As administrators try to figure out why the Medicare Drug Card program got off to a slow start, it's clear that PR is at the center of the controversy.When the Medicare Drug Card program launched with significantly fewer participants than projected, administrators scurried to learn what went wrong. The numbers are clear: Only 500,000 Medicare beneficiaries signed up voluntarily, and another 2.3 million were automatically enrolled through their Medicare-affiliated HMO, totaling roughly half of the projected number. What isn't clear is why. But there seems to be agreement on the point that PR is at the center of the controversy. The drug-card program, a temporary measure until full Medicare drug coverage begins in 2006, allows Medicare-eligible seniors and disabled individuals to sign up for one of more than 70 discount cards; in addition, low-income seniors can receive a $600 subsidy ($1,200 for couples) to cover drug costs. News stories leading up to the program's June 1 launch focused heavily on what was portrayed as mass confusion and heavy skepticism among senior citizens. On that day, Health and Human Services (HHS) Secretary Tommy Thompson told The Wall Street Journal that seniors had been "scared away" from the program by negative publicity. But the question boils down to whether the program is too confusing or whether certain partisan groups hyped the program as confusing to keep participation rates low. A syndicated op-ed by Rep. J.D. Hayworth (R-AZ) suggested that critics had purposely spun a "confusion campaign" around the issue to discourage seniors from taking advantage of the drug cards. Others in the administration concur. "It seems Democratic [leaders] have been huge nay-sayers from the start," says Pete Jeffries, communications director of special legislative projects for House Speaker Dennis Hastert (R-IL). "The ones who fall most victim are low-income seniors. If they're scared of this, that's a total disservice." Jeffries notes that House Republicans were encouraged to lessen the confusion by hosting events, such as an Illinois forum where HHS staff walked senior citizens through the sign-up process. Indeed, proponents of the program argue that seniors who need help can easily obtain it. Calling an 800-number would connect them with a knowledgeable representative. Accessing a specially created website would allow them to compare savings across multiple cards in a particular zip code. In addition to government-sponsored campaigns, independent pharmacies also used PR firms to field seniors' questions. Christy Guth, account director at Dancie Perugini Ware Public Relations, notes that client H-E-B Grocery Company hired the Houston-based agency to handle the hundreds of questions stores got from customers. The firm trained grocery employees at each location as drug-card experts and hosted weekly senior events where information was distributed. But in addition to explaining the nuts and bolts of the program, one store also had to contend with a local politician who showed up to criticize the cards. "It shouldn't be a political issue," Guth says, adding that many low-income seniors who qualify for the $600 medication subsidy are not even aware that it is available to them. "It was difficult making sure people were getting the right information." Combatting critics Jeffries singles out liberal advocacy group Families USA as the program's most vocal critic - and he is not the only one. A week before the program's launch date, the Pharmaceutical Research and Manufacturers Association (PhRMA) held a press conference to address a Families USA report that found that the cards do not offer savings to seniors. "It's very important that people not be misled by the claims of Families USA," says Rick Smith, SVP of policy and strategic communications for PhRMA. "It saddens me when people don't enroll in any discount card because they aren't receiving the right information." Ron Pollack, executive director at Families USA, dismisses the idea that his organization's criticisms might have discouraged seniors from signing up. In fact, he says, its PR around the issue should suggest otherwise. He notes that while Families USA is indeed critical of the legislation - a "pale comparison" to the type of program that should have been created, he says - the organization has actively encouraged seniors, especially low-income seniors, to take advantage of the drug cards. "What caused the low participation is the considerable weaknesses of the new law that was passed in December," he says. "The average senior has had difficulty navigating the system," he adds. "We prepared a 13-minute video, narrated by [former CBS anchorman] Walter Cronkite, to demystify this complex legislation." Blaming the critics for the confusion would be a difficult task - all reporters had to do to see the confusion was visit the Medicare website, says Mary Mouton, president of New Orleans PR agency Mouton Media, which has worked with some of the advocacy groups. "Was it the critics or was it the reporters themselves [who were calling the program confusing]? I think the reason the stories are saying that it is complex is because it is complex," she says. Therefore, PR pros had the most success communicating a specific message to the press when they were also able to explain the intricacies of the program to reporters, Mouton notes. "The insurance industry is the most dynamic that we have," says Mouton, who has pitched clients as experts on the issue. "It can be very intimidating for someone who really has no background just to maneuver through that." Other outreach Seniors have been hearing from not only politicians and activist groups on the issue. Drug companies and others have been reaching out. PhRMA's members have been working with their more than 80,000 sales representatives to disseminate information about the program to doctors, who can then relay it to patients, says M.J. Fingland, senior director of communications for the trade group. Eli Lilly devoted one of its monthly press forums to the drug-card program. There, John Rother, director of policy and strategy for AARP, a group that championed the Medicare legislation, spoke alongside drug company representatives, who promoted additional savings they are offering to Medicare drug cardholders. Pfizer provided grant support to one-time presidential candidate Bob Dole's Medicare Modernization Campaign, a state-by-state speaking tour to promote the program. Drug-card issuers also expressed unwavering confidence in the program. "There was some initial confusion, but the seniors were able to cut through the confusion and actually evaluate whether they'd be able to receive real savings," Barrett A. Toan, CEO of Express Scripts, a pharmacy-benefit company, said in late May. The administration fueled some of the criticism. It famously turned its own publicity around the program into a PR debacle when the General Accounting Office ruled that a Medicare VNR about the discount-card program was "covert propaganda" because it portrayed a government spokesperson as a news reporter. Some might argue that the entire Medicare overhaul is a PR play in itself - a short-term election-year program for an administration that has been challenged by both rising drug prices and marked declines in the number of employers offering workers health insurance. To be fair, since seniors can purchase a drug card at any time, enrollment might continue to grow until 2006, when prescription drugs will be included with Medicare benefits. But a report from the Kaiser Family Foundation suggests that part of the reason that senior citizens have been reluctant to sign up for a discount card is that the program is temporary and savings are not guaranteed. While the administration continues to spar with critics over whether the program has unduly confused seniors - and who is to blame for that confusion - PR professionals must think one step ahead of the game to make sure their clients are heard, Mouton cautions. "The story that the system is complex is now an outdated story," she says. "The challenge is to come up with unique angles to the story that are not already out there."