Republicans and Democrats have finally found something to agree on. From coast to coast, north to south, they agree that Medicare’s Part D introduction gets a big fat F for flop.

Part D, the prescription drug benefit, inherently hard to understand for both Medicare and Medicaid recipients (the latter now under the complex coverage), has equally confused and bollixed pharmacists, drug companies, and insurance providers—not to mention public health officials, congressman, senators and governors. Once again, hats off to George W. Bush & Company, who promised the greatest advance in Medicare since its inception in 1965.

Of course just figuring out Part D was the first curve ball thrown at Medicare seniors and some 6.4 million Medicaid/Medicare dual recipients, plus the millions of Medicaid recipients who formerly received their benefits directly from Medicaid, which kind of made sense. But they, too, were automatically switched to Medicare on Jan. 1. Why, because Bush said it would be more economical, more free market so to speak, with the private insurance sector taking over administration from Medicaid. Good luck.

And too bad his family didn’t switch from their lush drug coverage to Part D on January 1. It would have been a remarkable lesson in reality living, which we know is so very different from White House and congressional living what with the help of copious contributors, including Big Pharma, multi-national corporations, and Jack Abrahamoff spreading the bribes far and wide.

In real-folks reality, Mr. Bush, you might actually have to haul your padded butt down to a drug store and collect your life sustaining medicines in the wallet-busting morass you have created. But even before that, the holes inherent in Plan D coverage, including deductibles and co-pays, have to be covered by recipients through private insurance drug plans. Otherwise recipients have to eat those costs, maybe instead of dinner.

Part D for the Medicare, Medicare/Medicaid and Medicaid “Market”

What was the problem with the original Medicaid drug benefit being paid directly by Medicaid to people living below the poverty line? Were we making it too easy for poor people to get needed medicines to stay healthy? In fact, we switched them over to the Medicaid D group, lumping them in with Medicare seniors and “duals” (Medicare folks who are also disabled and have Medicaid). As far as I can see, this was done to make a bigger catch-net (market) for the private insurers offering supplemental plans. In fact, even the poor will have small co-pays and deductibles, so they don’t think life has gotten too easy I guess. If they’re really, really strapped, they can apply for co-pay and deductible assistance. That’s simpler, isn’t it?

If Not for Wars and Tax-Cuts, the Government Could Pay Rx Costs

Sad to say, if this lunatic government wasn’t pouring away hundreds of billions of dollars into two wars and endless tax cuts for the rich, actually trillions over a decade, they would have the money to cover those holes in coverage, both for the poor and the aged. Like they would have money for education, Social Security, even a national health plan that everyone could participate in, and pay into throughout their working lives. And the government would also have the money to rebuild infrastructure, jumpstart the manufacturing sector, and make America a First World nation again.

Also, Bush did not want Medicare to have the power to bargain with Big Pharma over the high prices of these prescription drugs. After all profits are profits, and people are, well, whatever, certainly not as important as Big Pharma’s bottom lines. The president also discouraged seniors from buying drugs from Canada, where they are cheaper, insisting that he and the FDA could not vouch for their quality and safety. Nothing like a little fear mongering.

Introducing Part D for the Doughnut Hole in Coverage

This information comes from Medicare.gov, which you can go to for any additional facts.

Basically, for eligible seniors Medicare basic Part D provides that on your first $2,250 of annual drug expenses, you pay a $250 deductible. Then, on the remaining $2,000 spent for your drugs you will be reimbursed 75 percent. Your 25 percent co-pay on $2000 equals $500. Add this co-pay of $500 to the $250 deductible and that equals $750 out of pocket. Now you come to the doughnut hole in the coverage. You and you alone are responsible for all following drug costs up to an additional $2850. If you needed that additional amount of drugs, your total out of pocket costs would have been $750 plus $2850, which will have equaled $3600. After that point, you will reach the other side of the donut. Here, one of the various private insurance plans you need to sign up and pay for to get part D will kick in and pay most of the costs. You will pay either $2 to $5 or 5 percent of all further prescription costs. You can check the link for park D plans.

In order to get the basic Part D, you are required to sign up with a private insurance plan.

The rates vary from and within states and according to the coverage you desire. Each private insurance company has the option to make this basic Plan D better, but cannot offer less than the above. For example AARP has a similar plan with no deductible, but the cost is higher. If a person does not want a plan that has a blackout or doughnut, that naturally will cost more. This may prove to be a cheaper option if they have high drug costs.

For instance, Wellmark Blue Cross Blue Shield in South Dakota (where my patient sister-in-law who helped explain all this is an insurance broker), has a plan for $99.50 per month that has no deductible. It will pay 70 percent of the drug costs until your total yearly out of pocket drug cots reaches $3,600. After that you pay a co-payment of $2 to $5 or 5 percent of the prescription drug costs depending on what tier the drugs are in: generic, brand name, special.

Medicare recipients who are at the very low end of the poverty scale also have relief from Part D cost and their drug costs. Their Part D cost will be subsidized at the rate of $33.11 per month. Their drug cost will be $2/$5 up to an out of pocket cost of $5,100. After that they pay nothing. People on the low end of the scale will have their Part D premium subsidized on a sliding scale. They will pay 15 percent of their drug costs up to $5,100 out of pocket expense. Then pay $2/$5 per prescription. There is no black out time or doughnut for these people.

The plan for all this was designed for everyone to participate, paying in some kind of premium depending on their need. The actuarial calculations are done using this data. Thus, people who decide not to participate at first and change their minds later pay a surcharge. When they enroll in Part D the premiums will be surcharged for the amount of months that they were eligible but were not enrolled, therefore not contributing to Part D. The person who does not need much or anything in the way of drugs has the option to pick a low cost plan. Humana has one for as low as $1.87 using a SD zip code.

In all fairness, when Medicare started, the cost of drugs for people that were using Medicare was 1 percent of their total medical cost. Obviously that has changed considerably, due to a variety of abuses and something called “progress.” The present day cost can run as much as 43 percent of a person’s total medical costs. There was obviously a need to overhaul the system and add some drug coverage for Medicare recipients, and so part D was born.

Also, Medicare was enacted by Congress in 1967 and expanded in 1973 to include younger persons that were disabled. No changes were made until 2003, when the Medicare “Modernization Act” set the stage for the changes now taking place.

Two thousand-three is also the year when the drug cards offered by companies came to life. These cards offered Medicare recipients a discount on their drugs.The cards were put into place as a temporary measure to give people relief until Part D was hatched. These drug cards expired on January 1 and were replaced by Part D. Most of the people end up paying about the same yearly out of pocket costs as they were when using the drug cards. What this indicates is that the cards did what they were supposed to do. Give relief to people until a permanent plan could be put into place.

At Last First Reviews of Part D

Aside from understanding plan D, the real trouble started on January 1 when the predicted disaster of Part D went into action or inaction. Here are some stories from three major newspapers around the country.

From the Washington Post

Ceci Connolly, writes in the January 14, 2006 Post, “The States Step In As Medicare Falters -- Seniors Being Turned Away, Overcharged Under New Prescription Drug [D] Program.” That was just the headline. Ceci went on to say, “Two weeks into the new Medicare prescription drug program, many of the nation’s sickest and poorest elderly and disabled people are being turned away or overcharged at pharmacies, prompting more than a dozen states to declare health emergencies and pay for their life-saving medicines.

“Computer glitches, overloaded telephone lines and poorly trained pharmacists are being blamed for mix-ups that have resulted in the worst of unintended consequences: As many as 6.4 million low-income seniors, who until Dec. 31 received their medications free, suddenly find themselves navigating an insurance maze of large deductibles, co-payments and outright denial of coverage . . ." Doesn’t this sound like some banana republic gone bad?

In fact, the muck-up is so bad that states are covering the drug costs of low-income seniors so they don’t have to go without. States like Ohio, Wisconsin, and every New England state, California (The Terminator himself stepped in), Illinois, Pennsylvania, Arkansas, New Jersey, North Dakota and South Dakota.

Jeane Finberg, lawyer for the National Senior Citizens Law Center, said: “All this is doing is harming the people who had coverage -- America’s most vulnerable citizens.” Isn’t that special?

This was Der Bush’s signature achievement, drug coverage (such as it was) slated for the first time to 43 million elderly and disabled Americans who qualified for Medicare. Plus those 6.4 million low-income beneficiaries who were getting their medicine through state Medicaid plans. Some of them were hit with deductibles and unaffordable co-payments. And some went home with no medicine at all. Doesn’t that just make your feel just cold inside? Those “dual-eligibles,” i.e., senior, hurting citizens, were overcharged or denied medicine.

Mark B. McClellan, administrator of the federal Centers for Medicare and Medicaid Services (CMS), shrugged his shoulders. He didn’t have authority to reimburse. He asked states, pharmacists and providers to work with his “folks” to collect reimbursements from insurance companies administering the prescription program. Oh no, we can’t have those insurance companies hurting, no sir, not them. But Mark was really bugged. He said: “That is simply not acceptable. We have been working around the clock and around the country to make sure those beneficiaries get the prescriptions they need.” So, what happened, Mark?

California Governor Arnold Schwarzenegger, in a rare burst of humanity, said he’d spend as much as $70 million for two weeks of medicine, although he expects reimbursement. The check is in the mail, Arnie. If you don’t get paid post haste, hasta la vista, baby. I’d go to D.C. and kick butt. But it wasn’t just Arnold who had a problem, what with a million or so folks on Medicare and Medicaid to worry about in California.

Politicians from both sides of the aisle scuttled to microphones and cameras, to express outrage at the mess with “dual-eligibles” with incomes below the poverty rate of $9,750 a year, who take an average of 15 medications a day. More than half of the “dual-eligibles” are women. Forty percent with cognitive conditions like Alzheimer’s. Twenty percent don’t speak English. Por favor, a little compassion.

In nursing homes, we have folks, who may be schizophrenic, deaf or blind or otherwise seriously ill, and may have a little trouble following the new system. These are all people from reality-land, even near the marble temples of D.C. In fact, Medicare made the problem worse by distributing a handbook that “incorrectly told low-income seniors they could enroll in any plan at virtually no cost.” And these Medicare savants actually have good-paying jobs with pensions and real health care.

From the New York Times

Robert Pear on Jan. 7 reported Vermont’s secretary of human services said, “The federal system simply is not working.” Soon after the Vermont Legislature passed a bill declaring, “There is a public health emergency due to the federal implementation of Medicare Part D, which has resulted in serious operational problems, causing Vermonters to be turned away from the pharmacy without drugs.” Simple, to the point, very Vermont.

“In New Hampshire, Governor John Lynch, a Democrat, signed an executive order authorizing the state to pay drug claims for aid that should have been covered by Medicare. Republican leaders of the state legislate called a special session to provide the money. The start of the Medicare drug program ‘has been a nightmare for many of our citizens,’ Governor Lynch said.”

And Governor John Hoeven of North Dakota similarly had to act on behalf of those old folks. In Maine, Governor John Baldacci, a Democrat, agreed to pay drug claims for those medicines for folks in need. Officials grew more and more impatient as federal officials' promises did not materialize.

Sam Rosenstein, the Medicaid director in California, said: “We are hearing more and more complaints. A significant number of people are not getting their prescriptions. That has us very troubled.” Yes, all of us, Sam. These folks were told their co-pays would not exceed $5 a prescription.

Carol A. Herrmann-Steckel, the Times reported, commissioner of the Alabama Medicaid Agency, said, “Medicare beneficiaries with very low incomes had often been required to pay the full $250 deductible and co-payments far exceeding $5. ‘One beneficiary borrowed the money,’ she said. ‘Another charged the $250 on a credit card because she was in such dire need of the medicine.’”

On and on it goes. “John J. Morris,” the Times tells, “42, of Ware, Mass., who has diabetes and multiple sclerosis, signed up for a Medicare drug plan on Nov. 16. The insurer told him his co-payments would not exceed $5, he said, but at the pharmacy this week, he was told he had to pay $23 for each of three drugs.” Kind of like, pay or die, isn’t it? Welcome to George’s World.

From the Los Angeles Times

Reporters Ricardo Alonso-Zaldivar and Peter Nicholas write on January 13, “State Orders Help for Elderly as Medicare Glitches Spread.” They add with a certain irony, “But the spectacle of governors bailing out Washington, poor people unable to get their medications and pharmacists angry over not getting paid could damage the Bush administration’s credibility on healthcare -- an important election-year issue that the White House wants to showcase in President Bush’s State of the Union speech, which is scheduled for Jan. 31.” I listened but heard nothing new, guys. How about you?

Parallel Stories

To add insult to injury, in a parallel NY Times story, “Governor Plans Agency to Fight Medicaid Fraud,” Clifford Levy reported on January 14, “Pataki proposed yesterday that several state agencies that are supposed to fight Medicaid fraud be stripped of that responsibility, which would be given instead to a new agency. He pledged to spend millions of dollars to hire scores of investigators and other workers to police the Medicaid program, which provides health care for 4.2 million low-income New Yorkers.” Mainly the task force is to tackle widespread theft from the program by doctors, pharmacies and other health care providers like nursing homes. So on top of it all, funds that could go to the poor and aged have to be spent stomping professional predators.

New York’s $44.5 billion Medicaid program, largest of any state, has actually been cutting back on “oversight” [stealing] as a cost-cutting measure the past several years. Rationalize that one for me if you will. Billions, the NYT tells us are lost through fraud, waste and profiteering. Maybe the ethic that starts at the top has a way of filtering down to the lowest, or visa versa. Anybody for rifling beggars cups, church boxes, mailboxes for Social Security checks?

In fact, with all those New York billions spent, the Times found the Health Department turned up only 37 cases of suspected fraud to their Fraud Control Unit in 2004. Since 2000, when you know who assumed office, department fraud and abuse inquiries have fallen by 70 percent, according to federal statistics. So we’re bad to go.

Visions of China

In another parallel story from the New York Times, “Wealth Grows, but Health Care Withers in China” by Howard French (Jan 14), we can garner a picture of the future, or of the now, for ourselves. This is the story of Jin Guilian, whose “family took him to a country hospital in this gritty industrial city after a jarring two-day bus ride during which he drifted in and out of consciousness, the doctors took one look at him and said: ‘How dare you do this to him? This man could die at any moment.'

“The doctors’ next question, though, was about money. How much would the patient’s family of peasants and migrant workers be able to pay -- up front -- to care for Mr. Jin’s failing heart and a festering arm that had turned black?”

Unfortunately, despite the relatives pooling their cash, when Mr. Jin, 36, did not improve, they had to move him to an unheated, barely equipped clinic on the outskirts of Fuyang “where stray dogs wander the grimy, unlighted halls.” Picture yourself in Mr. Jin’s pajamas.

As French goes on to say, “China’s economic reforms have turned an almost uniformly poor nation into an increasingly prosperous one in the space of a mere generation. But the collapse of socialized medicine and staggering cost increases have opened a yawning gap between health care in the cities and the rural areas, where the former system of free clinics has disintegrated.”

The point here is that the free market mentality, even in this once communist or socialist nation, a great nation of workers, has not only failed to improve national health care, but is destroying it. And I see America on that very track, heading to Mr. Jin’s adjoining room.

The Road Ahead

Keeping that room in mind, the day after Bush’s State of the Union Speech, the New York Times tells us that the “House Approves Budget Cutbacks of $39.5 Billion.” The Republican House will achieve $6.4 billion of this figure through cuts in Medicare, “the health care program for the elderly, through a variety of changes that include higher premiums for all beneficiaries, with steep increases for the more affluent and a freeze in payments to home health care providers.” Isn’t that great news? The Times goes on to say, “In the Medicaid health care program for the poor and disabled, $4.8 billion will be saved in part by increasing co-payments and reducing payments for prescription drugs.” Just what those folks need.

Rep. Mike Pence (R-Ind.) called the vote, “a step toward restoring public confidence in the fiscal integrity of our national legislature.” Are you more confident in our fiscal integrity after hearing this? The balance of the cuts will be in student loans and crop subsidies. Mr. Bush said, “He looked forward to signing the legislation and that the budget proposal he would send to Congress on Monday will continue to build on the spending restraint we have achieved.” Restraint, is it?

Yet, on the very next day, the New York Times reported that “$70 Billion More Is Sought for Military in War Zones.” This is a supplemental request that began in October as an add-on to the $50 billion in the overall budget request for the first months of the 2007 fiscal year. It now equals $120 billion. Overall the Bush Group will propose a total Defense Department budget of $439.3 billion for 2007, nearly a 5 percent increase over this year. So it’s good they are being so full of fiscal integrity for some people and so full of crap towards the rest of us.

But then it’s only us, the everyday folk, the not rich, it concerns. And Bush has bigger fish to fry, especially now that he wears a crown, not just a golf cap.