PART "D" FIASCO

Opinion:   Editor, www.seniorark.com      Updated November 2, 2007

Congress and the President had a golden opportunity to make a master stroke for Seniors. Imagine, prescription coverage for all Medicare recipients! An older American could rise up each day with one less worry: at least the meds would be covered. Finally we would have caught up with the rest of the civilized world in providing total care for at least one portion of our population. The lead weight that hung over the heads of Seniors for so long would disappear. Life-saving drugs could now be had by all.  For some it would mean funds are now there to buy more nutritious foods. For others, the thermostat could go up a few degrees in the winter. For still more it would mean the ability to gas up the car, or meet the apartment rent without fear. Perhaps the aging pet could see the vet for the first time in years. Just having the weight of fear removed would add spring to the step, and hope for the future. Seniors, including this one, would lift up this Republican Congress and  this President as heroes.  Never mind "nucular" and "reconize." Forget about "Abramoff", "Tom DeLay", and "CIA agent out-ing". This administration and this ( at the time of passage of the program) congress would have been elevated in the hearts of Seniors forever.

So then, what have they done? They have given us Part "D". "D" is a near failing grade in most settings, and also in this one. At best it is a "stingy" program for Seniors, riddled with confusion and the opportunity for greed on the part of insurers and drug companies. But  at least it is a beginning toward  prescription coverage; one that perhaps can be rehabilitated.   At the worst it becomes a government budget buster, (the administration said it would cost $400 billion over 10 years, while the Congressional Budget Office says it will be three times that amount--$1.2 trillion.) But it still fails to meaningfully provide the valuable medications Seniors will need in the future.  My fear is that the drug and insurance companies will use it as a wild, drunken party, and the conservative elements in Congress will kill it completely? Even now we are hearing about huge prices being charged Seniors for drugs purchased in the "doughnut hole." Previously, Seniors may have purchased these drugs for much less at Canadian Pharmacies (where the country actually negotiates for lower prices), or were offered discounts by manufacturers based on income levels. Many drug companies have now taken back the offer of these discounts. So many are now at risk, doing without critical drugs they cannot afford in the doughnut hole, waiting for the program to start over again each January.

 THE BASIC PLAN

So what are the basics of Part "D"? The bill signed by President Bush is 411 pages long, and takes a CIA decoding team to understand. Do we dare try to summarize it on one page?

Under Medicare Part D, private insurance companies (Prescription Drug Plans, called PDPs, or existing Medicare Choice plans, which will be renamed Medicare Advantage plans) will enter into contracts with the Department of Health and Human Services to provide insurance for prescription drugs. The coverage and requirements, such as use of formulary drugs, under the plans will vary by region to reflect differences in provider costs and patient demo- graphics. In 2006, the premium averaged $35 a month ($420 a year) , and by 2008 this has gone over $40.

In 2008:

*First the enrollee pays a $275 yearly deductible.

*Next Medicare pays 75 percent of drug costs of the next 2250 (another $558.75 out of pocket).

*Next, the enrollee pays 100 percent of costs until total drug costs reach  5,726.25 (another $3,216.25 out of pocket in the doughnut hole).

 *We have now reached what Medicare calls the "stop-loss" threshold. From this point, thru the end of the calendar year, Medicare pays approximately 95 percent of your drug costs.

*That means the Part D catastrophic protection will not begin until the individual's total spending reaches $4,050 , not counting the $420 or so annual premium.

  The premium will increase over time according to a formula similar to the one used by Medicare to regulate Part B premiums. The Congressional Budget Office (CBO) expects the average premium to rise from $35 to $58 a month between 2006 and 2013.

The plan deductible, initial benefit limit and stop-loss threshold will each be indexed to the growth in per capita Part D drug spending by Medicare beneficiaries. Since such spending is expected to rise much faster than the rate of inflation, the CEO believes that by 2013 the Plan deductible will increase to $466, the initial benefit limit will rise to $4,000 and the out-of-pocket stop-loss threshold will increase to $6,400.

The legislation bans Medigap prescription drug policies for anyone using Part D. As a result, many seniors will actually spend more on drugs than they would without Part D. Medigap policies for Parts A and B of Medicare will remain legal.

In order to encourage employers who already provide drug coverage to Medicare-eligible seniors to continue doing so, the law authorizes subsidies and tax benefits worth an estimated $86 billion for such employers. Public employers like the federal government will be eligible for these subsidies, though at the moment it is not clear who will receive them-the FEHBP plans or employing agencies (like the USPS).

 

2006, 2007, 2008

 

 This is how it looks in  Chart Form : 2006

AMOUNT  &  ITEM  WHAT YOU PAY    WHAT MEDICARE PAYS  
$420  PREMIUMS  (varies) $420 $0
$250 DEDUCTIBLE $250  $0
(25% / 75%)  NEXT $2,000 $500 $1,500
$2850"  DOUGHNUT HOLE"  $2,850 $0    
TOTAL $4,020  $1,500
SO UNTIL $5,520 IS SPENT, YOUR COST IS $4,020  ($3,600 if not counting premiums)
AFTER THAT YOU PAY $2 FOR EACH GENERIC, OR $5 FOR EACH BRAND NAME, OR 5% OF THE  TOTAL OF EACH PRESCRIPTION, WHICHEVER IS THE HIGHER NUMBER. EXAMPLE: A $200 DRUG COSTS YOU $10. THIS 5% ARRANGEMENT CONTINUES ONLY UNTIL DECEMBER 31, 2006
ON 1/1/07 IT ALL BEGINS OVER AGAIN, WITH HIGHER PREMIUMS AND DEDUCTIBLE, AND A LARGER DOUGHNUT HOLE.

Remember, if you have been in Part D for less than a full year in 2006, being in for a full 12 months in 2007 may mean that the doughnut hole takes on a greater significance for you.

 
    This is how it looks in  Chart Form :  2007
AMOUNT  &  ITEM  WHAT YOU PAY    WHAT MEDICARE PAYS  
$420  PREMIUMS  (varies) $420 $0
$265 DEDUCTIBLE $265  $0
(25% / 75%)  NEXT $2,135 $533.75 $1,601.25
$3,051.25 "DOUGHNUT HOLE"  $3,051.25 $0    
TOTAL $4,270  $1,601.25
SO UNTIL $5,871.25 IS SPENT, YOUR COST IS $4,270.00 ($3,850 if not counting premiums)
AFTER THAT YOU PAY $2.15 FOR EACH GENERIC, OR $5.35 FOR EACH BRAND NAME, OR 5% OF  THE  TOTAL OF EACH PRESCRIPTION, WHICHEVER IS THE HIGHER NUMBER. EXAMPLE: A $200 DRUG COSTS YOU $10.00. THIS 5% ARRANGEMENT CONTINUES ONLY UNTIL DECEMBER 31, 2007
ON 1/1/08 IT ALL BEGINS OVER AGAIN, WITH HIGHER PREMIUMS AND DEDUCTIBLE, AND A LARGER DOUGHNUT HOLE.

Remember, if you have been in Part D for less than a full year in 2006, being in for a full 12 months in 2007 may mean that the doughnut hole takes on a greater significance for you.

 

 This is how it looks in  Chart Form :  2008

AMOUNT  &  ITEM  WHAT YOU PAY    WHAT MEDICARE PAYS  
$420  PREMIUMS  (varies) $420 $0
$275 DEDUCTIBLE $275 $0
(25% / 75%)  NEXT $2,235 $558.75 $1,676.25
$3216.25 "DOUGHNUT HOLE"  $3,216.25 $0    
TOTAL $4,470  $1,676.25
SO UNTIL $6,146.25 IS SPENT, YOUR COST IS $4,470  ($4,050 if not counting premiums)

AFTER THAT YOU PAY $2.25 FOR EACH GENERIC, OR $5.60 FOR EACH BRAND NAME, OR 5% OF THE  TOTAL OF EACH PRESCRIPTION, WHICHEVER IS THE HIGHER NUMBER. EXAMPLE: A $200 DRUG COSTS YOU $11.20. THIS SO-CALLED "CATASTROPHIC COVERAGE" CONTINUES ONLY UNTIL DECEMBER 31, 2008

ON 1/1/09 IT ALL BEGINS OVER AGAIN, WITH HIGHER PREMIUMS AND DEDUCTIBLE, AND A LARGER DOUGHNUT HOLE.

Remember, if you have been in Part D for less than a full year in 2007, being in for a full 12 months in 2008 may mean that the doughnut hole takes on a greater significance for you.

 

THE PLAN IS INADEQUATE

Part D benefits will cover only about one-fifth to one-quarter of anticipated drug care costs over the next decade. And the peculiar "doughnut" design, with no benefits paid for costs between $2,250 and $5,100, is confusing and costly to many seniors. Although the plan  helps some seniors facing catastrophic drug expenses in any given year, most will see their out- of-pocket expenses continue to rise since the legislation fails to restrain sky-rocketing pharmaceutical prices or curb the power of the few large multinational drug companies that dominate the marketplace. In fact, it actually prohibits Medicare from using its purchasing power to negotiate the best prices for the elderly and effectively blocks the importation of U.S.-made drugs from other countries where prices are much lower. (We wonder who influenced THIS inclusion?)

 HIDDEN TREACHERY?

The new law squanders considerable resources to bankroll privatization experiments with Medicare Parts A & B. Despite Medicare's record of low administrative expenses and the failure of Medicare Choice (Part C) in the past, the new law directs billions in subsidies to HMOs and other private insurers to compete for traditional Medicare program enrollees in six metropolitan areas. These experiments, set to begin in 2010, and the introduction of means-testing for setting premiums for Medicare Part B (higher income retirees will pay higher premiums) have led many critics to fear the gradual privatization of Medicare.  Do these guys really believe that private companies will look after the well-being of Seniors more faithfully than Social Security or Medicare. NOT ON YOUR LIFE! We had better get on this fast.

PART "D" MUST BE RE-DONE

Part D has been plagued with problems from the start, many stemming from its complexity. It's true that many seniors save money with Part D, but millions of others are worse off. And yet taxpayers could pay nearly $1.2 TRILLION for this benefit in the plan's first 10 years. Congress has to do better. There is a solution. Congress should revamp Part D: Eliminate all the private insurance plans, make prescription coverage a simple, direct benefit from Medicare and negotiate drug prices in bulk with the pharmaceutical industry the way the Department of Veterans Affairs does. Under this program, medications already cost 46% MORE than the prices the Veterans Administration has negotiated for its folks. I suspect that gap will widen as lobbyists lurk around the pocketbooks of the Congress.

YOU have the power to assure that changes will be made in the program. Go to the SeniorARK "links"/"government" page. You will see links to email the president, senators, and your representative. They DO pay attention to these emails.