On December 8, 2003 Bush signed into law the Medicare Act of 2003, calling it "the greatest advance in health care coverage for America's seniors since the founding of Medicare." Promising prescription drug coverage, "better choices," and better access to diagnostic medicine, Bush concluded " Our nation has the best health care system in the world. And we want our seniors to share in the benefits of that system.... And today, by reforming and modernizing this vital program, we are honoring the commitments of Medicare to all our seniors."
Yet a Washington Post/ABC News poll found that 47% of seniors surveyed disapproved of the bill, while only 25% approved. And although proponents have suggested that the bill will gain in popularity once its benefits are better understood, the Post/ABC poll found that those who most closely followed reports concerning the legislation were also the most likely to disapprove of the so-called reforms.
Calling the issue a "hand grenade" that could explode "in the Republicans' lap," Steven Moore of the conservative Club for Growth cited a poll by his organization that showed 43% of seniors supporting the bill, but only half of that number supporting it once they learned that premiums would rise for some participants. A poll by the Annenberg Public Policy Center found the population at large evenly split, but 49% of seniors opposing the bill while only 33% supported it.
The program, which will cost an estimated $400 billion over the first 10 years alone, was christened "Trojan Horse" legislation by commentators and members of Congress.
Writing in the Woonsocket Call, Rhode Island congressmen Patrick J. Kennedy and James Langevin referred to the Medicare law as a sham.
... [T]he report is a Trojan Horse that looks like reform and looks like a benefit, but actually contains many provisions that threaten one of the most successful programs in our history.
The bill attempts to privatize Medicare, and at the same time, provides a poor benefit that is actually worse than the original House bill that we both opposed.
It contains an unreasonable deductible, makes no effort at lowering drug costs, has no guaranteed minimum drug benefit, and contains a huge doughnut hole that leaves many seniors without coverage.
Analyses by Consumers Union and the Center for Budget and Policy Priorities(CBPP) found that numerous provisions of the Medicare bill "harm Medicare beneficiaries and threaten the program’s long-term viability."
|Level of funding||The bill is underfunded. The designated $400 billion over 10 years covers only 22 percent of the anticipated drug costs, leaving consumers to foot the rest of the bill.|
|Covered drugs||Private Pharmacy Benefit Managers (PBMs) can pick what drugs are covered under the plan, with no public accountability requirement. Under the new law they are allowed to cover as few as two drugs in each "therapeutic class." Medicaid recipients who need a drug that is not covered by their private plan will lose coverage unless they file an appeal and are granted an exception. This process will not be a viable alternative for many elderly with disabilities or cognitive impairments. Moreover, the new law prohibits physicians from filing appeals on behalf of their patients -- a departure from current medical practice.|
|Competition||The bill requires competition between private health plans and Medicare in up to six metro areas but does not require the private plans to demonstrate cost savings that result from efficiency. Instead, the proposal provides additional subsidies to these private plans and allows them to benefit financially by choosing to enroll the healthiest members.
The idea of introducing more competition into Medicare through the expanded use of private plans has been presented as a "reform" that would help limit rising Medicare costs. But the legislation actually increases Medicare costs by overpaying private plans in order to induce more beneficiaries to enroll in them. The legislation's supporters allowed their belief in the goal of privatizing more of Medicare to eliminate the stated goal of using "competition" to limit the rate of growth in Medicare costs.
|Prohibition on negotiating prices for drugs||The bill prohibits the government from negotiating deep prescription drug discounts for consumers, which means that the average Medicare participant will pay more out-of-pocket for drugs in 2007 when the benefit begins, then they currently pay now without the so-called "benefit." Assuming current trends in increasing drug costs, the average Medicare recipient in 2003 who spends $2,318 a year for drugs without prescription drug coverage will pay $2,911 out-of-pocket in four years under the plan.|
|Prescription drug coverage||
Private plans will likely be able to offer drug coverage in the coverage hole and lower beneficiary cost-sharing (as well as extra benefits in other areas) because of the billions in federal subsidies they will receive under the bill. The legislation thus tilts the playing field in favor of the private managed care plans. Beneficiaries who would otherwise want to remain in traditional Medicare so they can retain their choice of doctors are likely to switch to managed care plans in order receive the broader drug coverage. The nonpartisan Congressional Budget Office estimates that 2.7 million retired people will lose employer-sponsored drug coverage because of the Medicare benefit.
|Demonstration projects for premium support||The bill creates so-called demonstration projects in six urban areas in which federal funds will be used to reduce premiums on private insurance for seniors as an alternative to Medicare. The premium support concept was developed in the 90s by Henry Aaron of the Brookings Institution and Bob Reischauer of the Urban Institute. Aaron and Reischauer warn that unless the it is regulated, premium support could lead to private insurance companies enrolling only healthier seniors, while the less healthy members of the population remain in traditional Medicare. Over time that could result in increased premiums for beneficiaries in the traditional Medicare program. The regulatory safeguards that Aaron and Reischauer recommend are not part of the current legislation.|
|Health savings accounts||The bill establishes accounts to which tax-deductible deposits can be made, and from which tax-free withdrawals can be made as long as the funds are used for medical expenses. This is the first time that tax-advantaged savings have offered a tax break when funds are both deposited and withdrawn. If political pressure leads to this kind of tax treatment being applied to other types of savings and retirement accounts it could produce even greater increases in federal deficits.
The health savings accounts could also undermine comprehensive health insurance if large numbers of healthy, affluent opt out of employer-based coverage in favor of the new programs. Studies by the RAND Institute and the American Academy of Actuaries referenced by the CBPP suggest that premiums for employer-based coverage could double.
|Effect on those covered by Medicare and Medicaid||Currently in most states, low-income people who qualify for Medicaid received prescription drugs free, or pay $1 or $2 per month per prescription. Under the new law, Medicaid recipients under the poverty line will pay $3 per month per brand name prescription, and $1 per month per generic prescription. Those above the poverty line will pay $5 and $2and the charges will increase at the same rate that drug costs rise, which, according to the CBO is at last 10% per year. Unfortunately, individuals in this category generally live on fixed incomes, such as Social Security payments, which are adjusted for inflation -- currently 2 or 3 percent a year. So over time prescriptions drugs may become unaffordable for people slightly above the poverty line who require a large number of prescriptions.|
|Cost containment||The new law requires the executive branch of the federal government to estimate the portion of Medicare costs that will be financed with general revenues (e.g. income taxes as contrasted to payroll taxes). When that portion exceeds 45%, the President is required to submit legislation to modify Medicare programs to bring the share funded by general revenues back to 45%.
Medicare costs for hospital care are funded from payroll taxes, not general revenue. Outpatient services and prescription drug Medicare costs are funded from general revenue. Advances in medical care are enabling shorter hospital stays, which tends to increase costs of outpatient care and prescription drugs. So ironically, advances in medical science may lead over time to drastic cuts in Medicare, as the share of costs funded from general revenue continues to increase. Cuts may include lower provider reimbursement rates, reductions in benefits, or higher premiums and other forms of cost-sharing.
This provision gives preferential treatment to income tax, as contrasted to payroll tax, which in turn favors higher income people. (In general if you earn more your income tax rate increases, while payroll taxes take a larger percentage of the income of low-income people than high-income people.)
|Effect on states||The House version of the bill would have assumed responsibility from the states for drug coverage to low-income beneficiaries. The final legislation contains no such provision, and leaves the states responsible for 75% of the drug costs for low-income elderly and disabled people that they would have carried under Medicaid. Without relief such as that contained in the House bill states are likely to make deep cuts in Medicaid as drug costs increase and baby boomers retire. The legislation compounds the problem by imposing new costs on the states, such as the costs of determining eligibility for the new Medicare low-income drug subsidies.|
Dismissing administration suggestions that the law was the product of a bipartisan effort, the Rhode Island representatives decried an" overreach by conservative Republicans who have always fought against Medicare, and it represents their last grasp at the Newt Gingrich era effort to see Medicare 'wither on the vine.'" Their chief objection was that the funds for so-called "premium support" -- essentially government subsidies to HMOs -- could have been deployed in other ways: improving physician reimbursement rates, protecting prescription drug coverage for retirees, or otherwise enhancing Medicare.
Suggesting that Rhode Island's experience provides insight into how the privatization of Medicare might work nationwide, Kennedy and Langevin noted that more than one Medicare managed care plan in Rhode Island dropped beneficiaries. In 1999 Harvard Pilgrim discontinued its Medicare managed care program, leaving 150,000 citizens of Rhode Island scrambling for new coverage.
Moreover, Kennedy and Langevin warned that traditional Medicare costs could increase by up to 88% for some seniors. And 9000 seniors now covered by employer plans are expected to lose coverage, because the new bill provides smaller subsidies to employer-sponsored retiree plans than to other private plans. 28,000 seniors in Rhode Island who now receive benefits from Medicare and Medicaid are expected to have to pay more for prescription drugs.
"Beware the legislation that professes to give seniors a meager drug benefit in two years, but destroys Medicare in five."
-- Reps. Patrick J. Kennedy and James Langevin of Rhode Island.
Reporter Bill Gallagher called the bill the "Pharmaceutical and Insurance Industries Enhancement Act," adding "I refuse to call it Medicare reform." Health care industry analysts at Atlantic Information Services apparently agree. "PBMs [pharmaceutical benefit managers] and the drug industry are pleased with the bill because it calls for the drug benefit to be administered by PBMs. This opens up a large new market for PBMs, and privatization is not expected to result in drastically reduced drug prices that might have occurred under a government-controlled purchasing plan," they wrote in their November 21 issue of the Drug Cost Management Report.
Rep. Marion Berry of Arkansas, the only licensed pharmacist in Congress, was quick to criticize the bill for not allowing the government to negotiate drug prices directly with manufacturers.
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The Bush administration has made much of the claim that a Republican-controlled Congress and executive branch have succeeded in providing prescription drug coverage for Medicare recipients, where the Clinton administration failed. One of the organizations lobbying against prescription drug coverage in 1999 was Citizens for Better Medicare (CBM). Notably the group sponsored television commercials featuring an arthritic bowler named "Flo" who warned Congress to stay out of her medicine cabinet. During the first half of 1999 CBM contributed more than $1 million to federal candidates, with more than two-thirds going to Republicans. According to the Center for Responsive Politics, CBM was founded by the Pharmaceutical Research and Manufacturers of America (an industry trade group representing more than 100 companies), and the Healthcare Leadership Council (whose membership includes 50 insurance companies, health care providers, and hospitals).
The Center for Responsive Politics reported that the lawmakers who voted for the medicare legislation "have raised an average of roughly twice as much since 1999 from individuals and PACs associated with health insurers, HMOs and pharmaceutical manufacturers as those who voted against the bill." For instance, pharmaceutical manufacturers have given an average of more than $28,000 to each of the 204 Republicans who supported the bill, while giving approximately $8,000 to the Republicans who opposed it. In the House, the biggest recipient of contributions from pharmaceutical companies is Rep. Mike Ferguson, Republican of New Jersey, who has received nearly $275,000 since 1999. In the Senate, Orrin Hatch leads the pack, with more than $300,000 since 1999. In the House, the biggest recipient of contributions from HMOS and insurance companies is Rep. Nancy Johnson, Republican of Connecticut. Of interest in the current Democratic presidential contest is that Sen. Joe Lieberman is the leading Senate recipient of contributions from HMOs. Sen. Max Baucus, Democrat of Montana, is the leading Senate recipient of contributions from insurance companies. Baucus was one of only two Democrats to participate in the joint House-Senate negotiations over the final form of the medicare bill.
Michigan Representative Nick Smith, a fiscally conservative Republican who voted against the Medicare bill, charged that unidentified lawmakers and business interests had "made offers of extensive financial campaign support" for Smith's son's campaign if Smith would vote for the bill. While refusing to say who made the offers, Smith did tell the Associated Press that he was pressured by Health and Human Services Secretary Tommy G. Thompson and House Speaker J. Dennis Hastert. Smith said he did not think the incident met the legal definition of bribery, although the AP noted "It is illegal to directly or indirectly promise something of value to a public official to influence a vote."
The alleged bribe attempt was first reported by syndicated columnist Robert Novak on November 27, who mentioned a figure of $100,000. The head of Smith's congressional staff, Kurt Schmautz, confirmed Novak's report as "basically accurate." The Democratic National Committee and the Center for Responsibility and Ethics in Washington sent separate letters to the Justice Department requesting an inquiry. The Justice Department is reportedly "reviewing" the requests. Charles Lewis of the Center for Public Integrity termed the incident "a revealing vignette." "It's a window into how politics works, and how closely tethered contributors are to their respective parties, and how they work hand in hand in getting their way legislatively," he commented to USA Today.
Senate Majority Leader Bill Frist and members of his family are likely to benefit directly from the new Medicare law. Frist's father co-founded Health Corporation of America (HCA), the nation's largest hospital chain. Frist's older brother served as HCA's chairman and CEO for a number of years. Forbes magazine estimated Sen. Frist's personal fortune at $1.7 billion, most of it in HCA stock. During his 1994 campaign, Frist's ownership of HCA stock was a major issue. Democratic candidates sought to take advantage of the issue, but voters were not interested. Frist has dismissed suggestions that his family history and investments might influence his judgement on health care issues, noting that his HCA stock is in a blind trust. An investigation by Nashville Scene discovered that the trust is not "blind," however:
- The trustees of Frist's investments are close associates from Nashville.
- At Frist's direction a clause was inserted in otherwise standard legal language creating the trusts, stating the trustee did not have to diversify the trust's assets. Nashville Scene's investigators assume that this is because of the preponderance of HCA stock in the trust. "One way to read this is that Frist is actually saying in this provision, 'Hey, I want to retain control of my HCA stock,'" Pamela D. Bridgewater, of American University's Washington College of Law suggested.
- Frist reports the trust's income in his annual financial disclosure to the Office of the Secretary of the Senate.
"A significant portion of HCA's business is tied to Medicare." Ira Loss, a health care analyst at Washington Analysis told the Nashville Scene. "That's one of many reasons why HCA has a pretty active voice on Capitol Hill. As well, not much can get done now in terms of legislation without Frist agreeing to it. He's the one who can engineer the deals."
The American Association of Republican Politicians
Critics and proponents of the bill have both compared the political context to the circumstances surrounding the attempted expansion of Medicare under Ronald Reagan. Reagan signed a bill that added catastrophic health-care and prescription drug coverage to Medicare benefits. Like the current law, the Reagan bill was hailed by supporters as a great achievement for the administration's social policies. Like the current law, the Reagan bill had the support of the AARP. But the Reagan bill was repealed in 1989 in response to protests from seniors who objected to the added plan premiums (which they labeled a "surtax.").
The Reagan plan was financed entirely by premiums from plan participants, however, while the current plan is voluntary, and includes substantial government funding.
Ohio Congressman Michael Oxley, Republican of Ohio, told the Findlay, OH Courier that AARP support for the Medicare bill was "final impetus which got the bill across the goal line." (Oxley added that $250,000 had been secured for the Center for Terrorism Preparedness at the University of Findlay, in his home district.) Now known only by what was formerly an acronym for the American Association of Retired Persons, and recently dubbed the American Association of Republican Politicians by New York Times cartoonist Jeff Danziger, AARP's support has puzzled some observers, because the plan seems so inimical to the interests its members. In commentary posted on TomPaine.com, Yale School of Management professor Ted Marmor asks, "Why is the AARP supplying political cover for a bad bill that a majority of their constituents will surely hate? And why is it working so hard to disguise what is actually going on through the massive publicity campaign it has already financed?"
The answer, says Marmor, can be found by looking at the history of AARP. The organization began as a cooperative that purchased health and life insurance. While not involved in the creation of Medicare, it benefited enormously by acting as a broker for health insurance that supplemented Medicare. So while AARP dues are low, because it has profited from its insurance brokering, its commercial interests can conflict with its membership's best interests.
AARP supported the Reagan-era attempt at Medicare reform because the so-called "catastrophic" health coverage would have benefited its membership. The plan left seniors with the entire cost of financing the benefits, however, and AARP was surprised when the legislation was repealed barely a year after it was enacted.
With the current legislation the situation is reversed. Whereas formerly AARP demonstrated poor political judgment while supporting goals that were in the interests of its members, now it has acted in such a way as to regain political clout, but while supporting legislation inimical to its members' interests. Some observers have gone so far as to voice the suspicion that the current AARP president, William Novelli, a public-relations executive who once wrote the foreword for a book by Newt Gingrich, is a covert Republican party operative. Whether one believes that suggestion or not, it seems that Novelli and the AARP board took action based on some assumptions that are dubious at best. AARP assumed that:
- 2003 was the last chance (ever) for passing a Medicare prescription drug plan.
- Democrats will not have a majority in Congress for the foreseeable future.
Ted Marmor suggests that, contrary to AARP's assumptions, "Had this bill failed, the best guess is that Americans would be debating prescription coverage in the summer of 2004—and if nothing happened in 2004, in 2005."
USA Today reported that AARP received more than $600 million in insurance-related income over the last four years, amounting to 30% of its total income, or an amount equal to that it receives from membership dues. Much of that business is Medigap insurance -- policies covering costs not covered by Medicare. In 1998 United Health Group signed a 10-year contract with AARP worth $3.7 billion to provide health coverage to its members. AARP also made $10.8 million last year selling its membership list to insurance companies. Harvard University's David Himmelstein, a proponent of national health insurance, observed "The same folks who are in the Medigap market would want to get into this, and the best route in is through the AARP membership list. It's almost unimaginable that [AARP] wouldn't stand to gain."
This is not the first time AARP has been accused of having a conflict of interest. Sen. Alan Simpson of Wyoming convened hearings in 1995 to investigate whether AARP was abusing its nonprofit status. In addition to insurance the group's business ventures include selling travel packages and credit cards to members. "If there was a sublime definition of conflict of interest, it would be AARP from morning to night," Simpson said. As a result of Simpson's hearings, AARP was force to back back taxes on its business earnings.
As of November 26, 2003 the AARP's Novelli reported that between 10,000 and 15,000 members had quit in protest of the organization's support for the Medicare bill. Leading a demonstration of about 40 people in Boston on November 24, Isaac Ben Ezra, president of the Massachusetts Senior Action Council, told the Associated Press that the bill destroyed "one of the most successful programs in the history of this country." "Shame, AARP," he added.
"I am absolutely convinced that on this issue AARP doesn't speak for their membership," said Edward Coyle, executive director of the Alliance for Retired Americans, which represents more than 3 million retirees. "It's a firestorm out there."
"The more we thought about the Republican plan -- the more we thought about it, the angrier we got and we felt the AARP was really selling us out," 77-year-old Sam Oser of West Palm Beach, FL, said. He organized a protest in his retirement community and burned his AARP card. Julia Kayser, 76, of Easthampton, N.Y., who is the president of an AARP chapter, said that she was encouraging seniors at a local center where she volunteers to quit the AARP. "A lot of people will not renew their membership when it comes due," she said. Bruce Livingston, executive director of Senior Action Network in the San Francisco area agreed. "We don't think AARP in the least represents seniors on this issue. We're going to encourage people to quit. This is just the beginning."
Cannons to the Right of Them
Recapping the political logic that passage of the Medicare bill shows that Bush can "get things done," that there is indeed compassion in his conservatism, the Economist suggested recently, "But turkeys, no less than slimmer poultry, eventually come home to roost." Noting that the economic impact of the bill will not be apparent until well after the election, since most provisions do not take effect until 2006, the Economist warns that "this hotchpotch of compromises provides neither a sensible drug benefit nor any real reform of the Medicare programme."
The plan's lack of popularity, especially among seniors, and especially as they learn more about what the program entails, may be one reason that Republicans ensured that most provisions do not take effect until 2006. But the real debate may be less about aspects of the program itself, and more, as conservatives have suggested, about lack of fiscal responsibility. The $400 billion figure commonly associated with the law refers only to program costs over the next ten years. The nonpartisan CBO has estimated that as baby-boomers start to retire, costs could reach $20 trillion over twenty years.
For fiscal conservatives of every political stripe, Bush was already sounding hypocritical when he called for "budget discipline" having overseen an 18% increase in non-defense discretionary spending. But as the Economist noted, "Post-Medicare 'reform', his rhetoric is a sham. When Americans see the consequences of the red ink and start to care again about the budget, the Republicans could pay a high political price."
Not surprisingly, then, some of the strongest criticism of the Medicare bill has come from conservatives. The editorial page of the December 1 Wall Street Journal referred to the bill as a "giveaway" and a "fiasco"
Republicans are bragging that by giving seniors a vast new entitlement they will sweep to victory in 2004. But the price of that "victory" has those of us who believe in limited government wondering what difference there is between the two parties.
Former House majority leader Richard Armey, Republican of Texas, wrote the Wall Street Journal that "the conservative, free-market base in America is rightly in revolt over this bill" and that "conservatives would be smart, and right, to reject it." Some conservative members of Congress, including Senators Trent Lott of Mississippi and Don Nickles of Oklahoma did.
The Medicare bill brought to the surface concerns that had been present among conservative leaders for some time. As Stephen Moore of the Club for Growth observed to the Washington Post, "In the last three years we've had the biggest farm bill, the biggest education bill, the biggest foreign aid bill and now the biggest health care bill in 30 years.... There's now not any pretense that Bush is committed to smaller government." Together the spending not including the Medicare bill amounts to a 23.7% increase since Bush took office. Brian Riedl of the Heritage Foundation, which boasts such conservative icons as Reagan Attorney General Ed Meese among its members, calculated that federal spending per household is at a 60-year high. "The president isn't showing leadership," Riedl complained to the Post "Conservatives are angry."
Some conservatives suggested that Bush's support for other elements of the conservative agenda has bought some flexibility, and that the concerns about the Medicare bill voiced by conservative intellectuals do not represent political danger at this point. But the same observers warned that conservative discontent could grow if increases in spending and deficits begin to affect interest rates. Spending excesses are already limiting Bush's policy options. Conservative economist Bruce Bartlett of the National Center for Policy Analysis noted, "the budgetary situation is getting so off track that you simply can't propose any more tax cuts without looking like a complete idiot."
In an indication that the administration took the conservatives' concerns seriously, a number of conservative economists were invited to the White House in early December to voice their opinions. Deputy director of the White House budget office, Joel Kaplan, presented an analysis showing that when homeland security and defense were excluded, spending was actually falling. Kaplan reluctantly admitted, however, that his figures did not include any of the so-called "emergency" supplemental spending bills Bush had requested each year. "I nearly laughed out loud," Brian Riedl told the Post. In contrast to the White House figures, Riedl estimated that $164 billion of $296 billion in new spending over the last two years, or 55%, is not related to defense or homeland security. This includes a 65% increase in spending for education, and an 85% increase in unemployment benefits. "It's really an across-the-board thing," Riedl. For the first time since World War II, federal spending per household exceeds $20,000, which is an increase of $4,000 in the past four years. Federal spending as a percentage of gross national product, which declined during the Clinton administration, is back up to 20%.
Speaking recently to the Washington Post, Robert Borosage of the Campaign for America's Future held Senate majority leader Tom Daschle responsible for the Democrats' inability to sustain a filibuster in the Senate, and for the defections of John Breaux of Louisiana, and Max Baucus of Montana, who voted with Republicans for the Medicare bill. "There's clearly an absence of forceful leadership at the top of the Senate," he said. "In the Senate we saw the difference between the other side's discipline and our lack of it, and I think Democrats are disappointed in the extreme." In the House, Minority Leader Nancy Pelosi held the Democrats together so well that Republicans were forced to make history by flouting the rule under which roll call votes are allowed 15 minutes, instead leaving the vote open for three hours while they pressured undecided Republican members.
Senator Edward Kennedy of Massachusetts, after lending his support to the bill's genesis, ended up denouncing the provisions granting subsidies to HMOs and other insurers as "obscene." Kennedy and others noted that new rules contained in the bill would guarantee that private plans would not be paid less than Medicare pays for patients in its fee-for service program. In doing so, critics suggested, proponents of privatization were implicitly retreating from the assertion that private plans would be more efficient (and less expensive) than those provided by the government. Moreover, the bill establishes a $12 billion fund to encourage private health care providers to offer plans in parts of the country where they are currently scarce. Health economist Marilyn Moon observed "It is very ironic.... To increase participation in private plans, we are going to overpay them for the foreseeable future."
James A. Thurber, a political science scholar at American University, suggests, "These interest groups and some lawmakers may already be thinking there will be more Republicans in the Senate and the House next Congress and Bush will be reelected. And they think this is the best they're going to get." Laura Nichols of the Center for American Progress put a positive spin on the issue. "Sometimes it takes a big fight like this to bring people around," she said. "I think we've accumulated enough years under a conservative government that people are finally beginning to understand the difference and what it means. That's the plus side.... Hopefully there's enough anger and dissatisfaction out there. We may have the makings of a real movement."
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Krugman, Paul "AARP Gone Astray" New York Times 21 Nov. 2003
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"Money and Medicare" Center for Responsive Politics 24 Nov. 2003.
"Drug War: Citizens for Better Medicare and the Prescription Drug Debate" Center for Responsive Politics
27 Sep. 1999
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Durbin, Dee-Ann "Michigan Congressman's Charge May Spark Inquiry" Associated Press. 6 Dec. 2003
Noah, Timothy "Who Tried To Bribe Rep. Smith?" Slate 1 Dec. 2003
de Rugy, Veronique and Tad DeHaven "On Spending, Bush Is No Reagan" Cato Institute. 1 Apr. 2003
"The biggest turkey of all?" Economist 27 Nov. 2003
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Marmor, Ted "A Terrible Purchase" TomPaine.com 26 Nov. 2003
Von Drehle, David "For Democrats, A Wake-Up Call" Washington Post 26 Nov. 2003
Goldstein, Amy "Medicare Bill Would Enrich Companies" Washington Post 24 Nov. 2003
Stern, Willy "Bill Frist's Built-in Conflict" Nashville Scene 10 Jul. 2003
Conason, Joe "The 'efficiency' that will bankrupt us" Salon.com 24 Nov. 2003
Drinkard, Jim and William M. Welch "AARP accused of conflict of interest Group stands to profit from Medicare bill" USA Today 21 Nov. 2003
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Park, Edwin, et al. The Troubling Medicare Legislation CBPP. 8 Dec. 2003
"Social Security Breakout" Wall Street Journal. 1 Dec. 2003
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