It’s a benefit, but for whom?

DANIEL J. STONE is a internist and associate medical director at Cedars-Sinai Medical Group.

AS A GERIATRIC medicine specialist, I am confronted daily by the chaos and confusion of Medicare’s Part D drug benefit. The program should reflect President Bush’s ideals of “compassionate conservatism.” Compassion would mean user-friendliness and easy access to affordable drugs. And a conservative plan would maximize “bang for the buck.” Instead, the priorities of the insurance and pharmaceutical companies have trumped these objectives.

Economics 101 tells us that the largest purchasers have bargaining power to get the best prices. Medicare could have used this power to gain large discounts on behalf of seniors. Similar national bargaining entities in Canada and Europe allow foreign consumers to pay a third to one-half of U.S. drug prices. A single Medicare bargaining entity, however, threatened to place unprecedented price pressures on drug companies and might have reduced or eliminated the role of private insurers.

So Congress sacrificed Medicare’s bargaining power in favor of a system in which multiple private insurers offer competing plans. This decision will ultimately transfer billions of dollars from seniors and the government to insurers and drug companies. Some claim the industry needs these resources to finance tomorrow’s drug breakthroughs. Although the need for research dollars is real, it seems unfair for Medicare seniors to shoulder costs that also subsidize Canadian and European consumers.


One of my patients, Betty L., is already feeling the pinch. A low-income senior on Medi-Cal, Betty was automatically enrolled in a Medicare Part D program on Jan. 1. Unlike Medi-Cal, her new Healthnet plan requires small co-payments. Like many Medicare Part D plans, it omits coverage for anxiety or sleeping pills, something Medi-Cal covered. To get those medicines, and cover her new co-pays, Betty will be charged an extra $30 a month. We all have a right to question a prescription drug program that will cost $700 billion over 10 years and yet increases drug payments for some of the poorest.

George A. and Mary S., two other patients in my practice, have “Medi-Gap” drug coverage policies, and they are less financially vulnerable than Betty L. In order to find the right Part D coverage, they must sort though multiple plans that vary by drug availability, co-payment charges and the participation of local pharmacies. There are about 80 different plans to choose from in Los Angeles County alone.

George A., an 85-year-old bachelor with multiple medical problems, knows that Medicare Part D might save him money on the 13 prescriptions that cost him thousands of dollars every year, he just hasn’t had the motivation to make an informed choice. Given his advanced age and relative financial security, George would rather pay more and worry less about the prospect of change.

Mary S., a relatively healthy 80-year-old, has Internet access, and she’s sophisticated about medication issues. I’ve explained that it would be relatively easy to use Medicare’s interactive website to input her medications and find plans that would cover her current prescriptions. “When you get old,” she countered, “nothing is that easy.”

As Mary’s comments suggest, Part D’s congressional architects seemed to think that seniors would be utterly at ease when it comes to using the Internet and reading the fine print in insurance plans. Unfortunately, that description doesn’t fit most Americans in any age range, much less seniors.

The Department of Health and Human Services is proclaiming that 21 million seniors have enrolled in the program. Conveniently, this statistic ignores the fact that the vast majority of those seniors, like Betty L., were participants in other programs that automatically enrolled them in Part D. About 22 million more seniors still need to make a choice, and many of them, like George A. and Mary S., remain too uninformed, confused or wary to make up their minds.

How did American seniors and AARP, their powerful watchdog, permit Congress to approve a complex and confusing drug benefit program that squanders its bargaining power? The answer is that it was better than nothing. That abysmal standard appeared sufficient for the reelection prospects of the plan’s congressional proponents and defensible for AARP. But seniors have a right to expect those in power to adhere to principles rather than corporate interests when their health and financial welfare are at stake. Saddling seniors with a flawed program that prioritizes special interests rather than seniors’ interests can be considered neither compassionate nor conservative.