Critics See ‘Expectations Gap’ on Medicare Prescription Bill

The Medicare reform bill expected to clear Congress in the next few days promises the prescription drug benefit older Americans have been waiting for. But analysts say many seniors will find that the plan fails the what’s-in-it-for-me test.

The drug benefit is the centerpiece of a $400-billion bill, endorsed by a conference committee Thursday, that would make the most far-reaching changes in Medicare since its enactment in 1965. But the bill’s particulars suggest that the benefit will vary depending on seniors’ drug needs and incomes.

“Seniors felt they had been promised the kind of prescription drug coverage that members of Congress have,” said Judith Feder, dean of public policy at Georgetown University. “What they’re getting doesn’t even remotely resemble that.”

Just last week, President Bush implied that the new benefits would be much like those enjoyed not only by many working average Americans, but also by their elected representatives.

“Every member of Congress gets to choose a health-care plan that makes the most sense for them. And the same for federal employees. If choice is good for members of the Congress, then choice is good for America’s seniors,” he said.

Drew Altman, president of the Menlo Park-based Kaiser Family Foundation, an independent health-care philanthropy, said seniors were expecting the bill to create a benefit similar to employer coverage -- a patient makes a co-payment of perhaps $10 or $20 toward each prescription, and insurance picks up the rest. But the plan in Congress is very different, Altman said, resulting in what he called an “expectations gap.”

The first gap is one of timing. Even if Congress passes the bill by Thanksgiving and Bush signs it soon after, the prescription drug benefit wouldn’t begin to kick in until 2006.

To fill that void, the bill would create a Medicare-endorsed discount card that the Bush administration estimates would help seniors save from 15% to 25% on their prescriptions. Low-income seniors would also get the equivalent of a $600 credit for each of the two years the discount card would be valid.

Once the real benefit begins, what seniors with low to moderate drug expenses would get indeed would not be very different from what many employer-based plans provide. Seniors who chose to join the program would pay a monthly premium of $35, plus the first $250 of their drug costs each year. Medicare would then start picking up 75% of additional expenses.

But as seniors’ drug expenses mounted, the Medicare benefit would differ significantly from traditional health coverage. When total annual drug costs reached $2,250, government support would stop. Seniors would be responsible for the next $2,850 in drug costs. Only when their drug bill for the year reached $5,100 would Medicare begin paying 95% of all further costs.

The span of drug expenses in which Medicare would contribute nothing would affect millions of people. It would begin at close to the $2,322 that the average Medicare user paid in 2003 for prescriptions, according to the Kaiser Family Foundation.

And Medicare drug insurance would kick in again for only a relatively small slice of seniors.

Gail Shearer, director of health policy analysis for Consumers Union, estimated that substantially fewer than 10% of seniors would have drug expenses that qualified for Medicare’s “catastrophic” coverage for costs above $5,100.

Because Medicare’s coverage likely would not offset any drug price increases, most seniors, she said, would spend more for drugs in 2007, with the program fully in effect, than in 2003.

In most areas, Medicare will not be the only choice for drug coverage. The bill allows for health-maintenance organizations, preferred-provider organizations and stand-alone drug insurance to compete for business.

But Feder said she saw “no evidence that the insurance industry is willing or able to fill this need.” The bill recognizes this possibility by authorizing government-run drug plans in areas where no private plan or only a single plan is available.

Shearer warned that in areas where stand-alone drug plans competed with Medicare, seniors would probably have difficulty determining which one offered the best deal. What’s more, she said, plans would vary from state to state and region to region, adding to the confusion.

Retirees whose drug costs are covered by insurance from their former employers would face another risk: that their employers will use the Medicare drug benefit as an opportunity to shed their own retiree coverage. The bill sets aside $71 billion in tax-free subsidies to encourage employers to keep such coverage.

But even the bill’s supporters acknowledge that 16% of retirees who now have such coverage -- roughly 2 million seniors -- would likely lose it anyway.

The bill’s prescription drug benefit makes allowances for seniors whose incomes are under the poverty line -- $8,980 for an individual and $12,120 for a couple. They would have no premiums or deductibles and would pay $1 a month for generic prescription drugs and $3 a month for brand-name drugs.

Those seniors earning up to 35% above the poverty level would pay $2 and $5. Those with incomes up to 50% more than the poverty level would be required to pay a $50 deductible, 15% of their drug costs up to $5,100, and $2 or $5 for each prescription above that level.

But those small co-payments could become harder to make because the bill apparently would eliminate the practice of using Medicaid, the health insurance program for the poor, to pick up the costs that Medicare misses for the elderly poor.

Bob Greenstein, head of the liberal Center on Budget and Policy Priorities, said most of the 6.4 million people who qualified for both Medicare and Medicaid would pay more for their prescriptions than they did now.

Two public opinion polls conducted this week by AARP, the nation’s largest seniors organization, indicated that many of the 40 million elderly and disabled people affected by the legislation have mixed feelings.

A poll commissioned by the Democratic-leaning AFL-CIO found that the more seniors learned about the Medicare bill, the less they liked it.

“When they get the details of this deal, older voters will be furious with their representatives,” said federation President John Sweeney.

The conclusion of Stephen Moore, president of the conservative Club for Growth Advocacy, whose poll focused on the costs of the bill to the government, was about the same.

“When America’s seniors learn of the potentially devastating impact of the bill, they turn strongly against it,” he said.

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Times staff writer Joel Havemann contributed to this report.