The reported tentative congressional agreement to provide something like a drug benefit under Medicare while driving seniors into less stable, higher-cost care is no agreement at all. In their desperation to get a Medicare package, Senate negotiators are giving into the House on details of the bill they crafted that will attack the foundation of the health-care system for the elderly: that it is accessible to all who qualify.

Under the agreement, a beneficiary would pay 25 percent of drug costs from $275 to $2,200 a year, then get nothing until the beneficiary’s cost rose to $3,600, when almost all the cost would be covered. The gap between $2,200 and $3,600 is called “the doughnut hole,” and while it existed in both House and Senate plans it has grown larger in the conference to reconcile the two versions of the bill. Previously, Congress was working to close the hole so seniors with substantial drug bills weren’t stuck with large bills. As the agreement stands, this is a poor benefit, though an understandable one given Medicare’s shaky finances.

Much worse, however, is a provision for premium support. Premium supports pay a set level of an average cost for a region’s Medicare and private coverage, with the beneficiary either paying more for more extensive coverage or saving for cheaper coverage. After 2010, under the tentative deal in Congress, Medicare beneficiaries would have premium supports for private insurers that submit bids for coverage. But the experience with similar arrangements should concern Congress. The Federal Employees Health Benefits Plan, for instance, has had half its insurers drop out in the last five years. And the private plans, through their advertising and marketing, tend to attract healthier beneficiaries, which would leave the sicker to drive up costs in Medicare.

And, says Families USA, private Medicare+Choice plans in 2002 were about 5 percent more expensive than average expenditures in traditional Medicare. This was true of all private plans, whether HMOs, PPOs, and private fee-for-service plans, according to the consumer organization. There is no good reason for Congress to push seniors into a less stable, more expensive plans. There is no good reason for Congress to push them into plans that inadequately serve the frail elderly, as the Medicare Payment Advisory Commission has warned.

A letter to the conference, signed by 41 senators including Olympia Snowe, states clearly what is required: drop premium support, include federal fallback drug coverage in the absence of private plans, strengthen incentives for employers to retain existing retiree drug coverage and speed up a generic drug approval process, among them. These changes would turn the mess in conference into real reform.

House and Senate conferees have been playing chicken over these issues since they passed their respective reforms. The House bill won 216-215, and their conferees since then have warned the Senate that any move to make the final bill more like the Senate’s would doom it in the House. It is time for Senate Republicans to appeal to House Democrats, pick up the needed votes with a much strengthened guarantee of full coverage and stop trying to placate an ideology that would end one of the most successful health care programs in the nation.