Shades of Blue: Medicare, Part D: What Were They Thinking?
Article in the Nogales International
February, 2006
Lois Kolesar, Sonoita, AZ
The 2003 Medicare Prescription Drug Improvement and Modernization Act was hailed as a great enhancement to Medicare that would help older Americans with prescription drug costs.
Last fall after the unusually thick "2006 Medicare and You" booklet arrived, I tried to understand how the prescription drug program, Part D, worked. I wanted to help my ninety-three-year-old mother choose among the forty-four plans available in our area. My mother has been spending between $350 and $600 per month on prescriptions for the last few years. I hoped she would be able to save money. I realized that she would have to pay insurance premiums and a $250 deductible, as well as deal with the "doughnut hole," a gap in coverage between $2250 and $3600 in prescription costs.
To choose a plan I considered two things: the cost of the premiums and co-pays, and the covered drugs. Each plan has its own drug formulary, a list of approved drugs which are classified into three or four tiers. If you take a drug that is not on your plan's formulary, you pay the entire cost, and your payments are not counted towards your deductible or total prescription costs.
The "Plan Finder" on the Medicare web site allows you to compare what your cost will be on each plan available in your area. However, the costs quoted are based on generic drugs. If a generic is available and you are using a brand name drug, you are encouraged to ask your doctor to change your prescription. When I started searching formularies for my mother's prescription drugs, I ran into some difficulty. Some of her brand name drugs have $55 co-pays or are not on a formulary. My mother appears to be tolerating her present drug regimen and her condition has remained stable for more than a year, so we are reluctant to change her brand name drugs to generic ones; however, if my mother continues with her current prescriptions, she will save less than $500 per year.
My aunt is an eighty-three-year-old retired nurse who lives in Pennsylvania. She asked me to help her because she couldn't understand the information she received from Medicare. When I checked the Medicare web site, I was surprised to see that the insurance premiums are higher in Pennsylvania than they are here for the same plans. My aunt uses only one prescription. It costs her $62 a month. If she buys the cheapest insurance plan in her area, she will pay $196 a year in premiums. After she pays the $250 deductible, the co-pay for her medicine will be $60.00 a month. Even though that would cost her $180 more a year, she's considering it because if she does not sign up for a plan by May 15th of this year, an extra one per cent will be added to the premium she will need to pay for Part D insurance in the future for each month she delays.
Thirty-five million Americans, most over sixty-five years old, are now covered by Medicare Part A, the hospitalization insurance. Most of them also elect to enroll in Part B which covers doctor visits, outpatient services and laboratory tests. Fees for all eligible services are set by Medicare. Generally, considering the huge size of the program, it runs smoothly. Why then wasn't it used as a model for the prescription drug program, Part D? Why isn't there one plan with fees set and administered by the government instead of 44 insurance company plans with different premiums, co-pays and formularies? Why is the importation of drugs and the negotiation of prices banned? Why is a program which is meant to benefit the oldest, sickest and most fragile segment of the population so complicated and difficult to understand? Who developed this plan and who benefits most from it?
Usually when laws are being formulated in the US Congress, many experts are consulted to help our legislators who, understandably, are not knowledgeable about every area involved in every law. Frequently the corporations or industries that will be most affected by a law send their own experts to discuss the issues involved. Invariably these experts help develop a law that will be advantageous to their bosses. It seems to me that the Republican Congress allowed such lobbyists to write the 2003 Medicare Act and that the insurance industry and pharmaceutical companies, rather than senior citizens and the disabled, will be the biggest beneficiaries.
