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Wednesday, June 14, 2006 

The Donut Hole: It's Not for Breakfast

The donut hole in the Medicare Part D program is about to become apparent to many new subscribers here in Texas. Under the new Medicare D plan passed by Congress in 2003, out-of-pocket prescription expenses between the annual amounts of $2,251 and $5,100 are not covered - hence the "donut hole." The New York Times' Robert Pear reports how Texas' Hispanic elderly are getting a crash course about the notorious and the impact of the donut hole on them.
Jose M. Flores, a Medicare beneficiary who lives outside McAllen, used the new drug benefit four times from January to April to purchase Byetta, an injectable medicine for diabetes. Each time he paid $40.

So when he went to the pharmacy on May 25, he was dismayed to be told that he owed $167.56 for the next month's supply. Mr. Flores had reached the notorious gap in Medicare's drug coverage. He had to pay the full price of Byetta. His Medicare drug plan paid nothing.

"It's almost useless," said Mr. Flores, a 66-year-old school bus mechanic who was interviewed at his home in La Joya, Tex. "I'm paying the premium, but not getting protection."
...
In coming months, millions of beneficiaries will have similar experiences, as the cost of their drugs reaches the initial coverage limit of $2,250. Like Mr. Flores, they will have to pay the full cost of each medicine until their out-of-pocket costs reach $3,600. At that point, Medicare coverage resumes, paying 95 percent of the cost of each prescription.
Yet, BushCo continues to pull the wool of over the eyes of millions of American citizens with their lies.
In Washington, Bush administration officials say Medicare's new prescription drug program is humming along smoothly, filling more than three million prescriptions a day and cutting costs by an average of 50 percent for each beneficiary.
Seniors on Medicare are in this bind because BushCo once again filled the pockets of the insurance industries and the pharmaceutical companies. PhRMA's Medicare plan has made sure that the government are not allowed to negotiate lower costs with the pill pushing drug companies — as other federal agencies, hundreds of corporations and several states do.

According to the Alliance for Retired Americans, BushCo and the robber barons manipulated the system to achieve their agenda:
  • Censored C-SPAN cameras and drafted legislation in exclusive GOP closed-door sessions
  • the Bush administration violated the law by withholding cost estimates for the drug benefit from Congress and threatened a federal employee with his job if he disclosed them
  • House leaders held the middle-of-the-night vote open for an unprecedented three hours resorting to bribes and backroom deals to narrowly pass the bill
  • following passage of the bill, the White House revealed the cost would exceed the $400 billion ceiling it had promised lawmakers
  • the Bush administration illegally used taxpayer funds for a multi-million dollar propaganda campaign to promote the Medicare drug deal to the public
The conflict of interst between ex-lawmakers and lobbying firms:
  • one of the principal authors, former Rep. Billy Tauzin (R-LA), negotiated a $2 million deal to head PhRMA, the drug industry's trade group, while working on the law
  • former head of the Centers for Medicare and Medicaid Services, Thomas Scully, who left to join Alston & Bird, a law firm representing hospitals, pharmaceutical companies and other health care companies. (Side note: CMS is now headed by Dr. Mark McClellan, son of TX Governor Independent candidate Carole Keeton Strayhorn)
We can now expect that millions of seniors on fixed incomes, especially those with chronic illnesses and with disabilities, will be struggling to pay for the life-sustaining medications they need but can’t afford without coverage.

Currently, many patients are having difficulty getting the drugs they need. Yet, the BushCo spin according Pear:
Bush administration officials say that low-income people like those in McAllen stood to gain most from the new program because they were often eligible for extra help. Medicare officials said they were trying to solve the practical problems reported by pharmacists here. And they said that a typical beneficiary would save at least $1,500 before reaching the gap in coverage.
This is nothing more than a scam by Big PhRMA and Big Insurance to screw millions of low-income elderly out of their limited funds. Under Part D, a "standard" drug plan pays 75 percent of initial drug costs up to $2,250 after a $250 deductible for most seniors. But then the program pays nothing until drug expenses reach $5,100, after which the government pays 95 percent of all costs.

In Texas, there are 47 Medicare drug plans, with different premiums, co-payments and lists of approved drugs. However, doctors and pharmacists are having trouble figuring out what drugs are on the approved drug list.
Typically, a doctor writes a prescription, and the patient takes it to a pharmacist, who submits a claim to the insurer. In many cases, the doctor learns the drug is not covered only after the claim is rejected. The doctor and the pharmacist may repeat the process three or four times until they find a drug that is covered.
There are other problems with Big PhRMA's Medicare plan.
  • Many beneficiaries told the government to withhold Medicare drug premiums from their monthly Social Security checks. But Social Security did not always act promptly on such requests.
    • John R. Morris, 83, a retired salesman in Mission, said he was annoyed when four months' worth of premiums — more than $155 — was deducted from one month's Social Security check.
  • Insurers sometimes jumble the claims filed for different beneficiaries.
    • Nine of Mr. Morris's drugs showed up in the latest monthly statement for his wife, Joan D. Morris. As a result, her drug spending appeared much higher than it actually was. If the error goes uncorrected, she will reach the coverage gap sooner than she should.
Will anything be done? No!!! It will get worst for low-incomes individuals. Last month, the Centers for Medicare and Medicaid Services (CMS) will be increasing deductibles, out-of-pocket maximums and other costs for seniors by 6.8% beginning Jan. 1, 2007. The deductible for the standard benefit will increase from $250 to $265. In addition, seniors will have to spend $3,850 out of pocket before having 95% of their drug costs covered, instead of the $3,000 they have to spend in 2006.

Even worse, beginning next month, ALL low-income individuals (regardless of their citizenship) will are required to show proof they are citizens. Not a joke.

It seems Dudya and Congress pulled another fast one. According to the NY Times:
The Bush administration plans ... to issue strict standards requiring more than 50 million low-income people on Medicaid to prove they are United States citizens by showing passports or birth certificates and a limited number of other documents.

The requirements, which take effect July 1, carry out a law signed by President Bush on Feb. 8 [Public Law No. 109-171,§ 6037].

... The purpose of the law was to conserve federal money for citizens, reducing the need for states to cut Medicaid benefits or limit eligibility.
According to HealthLawProf Blog the new standards will create an additional hardship and possible loss of benefits to millions of children, older Americans and poor people born at home in rural areas who never received birth certificates. HealthLawProf also explains:
Federal policy may be to deny health care benefits to undocumented immigrants, but it obviously doesn't go so far as to require (or even permit) the denial of health care services (emergency services, at any rate) to undocument immigrants. EMTALA requires Medicare-certified hospitals to provide a medically appropriate screening for patients who come to their ER's and to attempt to stabilize any emergency condition found to exist, and this requirement applies (as it should) regardless of the patient's citizenship status. Tightening up Medicaid eligibility rules may (or may not) make some kind sense as a matter of immigration policy, but as a health care policy it only makes a bad situation worse -- and not only for hospitals.
However, all States must comply because if they fail to do so, they can lose federal Medicaid money.

The guidelines list four categories of documents that can be used as evidence of citizenship:
  • 1st category: US passport or a certificate of naturalization;
  • 2nd category: state and local birth certificates and State Department documents issued to children born abroad to United States citizens;
  • 3rd category: nongovernment documents - medical records from doctors, hospitals and clinics, nursing home admission papers, and records from life and health insurance companies; and
  • 4th category: affidavits, which can be used "only in rare circumstances when the state is unable to secure evidence of citizenship" from other sources.
Feeling dizzy yet, as Grandmaster Rove and DJ Fly-boy Luntz keep spinning their Pipe Piper tunes, as the Big PhRMA and Big Insurance Robber Barrons rob you blind. These Merchants of Death sleep easy in their nice penthouse suit, vaction in one of their multiple summer homes knowing they shorten the life exceptency of millions of low incomce elderly.

Now that Grandmaster Rove is off the hook, don't be surprised when he starts seeking redemption as he releases a remix of his popular spins to wreck vengeance upon those who attempted to take him down.

But for now kiss your health care good bye, if you do not have insurance.

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