Trent Franks, R-Ariz., switched their votes to give the Republicans a 218-216 victory, other lawmakers changed their votes as well, bringing the final tally minutes later to 220-215.
At the center of the 681-page Medicare bill is an optional prescription drug benefit that would begin in 2006. Those who chose to join would pay monthly premiums of about $35.
For the first $2,250 in drug costs, Medicare would pay 75 percent after a $250 deductible. Then there would be a gap in coverage, with patients being solely responsible for the next $2,850 in drug costs. Once seniors had paid $3,600 out of their own pockets for drugs, Medicare would cover 95 percent of the cost of subsequent prescriptions.
For the more than 4 million retirees who have supplemental health coverage through their unions or former employers, the drug benefits they receive are more generous than the Medicare benefit. To encourage employers to maintain that coverage, the bill includes more than $71 billion in subsidies.
One of the bill’s most controversial provisions calls for traditional Medicare to begin competing against private managed care plans in six areas of the country in 2010. Seniors remaining in fee-for-service Medicare would face premium increases beyond inflation if the government’s share of their health costs was higher than that for seniors in private plans.
Drug companies would also benefit from the bill, which does very little to control drug prices. Republican sponsors beat back the attempt of some lawmakers — prodded by millions of seniors — to allow the legal importation of U.S.-made drugs from Canada. Provisions to make it easier for generic drugs to get to market were included in the bill in a somewhat weakened form.
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