Washington ? To understand why the Medicare prescription drug bill won House approval late last week by the slimmest possible margin, look at how the Kansans voted.

Republican Reps. Jim Ryun and Jerry Moran voted against it, as did Democratic Rep. Dennis Moore. Republican Rep. Todd Tiahrt voted for it but didn’t decide he would support it until the day before.

GOP Sens. Sam Brownback and Pat Roberts voted for the Senate version of the bill.

“I think we could have done much more,” Ryun said. “You’re going to have the baby boomers coming onboard an already-overburdened system. I didn’t want to leave this for our children and grandchildren.”

Market competition

Ryun and other conservatives wanted to inject more market competition into Medicare, arguing that better care would come from private insurance companies than from the government. They also worried about the cost of the bill.

He said the Budget Committee, on which he serves, had set a $400 billion ceiling on the program.

“I have some concerns it’ll quickly go beyond that,” Ryun said.

The lobbying effort by the Republican leadership and the White House was intense. President Bush and Vice President Cheney brought Ryun and several other conservatives to the White House to try to win them over.

Several lawmakers said they had never been pressured so hard to walk party lines.

“Never this intense,” said Ryun, who remained in the chamber near the heart of the action, where a bevy of GOP leaders hovered over lawmakers trying to change “no” votes to “aye.”

They succeeded in winning over two Republicans, Idaho Rep. Butch Otter and Missouri Rep. Jo Ann Emerson, which was enough for the 216-215 vote that passed the bill.

“I had the option of leaving, but I wanted to be there with my colleagues who were voting no and offer support,” Ryun said.

Tiahrt, a deputy to Majority Whip Roy Blunt of Missouri, was nearby, working with leaders to win support. Like Ryun, he is a conservative, but Tiahrt concluded the bill would improve the current system.

“We are helping low-income seniors, it’s going to be market-driven, and I think it will drive down the price of drugs in America,” Tiahrt said.

Rural worries

On the other side was Moran, who said the prescription drug benefit wouldn’t work in rural places.

“Managed care has not worked in Kansas, certainly in rural Kansas,” said Moran, who represents the western two-thirds of the state. “We have not many people and not many health care providers. It would be very difficult to deliver this prescription drug benefit for most of Kansas. We have to do something about the underlying cost of drugs. Otherwise, all we’re doing is opening up a blank check to the drug companies.”

Moran said he came under pressure, too.

“I didn’t hide, but I also didn’t stay around in the middle of the throng waiting for the arm-twisting,” Moran said, remarking that in his seven-year tenure he had never seen such intense lobbying by leadership.

“Every member who intended or even thought about voting no has had tremendous pressure applied over the last several days, but especially yesterday, and especially during the vote,” he said Saturday.

No voucher system

Moore, meanwhile, said older Americans needed a prescription drug benefit under Medicare, but this plan would not guarantee such a benefit.

“This bill, if it becomes law, would greatly modify and perhaps even destroy the Medicare system as we know it now and turn it into a voucher system within seven to 10 years,” Moore said. “Senior citizens understand the Medicare program. They want to keep it, and they don’t want it privatized.”

Kansans lauded provisions that would result in an infusion of Medicare dollars into rural areas. Roberts said the Senate bill would bring an estimated $223 million to Kansas hospitals in the next decade.

“High-quality health care comes at a very high price for facilities in rural areas that have trouble achieving the economies of scale of their larger urban counterparts,” Roberts said. “We need to ensure that the patient in Beloit, Kansas, can receive the same kind of care as a patient in New York City.”

Brownback said he was worried about the long-term cost of the program but was pleased with help for rural hospitals.