The $395 billion Medicare bill passed by the House yesterday, advertised as a way to provide a long-awaited prescription drug benefit for seniors, also has become a vehicle for scores of narrower provisions tailored to benefit special interests.
Such measures, dubbed "rifle shots" for their narrowly targeted effects, are commonly attached to complex, high-profile legislation in the crunch as a way both to build support for the larger bill and to provide an avenue to passage for provisions that likely would not succeed on their own.
One two-paragraph provision tucked deeply into the 678-page Medicare bill, for instance, would provide higher Medicare payments to physicians in Alaska, the home state of Republican Sen. Ted Stevens, chairman of the Senate Appropriations Committee. It would cost the government $100 million between 2004 and 2008, according to the Congressional Budget Office.
Aides to Stevens defended the higher payments as necessary because Alaska has a high cost of living, a dire shortage of physicians and the smallest percentage of seniors in the country, at 5.7 percent of its population. As a result, seniors have trouble finding doctors who accept Medicare, which in Alaska typically covers less than 40 percent of the cost of treatment.
"What this does is it allows Alaska's seniors to have adequate access to health care," said Courtney Schikora, Stevens's spokeswoman. "This simply gives them equity."
Another provision, sought by the American Chiropractic Association, would establish four two-year pilot projects -- at least two of them in rural areas -- to determine whether Medicare should pay for more chiropractic services. Medicare currently pays only for spinal manipulation in limited cases of back injuries. The studies will examine whether diagnostic services and treatment for other conditions should be covered, as well.
The language was backed by Sen. Charles E. Grassley (R-Iowa), the lead Senate negotiator on the bill and chairman of the Senate Finance Committee. Davenport, Iowa, is home to the Palmer College of Chiropractic, a 1,600-student school that describes itself on its Web site as the "fountainhead of the profession."
Jill Gerber, a spokeswoman for Grassley, said no one from the school approached the senator for help with the provision, but plenty of Iowa chiropractors and the Association of Chiropractic Colleges did.
"A lot of seniors enjoy the benefits of chiropractic care, and Medicare covers very little on that front," she said, adding that "there's nothing in the language that says that any of these demonstration projects has to be in Iowa."
George B. McClelland, chairman of the American Chiropractic Association, said: "This is chiropractic's biggest win ever on Capitol Hill, and we have Senator Chuck Grassley to thank for it."
"Every doctor of chiropractic and chiropractic patient in Iowa and across America should know that it was Senator Grassley who took on and defeated organized medicine and other special interest lobbyists seeking to stop this day from happening," McClelland said in a statement.
Another narrowly drawn provision in the Medicare bill would benefit Saginaw Community Hospital in Saginaw, Mich., by extending an existing moratorium that prevents the hospital from being designated as an "institution for mental disease." That designation would deny Medicaid reimbursements for patients aged 21 to 65, a move that would cost the hospital as much as $100,000 a year, said an aide to a Democratic senator who pushed to include the provision in the bill.
"We asked the conferees to put it in," said the aide, who spoke on condition of anonymity. "The Saginaw hospital is the provider of last resort. It has a huge Medicaid population. . . . It only has an impact of about $100,000, but that's obviously a lot to a hospital like that. That's how much they won't lose now."
Another rifle shot would temporarily continue a reclassification of some rural counties in seven states that makes health care providers in those counties eligible for higher Medicare payment rates typically paid in larger metropolitan areas. The provision, which expires in October 2004, will help 20 rural hospitals in North Carolina, New York, Indiana, Illinois, Ohio, Texas and Vermont.
Lawmakers say the move is necessary to help rural providers compete with urban medical facilities in hiring and retaining doctors and nurses, who could possibly live within commuting distance of the better-paying hospitals. In Iredell County, N.C., for instance, many medical and other professionals commute to the Charlotte area for work, said an aide to Sen. Elizabeth Dole (R-N.C.), who fought unsuccessfully for a permanent extension. The change in payment status puts rural Iredell on a par with its more densely populated neighbors.
"There was a loophole in the law that needed to be addressed to provide adequate health care for the residents," said Brian Nick, a Dole spokesman. "While the goal is to make the reclassification permanent, temporary relief is certainly welcome, and we're happy with the result."
Hunting for narrowly targeted provisions in such a massive bill "is an interesting adventure," said Ed Haislmaier, visiting research fellow at the Heritage Foundation's Center for Health Policy Studies. "Some of us are all going through it together. We call each other up and say, 'Have you seen this?' "
Thomas Mann, a congressional scholar at the Brookings Institution, said rifle shots are especially common in annual spending bills and measures written largely by House and Senate negotiators in complicated conference committee negotiations. Even so, the Medicare bill may be home to fewer of them than most such bills, Mann said. That is because political divisions over the bill are so deep that a pet provision here or there would be unlikely to lure members across the divide, he said.
"Too many members are too committed by virtue of the party and ideology to be bought off so easily," Mann said.
Sometimes narrowly tailored provisions are notable for their absence. The Senate version of the bill, for instance, included a measure that would have limited Congress's government-provided prescription drug care benefit so that it would be no more generous than the benefit provided under the Medicare legislation. House and Senate negotiators took that out of the final bill.