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The 2003 Medicare expansion shows how far the Bush-era GOP was from fiscal conservatism.


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Since Republicans lost control of both houses of Congress in 2006, and certainly since John McCain lost to Barack Obama in 2008, the proposition that Republicans have abandoned their conservative principles has become conservative dogma.

Perhaps the most prominent example of big-government Republicanism during the Bush years was the passage of the Medicare Prescription Drug, Improvement, and Modernization Act (MMA). On December 8, 2003, President George W. Bush signed the MMA, which expanded Medicare Advantage and created a Medicare prescription-drug plan (Medicare Part D), into law. Taking all the provisions together, it was the largest-ever expansion of Medicare. This year marks the tenth anniversary of the bill’s passage, which was one of the worst moments of the Bush administration and the Republican congressional majorities.

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President Bush had championed reforming Medicare during the 2000 campaign and throughout the early stages of his presidency. Bush, the nation’s most prominent “compassionate conservative,” called Medicare “one of the greatest, most compassionate legislative achievements of the 20th century.” Myron Magnet, writing in the Wall Street Journal in 1999, explained that compassionate-conservative politicians “don’t see their main goal as saving money” but as encouraging self-empowerment. Indeed, at a September 2003 press conference, a reporter asked President Bush whether he had “any qualms about spending $400 billion on Medicare prescription drugs.” Bush answered, “No, I don’t. I think it’s the right thing to do.”

In addition to his ideological purposes, Bush had personal reasons for reforming Medicare. Some political commentators speculated that George H. W. Bush’s failed reelection bid convinced his son to push for a sweeping domestic-policy accomplishment. “The first President Bush was pilloried for ignoring needs on the domestic front,” Jake Tapper reported at the time. “His son is determined to not allow that perception to cost him re-election.” The first Bush’s popularity skyrocketed after the Gulf War, but he became increasingly unpopular as the economy floundered. The younger Bush needed a substantial domestic-policy achievement to avoid his father’s electoral fate. Norman Ornstein of the American Enterprise Institute called MMA a “huge trophy” for the Bush reelection team, and Senator Chuck Hagel (R., Neb.) commented, “The fact is there was an awful lot riding on this bill politically — for the president and for the Republican party.”

That is not to say, though, that Bush was the law’s only shepherd. Without Republican congressional leaders, such as Senate Majority Leader Bill Frist (R., Tenn.) and Speaker of the House Dennis Hastert (R., Ill.), the bill would never have passed. Republicans, who had controlled the House of Representatives since 1995, kept the topic of a Medicare prescription-drug plan on the table for several years, as they passed two bills earlier in the Bush administration; the Senate simply ignored them. And so the idea lay dormant until Senators Chuck Grassley (R., Iowa) and Max Baucus (D., Mont.), the authors of the original Senate bill, took up the cause.

At first, many Senate Democrats opposed the Grassley/Baucus proposal, but that changed when Senator Ted Kennedy (D., Mass.) announced his support forthe plan. “This is not the bill we would have written,” he explained, “but to finally get something moving is a major step forward.” Soon after Kennedy’s announcement, Tom Daschle (D., S.D.), the Senate minority leader, also set aside his opposition. The Grassley-Baucus plan passed the Senate on June 27, 2003, by a vote of 76–21.

When it came time for a conference with the Senate, Republican congressman Bill Thomas (R., Calif.), the chairman of the conference, excluded all Democratic senators except Baucus and John Breaux of Louisiana, saying they were the only two Democrats with whom he could negotiate. The conference was slow to reach an agreement. The two sides had trouble agreeing on premium support, a policy that is still being debated. In November 2003, Frist and Hastert resolved this dispute by dropping the premium-support proposal.

After supporting the initial version, Kennedy and Daschle tried to stop the conference bill. Kennedy’s filibuster attempt failed, and Daschle’s claims that the bill violated budget rules did not gain traction. The Senate passed the bill on November 25 by a 54–44 margin.

By that point, the House had already passed it. The House began to vote on the bill at 3:01 a.m. on Saturday, November 22, 2003; the vote was supposed to last 15 minutes. Within the first few moments, 17 House Republicans voted “no,” and by 3:48 a.m., about 30 minutes after voting was supposed to end, 218 House members had voted “no” and 215 had voted in favor. The bill seemed destined to fail. But Republican House leadership started to pressure Republicans who had voted against the bill to change their votes. Speaker Hastert “openly strong-armed” Republicans, which is, according to Ornstein, “a gross violation of the normal role of the speaker.” Pat Toomey (R., Pa.) had organized a group of twelve conservative Republican congressmen who opposed the bill, and in the initial stages they all voted against the bill. By the end of the vote, eight of the twelve had switched their votes.



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