David Earl Johnson, LICSW

3 minute read

Corpus Callosum has great post about an article that appeared in the New England Journal of Medicine. He brimes with pride at the “venerable” journals departure from it’s usual decorum in commenting on Medicare Part D. It is a worthy read, and a withering criticism from a high respected journal with starched credentials. Here is an excerpt from the grand ol’ journal. [Part “D” for “Defective” — The Medicare Drug-Benefit Chaos][2]

True, the program provides drug benefits for some Americans who previously had none. But because of its strange design, enrollment is falling far short of expectations. Officials in the Bush administration boasted that 25 million people are receiving benefits through Medicare Part D. But the government’s data reveal that about 20 million of them already had adequate drug coverage through Medicaid, their employers or unions, or health maintenance organizations; as of late February, the new benefit was providing only 12 percent of the elderly with coverage they did not already have.1 In many cases, the program worsened patients’ situations, with a particularly heavy burden falling on indigent Medicaid enrollees. Before the new entitlement, most had virtually all their medications covered fully by the states.

But on January 1, 6.2 million of these vulnerable elderly were reassigned to one of the private insurance companies designated by Medicare to run its program. Word of these arrangements didn’t always reach the patients, insurers, or pharmacies accurately, and tens of thousands of indigent patients were told to get prior authorization, pay a large initial deductible, or make substantial copayments for regularly used medicines they previously received at no cost.2

Thousands discovered that the drugs they had been taking for years were not covered by their new insurers. Clinical crises ensued, and 37 states had to provide emergency payments for frail citizens.3

Despite its youth, the Medicare drug benefit is already chronically ill. But with extensive rehabilitation, it could go on for years, albeit with impaired functional capacity. Debate continues over whether its early spasticity was caused by inept management of its birth or a genetic disorder present at its creation. Proponents of the first explanation suggest that Medicare and its private insurers were not ready for the millions of applicants and hundreds of millions of prescriptions that poured in early in January, in a flood that they were ill prepared to handle.

Alternatively, the lethal flaw may not have been in the implementation of the program but in its conception. The program’s poor functioning may result from mutations at multiple loci: the reliance on private companies to shape a public program and contain use of costly medications; the expectation that most older Americans would readily choose among myriad competing plans, making necessary comparisons on the Internet; the right granted insurers to require patients to switch to the companies’ “preferred drugs”; and the vision that millions of disabled patients — many cognitively impaired, chronically ill, poorly educated, unable to speak English well, or all of the above — would successfully work the new system as enlightened consumers. Instead, the new public–private partnership expressed the worst traits of each parent.

The government was ill equipped to coordinate the complexity it created, and the companies were too fragmented and bottom line–driven to fulfill this vital public health function.

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