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Tilting at Windmills

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January 19, 2006
By: Kevin Drum

MORE ON PRESCRIPTION DRUGS....Jon Cohn returns to the Medicare prescription drug debacle with a simple question: are the kinds of problems we're seeing just the inevitable startup bugs you get with any big new government program? He takes a look back at the start of Medicare itself to get the answer:

So what happened on the day that this complex program was implemented? Thousands of senior citizens simply went to the hospital and got the health care they needed. "There were no crises that I remember," says Yale University political scientist Theodore Marmor, who worked in the office overseeing Medicare implementation and went on to write The Politics of Medicare, the program's definitive history. Newspaper accounts from the '60s back him up. Under the headline "medicare takes over easily," a Post writer described the program's first day as "a smooth transition, undramatic as a bed change." Three weeks later, the Times affirmed that "medicare's start has been smooth."

There's nothing inevitable about the chaos we're seeing with the prescription drug rollout. If the program had been designed with patients in mind, it would have rolled out smoothly. But it wasn't. It was designed to benefit corporate special interests and to provide a test bed for crackpot free market theories.

What's more, we haven't even begun to hit the "donut hole" problems. That should start happening a couple of months before the midterm elections, which is poetic justice indeed. By then I hope that everyone knows exactly which party was responsible for all this.

UPDATE: Michael Hiltzik's column today is a pretty good wrapup of the whole prescription drug debacle.

Kevin Drum 11:58 AM Permalink | Trackbacks | Comments (71)

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Comments

I think "donut hole" pretty much sums up this whole administration, don't you?

Posted by: craigie on January 19, 2006 at 12:03 PM | PERMALINK

Donut wasn't the word I was thinking of.

Posted by: Joltin Joe Orsulak on January 19, 2006 at 12:04 PM | PERMALINK

So what happened on the day that this complex program was implemented?

Does Cohn admit that when Medicare was implemented, there were far, FAR fewer beneficiaries than can take part in the Medicare drug program today? Of course not. Because offering a fair analysis would undercut the DNC talking points.

Posted by: Al on January 19, 2006 at 12:07 PM | PERMALINK

Perhaps the whole purpose of this is to permanently discredit government support of healthcare ...something that Democrats have to support to win nominations...

I printed this quote yesterday, but what the hell, it's still relevant today!

"Republicans are the party that says government doesn't work, and then get elected and prove it."
-P.J. O'Rourke

Posted by: craigie on January 19, 2006 at 12:08 PM | PERMALINK

Does the Al-bot admit that when other people were president, there were far, FAR fewer complete fuckups than there are in this administration? Of course not. Because offering a fair analysis would undercut the RNC talking points.

Posted by: craigie on January 19, 2006 at 12:10 PM | PERMALINK

Perhaps the whole purpose of this is to permanently discredit government support of healthcare ...something that Democrats have to support to win nominations...
Posted by: Mcaristotle on January 19, 2006 at 12:04 PM | PERMALINK

Yes, if they do a bad enough job at the prescription drugs, people will never let the government touch healthcare again. Like when my wife forbid me from doing any more laundry: I ruined one too many of her garments...

Posted by: rusrus on January 19, 2006 at 12:11 PM | PERMALINK

But don't think your going to defeat the GOP in 06 or 08 on an incompetent rollout of this program, because your not. When the time comes, the GOP will scream Terrorists and all will be forgiven and the poor dems (me included) will be left scratching thier heads.
Plamegate,
Abramoff,
Tax reduction for the rich,
Iraq mess,
WMD,
NCLB,
Iran,
NK,
Medicare incompetenace,
and Katrina...don't mean shit to the American people when OBL is calling for attacks in the US as headlined in CNN this morning. And until the Dem figure this out and get strong on security, we'll be left behind racking our considerable brains for the nuiance of the problem.

Posted by: the fake Fake Al on January 19, 2006 at 12:12 PM | PERMALINK

Could we get some comments from actual healthcare professionals?

Just asking.

Posted by: obscure on January 19, 2006 at 12:17 PM | PERMALINK

don't mean shit to the American people when OBL is calling for attacks in the US as headlined in CNN this morning.

Yes, but why should this be so? Shouldn't the immediate reaction be "damn, that Bush guy said he would catch this guy and keep me safe, and now it's been 4 years and 200 billion dollars, and the fucker is still out there mocking us"

I truly don't understand how people process this...

Posted by: craigie on January 19, 2006 at 12:17 PM | PERMALINK

I see, Hhere we go again with the terror alerts just like i said,More to come as mid term nears.

Posted by: patton on January 19, 2006 at 12:20 PM | PERMALINK

Kevin,

No comments on the Maryland minimum wage bill? My brief comments, on my new blog, here.

Posted by: Marcus on January 19, 2006 at 12:22 PM | PERMALINK

No one believes Democrat legislation can use the same civil servants and yet generate a different result.

You're right. The Dems would use actual civil servants with actual skills, instead of an army of relatives and friends.

Posted by: craigie on January 19, 2006 at 12:23 PM | PERMALINK

"OBL calling for attacks"

Oh, heavens yes - What is the color stage today? Mauve, puce or ocher?

Posted by: thethirdPaul on January 19, 2006 at 12:24 PM | PERMALINK

It was designed to benefit corporate special interests and to provide a test bed for crackpot free market theories.

Not unlike our occupation of Iraq, and look at how chaotic that turned out to be.

Posted by: Gregory on January 19, 2006 at 12:25 PM | PERMALINK

Sorry to be so ignorant, but what's this donut hole reference I keep seeing?

Posted by: shortstop on January 19, 2006 at 12:27 PM | PERMALINK

I have a theory. Remember the K-Street Project. It was designed to provide a funnel of campaign money to Republican coffers. If you want to play in Washington you have to pay a Republican lobbyist. Big PharMA and the insurance companies hired Republican lobbyists. They spent millions making sure the benefit was carefully crafted to satisfy their needs. Poor people, on the other hand, didn't spend millions to hire K-Street lobbyists to represent their interests. They mistakenly thought members of congress were looking out for them. Of course, they were wrong. Republicans work exclusively for Republican lobbyists. If poor people had wanted the system to work for them they would have spent millions to hire Republican lobbyists to pay the Republicans the necessary tribute to secure an efficient drug benefit.

Clearly poor people are to blame for the inefficiency of Medicare Part D.

Posted by: Ron Byers on January 19, 2006 at 12:29 PM | PERMALINK

Sorry to be so ignorant, but what's this donut hole reference I keep seeing?

I think the new coverage has a "donut hole", meaning that it covers you up to a certain amount of expenses, then it doesn't cover you at all for higher amounts (the hole) and then at a still higher amount, you get coverage again.

Or, it refers to the anti-matter just between Bush's left ear and his right.

Posted by: craigie on January 19, 2006 at 12:30 PM | PERMALINK

Clearly poor people are to blame for the inefficiency of Medicare Part D.

I believe you have nailed it, and the whole GOP "philosophy" as well.

"We're only as good as the bribes we get."

Posted by: craigie on January 19, 2006 at 12:32 PM | PERMALINK
Sorry to be so ignorant, but what's this donut hole reference I keep seeing?

From healthinaging.org

Q: What is the "donut hole" I keep hearing about?

A: This refers to a period when no insurance for prescription drugs will be available. After total drug costs reach $2,250, you will pay an additional $2,850 out-of-pocket before Medicare Part D will continue coverage. This coverage gap is called the "donut hole." After this point Medicare pays for 95% of your drug costs; you will pay the remaining 5%.

Posted by: cmdicely on January 19, 2006 at 12:33 PM | PERMALINK

Craigie, completely agree, OBL should have been caught by now, and most Amers, about 60% apparently, see Bush as imcompetant. But he is strong on security, no? Security is what the GOP sells and security is what post 911 america is buying. And guess what, the dems don't have a strong security policy. Why the hell not!!! Its the biggest issue since 911 and the dems still can't agree on an easily articulated security policy.

Bush can...for better or worse...bring em on!

Posted by: the fake Fake Al on January 19, 2006 at 12:34 PM | PERMALINK

thanks. sorry I'm so lazy these days.

Posted by: shortstop on January 19, 2006 at 12:34 PM | PERMALINK

Shortstop,

Medicare covers you up to $2,200 - you are on your own until you have reached $5,100.

Could be off on the 2200, but it is this almost $3,000 difference that is referred to as the "donut hole".

Posted by: thethirdPaul on January 19, 2006 at 12:35 PM | PERMALINK

As someone with a great deal of professional experience with the Medicare program, both as an insider and an outsider, I can speak confidently on this subject. Implementing major policy changes becomes exponentially more complicated as the complexity/choice built into the policy increases, especially if you are implementing something entirely new to market place.

The original Medicare program was based on the Blue Cross/Blue Shield insurance model of the 1960s. State BC/BS plans were the first administrators of the Medicare program. They knew how to run their own insurance model. They had strong, trust-based relationships with doctors and hospitals. (In fact, BC/BS was created by doctors and hospitals.) The program was simple, if for no other reason that the computing capability didn't exist to support a very complex coverage and payment schema. The eligibility process flowed directly from Social Security and was handled by the countless field offices of the Social Security Administration, a mature and competent bureaucracy by the 1960s. Thus, you had trained professionals, doing what they already KNEW how to do.

Fast forward to 2006. Medicare "policy makers" are besotted by choice and intoxicated by what they perceive as the unlimited complexity that modern computing enables. You should see how many algorithmic hoops a hospital has to jump through just to get paid (inadequately) for a routine outpatient procedure on a Medicare patient.

As a result, we have an unbelievably complicated benefit being implemented by numerous insurers, many of whom have no experience with this particular benefit program, since nothing LIKE the repub-designed benefit has EVER been offered before. It is impossible for insurers, Medicare beneficiaries or pharmacists to understand this program and communicate about it to each other. Even computer programers, our modern-days masters of complexity, are having a hard time converting all the implementing regulations into correct algorithms. This IS a recipe for disaster. It doesn't help that the source legislation does incredibly stupid things like forbidding coverage for drugs like anti-seizure medication.

Taking the long view, I think the debacle of Medicare Part D will actually significantly advance the prospects of a much simpler, more universal health coverage regime in the U.S. After this, no politician, no matter how talented and devious, can successfully pass one of these "choice-based" private/public nightmares of complexity.

Posted by: rdb on January 19, 2006 at 12:39 PM | PERMALINK

rdb, thank you for your explaination. Well done.

Posted by: Ron Byers on January 19, 2006 at 12:41 PM | PERMALINK

Maybe this has already been thoroughly debated, but what would stop some state from implementing a form of universal health care? If they are left holding the bag on medicare part d, why not just pay for the whole shebang? Granted it would mean higher taxes on its citizens, but who wouldn't like to live there? My guess is that buisness would flock to the state, even in the face of higher taxes, as that health care expense would be gone. I know of a few corporations here in Michigan that would like to get out from under.

Posted by: newtons.third on January 19, 2006 at 12:42 PM | PERMALINK
Maybe this has already been thoroughly debated, but what would stop some state from implementing a form of universal health care?

Nothing. In fact, California has a proposal to do just that in SB 840. Though its harder for a state, since there are federal healthcare programs and federal/state joint programs where the interface needs to be handled somehow, whereas a single federal program can destroy all the interface issues by being one, single program.

Posted by: cmdicely on January 19, 2006 at 12:46 PM | PERMALINK

Medicare works pretty well, and seniors and providers understand it, more or less. There is probably a simple answer to this, but why couldn't Medicare just have been amended to add prescription drugs to the list of covered services? And then have the gov't use its clout to negotiate a reduced level of reimbursement for this steady supply of prescriptions? It would seem that not having to fund the incentives and subsidies for HMOs and the higher drug proices, plus all the added administrative costs with the new program, would enable the increased benefot to be close to fully funded.

Posted by: Mimikatz on January 19, 2006 at 12:49 PM | PERMALINK

Hi,
Check out the latest Political Comic from H.L.

Michelle Malkin Gets Manipulated

The Hollywood Liberal

If you like it there is lots more at Theres lots more at H.L. Comics Links
Thank You

Posted by: HL on January 19, 2006 at 12:56 PM | PERMALINK

Kevin D., read Mark Schmitt's latest at The Decembrist about what's behind this medical mess:

Cynicism and the Anti-Entitlement

... Sometime after the [Medicare prescription drug] bill passed, I tried to write an essay called, "Bad government is good politics." It turned out not to be publishable because it was largely speculative and because the Medicare bill was really the only example I had at the time. But I wish I"d stuck with it. . My thesis was that Republicans knew there would be a backlash against the Medicare bill, but they understood that it would take the form of a backlash against government in general, and that would be to their advantage. Seniors struggling over a dining table covered with complicated forms, small-print prescriptions, and no-win choices weren"t going to be muttering, "Goddamn Dennis Hastert, I"m never voting for his party again." They would be muttering, "Damn government, can't do anything right."

Seniors have been bonded to government, and hence to the Democratic Party, by the painless single-payer health system known as Medicare. The Medicare drug benefit would, in effect, reverse this bond. In another piece last year, I referred to the prescription drug benefit as an "anti-entitlement," because it takes all the advantages of an entitlement -- predictability, fairness, efficiency -- and turns them on their head. As I see it, the political goal of the Medicare drug bill was not to cement a new alliance between seniors and the Republican Party around a government program, but primarily to destabilize the old alliance.

Posted by: David W. on January 19, 2006 at 12:57 PM | PERMALINK

cmdicely,

Thanks for covering Shortstop's question. I tried to wing it.

Mimikatz,

Your comment is the logical response to the success of the program. However, this bill was designed to destroy the system. A short term gain for the Pharmas, money kicked back to the RNC and then the entire medicare system could be "proven" to be a failure. Junk it and have everything privatized. Thank whomever, that I have the VA, although they are underfunding that system as well.

Posted by: thethirdPaul on January 19, 2006 at 12:58 PM | PERMALINK

and most Amers, about 60% apparently, see Bush as imcompetant. But he is strong on security, no?

But this makes no sense. So what if he is "strong on security" if he is also incompetent at doing anything about it.

I'm pretty gung-ho on being able to flap my arms and fly to work. Sadly, I can't really make this happen. Should I be in charge of the FAA?

Posted by: craigie on January 19, 2006 at 1:04 PM | PERMALINK

Where are the Dems on this issue? Are any Dem leaders going to write opeds in newspapers on it? Maybe I'm just missing it, but do the Dems have anything to say about the President's prescription drug program? I mean, this is MEDICARE we're talking about here. I'm not sure if there is a more Democratic issue.

Posted by: KC on January 19, 2006 at 1:06 PM | PERMALINK

Your comment is the logical response to the success of the program. However, this bill was designed to destroy the system. A short term gain for the Pharmas, money kicked back to the RNC and then the entire medicare system could be "proven" to be a failure. Junk it and have everything privatized. Thank whomever, that I have the VA, although they are underfunding that system as well.

That's how the Republicans planned to destroy Social Security.

That's how the Republicans are destroying Amtrak.


And yes, that's how the Republicans are destroying the VA.

Posted by: Phoenix Woman on January 19, 2006 at 1:09 PM | PERMALINK

What is the average amount spend by Medicare recipients on drugs per year?

I suppose the gap can be thought of as a way to meet the bear minimum cost for drugs consumed by American seniors so that the Republicans can, "Hey, you're covered," but then to perversely incite the elderly to over-medicate (or doctors to over-prescribe) in order to drive higher sales to pharmaceutical companies. It's a really sleazy shell game.

Posted by: Demo on January 19, 2006 at 1:12 PM | PERMALINK

Does anyone else remember the dustup last summer over this Washington Montly article?

Solved! by Ezekiel Emanuel and Victor R. Fuchs

The Medicare Part D prescription drug program looks like a mini-version of their proposal -- a kind of trial run.

I guess it's not really funny since so many people are suffering with the new drug program.
Still it is kind of amusing to find that the many, many blog commenters who objected to the Emanuel/Fuchs plan as a potential nightmare were right.

Bloggers 1, Wonks 0

---

Posted by: Emma Zahn on January 19, 2006 at 1:12 PM | PERMALINK

I am a physician, and I can confirm that Medicare patients are frightened and confused about Medicare D. In my particular South Florida medical practice we have not yet had a real crisis, but remember that patients only refill their medications every 30 to 90 days. We fear that there may be a tsunami headed our way. Then again, there may not be, since we have been counselling our patients to NOT enroll in Medicare part D. What we have already noticed is a large increase in paperwork: we are being asked to fill out reams of special authorization forms for drugs that patients have been taking for years. Now, they need "special approval."
Every one of the fifty-odd plans has its own formulary, and exzperience with restricted formularies shows that they will change frequently; perhaps, even monnthly. There is no way at present that we can keep up with this, so that we prescribe only formulary drugs on the plan.

My greatest concern is for the many patients in our practice with HIV whose coverage is Medicare/Medicaid. They have been forced into Part D, and they will not be able to afford the copays. IDSA and HIVMA (doctor's associations) have been opposed to this aspect of Part D from the beginning, but they were ignored.

Kevin is dead on with his comments. A system - if it works at all - does what it is designed to do. It cannot be expected to incidentally do something else that it wasn't created to do. If it is designed to siphon public money into the vaults of pharmaceutical companies and insurance companies, then it will not incidentally provide good patient care, any more than a war launched on false pretenses to expand American hegemony over oil resources is likely to incidentally create a Jeffersonian democracy in the sands of Iraq.

So, intentions matter.

Posted by: Galen on January 19, 2006 at 1:16 PM | PERMALINK

"I think "donut hole" pretty much sums up this whole administration, don't you?"

Except for the lack of the donut. "All hole, no donut," is how I'd characterize them. Except that the "donuts" still cost $400 Billion in deficits as far as the eye can see.

Ed

Posted by: Ed Drone on January 19, 2006 at 1:17 PM | PERMALINK

Thanks cmdicely, it is good to know that. Maybe if CA passes it, they will have a sudden influx of people and business.

Posted by: newtons.third on January 19, 2006 at 1:17 PM | PERMALINK

Unlike the original roll out of Medicare, theamount of beneficiaries with this plan was a total known quanitiy, all the more reason the failure is so predictable. When I received my literature for my dear old mom, I was was totally befuddled as how this was going to be implemented. I am a college graduate with a degree in finance and have been handling her Medicare and insurance claims for years.

The next step will be the swift boating of any who criticize this ungodly mess of a program.

Like Abramoff, the GOP will try to smear the dems with the stench of this failure. Indeed, that is what they do best.

Posted by: dss on January 19, 2006 at 1:22 PM | PERMALINK

I understand that the Republicans wanted to destroy seniors' bond with gov't and the Dems, if not the Medicare program itself. I was actually asking a sincere question: Could it have been done just by adding drugs to the covered services and using gov't clout to negotiate lower costs? Because of if itcould have, that is a simple program to push. A reference at TAPPED suggests it could have been, but I'm still interested.

Posted by: Mimikatz on January 19, 2006 at 1:24 PM | PERMALINK

Medicare Katrina, Medicare Katrina, Medicare Katrina, Medicare Katrina, Medicare Katrina!

All we need is a name for this debacle.

Posted by: adam on January 19, 2006 at 1:33 PM | PERMALINK

There is probably a simple answer to this, but why couldn't Medicare just have been amended to add prescription drugs to the list of covered services? And then have the gov't use its clout to negotiate a reduced level of reimbursement for this steady supply of prescriptions?

This would have either been horribly expensive or required price controls on pharmaceutical companies. That wasn't going to sell on Capitol Hill.

The elephant in the room that neither party wants to look at, of course, is that, prescription coverage or not, Medicare as a whole is going broke. Unlike Social Security, where you can put a hand over one eye and pretend its going to be solvent forever, there's no such illusion here.

Of course, for politicians, that's Somebody Else's Problem.

Posted by: tbrosz on January 19, 2006 at 1:45 PM | PERMALINK

Does Cohn admit that when Medicare was implemented, there were far, FAR fewer beneficiaries than can take part in the Medicare drug program today? Of course not. Because offering a fair analysis would undercut the DNC talking points.

Als RNC talking points are misleading. 19 million people enrolled when Medicare began on July 1, 1966 vs 24 million Medicare Part D if you accept Leavitts own numbers (although it is hard to imagine why anyone would accept anything coming out of this administration as fact). Thats hardly far FAR fewer enrollees especially given that the advances in technology that have occurred over the 40 ensuing years

see Medicare stats here
http://www.cms.hhs.gov/MedicareProgramRatesStats/downloads/MedicareMedicaidSummaries2002.pdf
(p5)

ADP

Posted by: Andy on January 19, 2006 at 1:50 PM | PERMALINK

Mimikatz, the short answer to your query is "Yes". Medicare already pays for medications delivered via IV in clinic settings, and over the past few years, has begun covering oral chemotherapies taken home by patients. All covered by MC PArt B (Medical & Outpatient), with MC picking up 80% of "reasonable and customary", and the recipient/supplemental insurance/MA picking up the 20%. *Any* additional service, to include meds, could have been added on to that basic structure using a working system. It would have cost a bunch, but I'm not convinced it would cost more than the hoax perpetrated by Part D.

My son has MC/MA, and just received his card this past week. Spouse went to fill his meds, and waited 45 minutes as we discovered (for the first time) that two of his routine meds need prior authorization. The local chaim pharmacy pondered the issue, and deciuded to use some "special" process which they set up for these prior auth situations, but it was still a surprise. I think we're lucky. I'm hearing worse.

For the record, I'm a clinical social worker, worked in health care for 27+ years, oncology prcatice in a teaching hospital the last 15, and I've never seen a gov't program roll out so poorly (welll...Maybe Tommy Thompson's W2 program). I've spent hours with elderly clients, using my office , researching choice under D. I agree with the writer who described this as "all hole, no donut". Just remember: Part D is brought to you by the same folks who brought you Iraq and Katrina....

Posted by: NOC on January 19, 2006 at 1:50 PM | PERMALINK

Thousands of senior citizens simply went to the hospital and got the health care they needed.

What are we up to now? About 40 million or so? Already on medications and simultaneously switching to a new payment regime?

Posted by: contentious on January 19, 2006 at 2:04 PM | PERMALINK

I highly recommend Hilzoy at Obsidian Wings on Medicare.

Posted by: DonBoy on January 19, 2006 at 2:15 PM | PERMALINK

Chaos is always inevitable with conservatives and especially with the Bush administration.

This is news?

contentious: What are we up to now? About 40 million or so? Already on medications and simultaneously switching to a new payment regime?

Are you saying that the Bush administration, desite a year of planning, was utterly unaware of the number of individuals to be served by the program?

Thought so.

Sorta like they were utterly unaware of any possible insurgency in Iraq, despite a year of . . . oh, that's right, there was no planning for the war in Iraq (except by State, a plan that was rejected in favor of the no-plan approach).

So, we see that there is essentially no difference in outcome for the Bush administration whether they plan or don't plan ahead.

That's reassuring.

Not.

Posted by: Advocate for God on January 19, 2006 at 2:18 PM | PERMALINK

Al, that's the best you can do? There are so many more elderly today?

In 1965, 16 million Americans were enrolled in Medicare without a hitch. In 2005, an era of far superior techonology and communications, the Bush Administration can't keep its promise to 9.5 million people, just over half that number, to deliver a drug benefit.

Incidentally, of those roughly 9.5 million, fully 6.5 million, 2/3, are people who were already covered under Medicaid. For Chrissake, for 2/3 of the people it was just a matter of figuring out how to get the bills to go to Washington, DC instead of the state capital. And the incompetents in the Bush Administration even managed to screw that up!

Have I mentioned that the Bush Administration initially claimed they expected 40 million people to sign up for this benefit? Thank God only 3 million chose it.

Posted by: theorajones on January 19, 2006 at 2:31 PM | PERMALINK

the Bush Administration can't keep its promise to 9.5 million people, just over half that number, to deliver a drug benefit

Huh? There's going to be 28 - 30 million enrolled this year.

Posted by: Al on January 19, 2006 at 2:44 PM | PERMALINK

Really, Al? There will be 28-30 million enrolled? Do you have a magic ball?

Besides, you're conceding the point. The Bush Administration todaycan't competently deliver a benefit to 9.5 million people, while in 1965 Medicare competently delivered a benefit to nearly twice that number, 16 million.

Posted by: theorajones on January 19, 2006 at 2:50 PM | PERMALINK

This would have either been horribly expensive or required price controls on pharmaceutical companies. That wasn't going to sell on Capitol Hill.

By "price controls", I assume you mean "negotiating on price?" I work in Federal acquisitions and the Government sure as hell isn't shy about getting the lowest price from vendors under normal circumstances.

That's all that the Canadian government does differently: it uses its enormous buying power to negotiate lower prices from suppliers. Nobody's holding a gun to the heads of the drug companies to sell their drugs under the Canadian plan.

Posted by: ericblair on January 19, 2006 at 2:52 PM | PERMALINK

Mimikatz asked "but why couldn't Medicare just have been amended to add prescription drugs to the list of covered services? And then have the gov't use its clout to negotiate a reduced level of reimbursement for this steady supply of prescriptions?"

Because that would have eaten into the profits of Pharma, silly! This was written to INCREASE Pharma's profits, not decrease them. Don't you know anything?

Every single bit of legislation passed by the Republican Congress is either written to increase profit for some sector of big business, or to impose their "morality" on us lesser beings.

Posted by: Cal Gal on January 19, 2006 at 2:54 PM | PERMALINK

TNR?

No thanks.

Posted by: luci on January 19, 2006 at 3:02 PM | PERMALINK

After extensive research and attending a meeting put on by a drug insurer for my in-law's benefit I have learned some about this system. One thing that stands out is that the insurance company's own representatives have stated that the amount spent first each year will be tracked by medicare to show when the recipient has reached the deductible level (usually $250). This must be tracked so that the pharmacy knows when to begin to charge a co-payment. Then the copayment must be tracked so that the lower level of the donut-hole is reached so that the pharmacy will know when to begin charging the recipient the total amount for the drugs. All expenses, deductible and co-payments, must be tracked to determine when the lower level of the donut hole is reached because it varies with every insurance company and copayment. This all must be tracked at some central point of organization because the recipient might switch pharmacies or be travelling and need drugs. With the problems all ready showing up, I cannot believe what a mess this will be. The insurers say that they will not be tracking this nor will the pharmacies.

Posted by: MRB on January 19, 2006 at 3:06 PM | PERMALINK

Medicare is a impending financial disaster and this drug benefit, which is a giant gravy train for big pharma, is making it worse.

In their joint 2005 annual report, the trustees of Social Security and Medicare summarized the situation this way: "The financial outlook for Social Security has improved marginally since 2000... In sharp contrast, Medicare's financial outlook has deteriorated dramatically over the past five years and is now much worse than Social Security's."

(see http://www.ssa.gov/OACT/TRSUM/trsummary.html)

Republicans want to dismantle Social Security by privatizing it, and Medicare by bankrupting it.

Posted by: Will on January 19, 2006 at 3:15 PM | PERMALINK

Let's see, Stalin starved around 20 million people during his forced collectivization of agriculture.

The Bush Medicare plan, while it certainly won't kill that many people, is almost certain to kill any number of people. Like their feeble..err, FEMA response to New Orleans. All in the glorious name of forced privatization.

Stalin was evil because, despite his intentions, he caused widespread suffering and death. Cannot the same be said of the current regime in Washington?

Posted by: Dr. Morpheus on January 19, 2006 at 3:22 PM | PERMALINK

Humana proudly claims the new program lets you easily predict Rx costs thoughout the year. They provide a Rx Calculator to make the predictions. It shows the effect of the Donut Hole problem.

Go to http://www.humana-medicare.com/, fill in your ZIP code and follow the intructions to look at the plans and look for the "Calculate Rx Costs" link.

I calculated my mother's suite of presriptions and here are the results for just Lantus in the HumanaChoicePPO R5826-006 Prescription Drug Plan:

Month 1 You Pay $75.00
Month 7 You Pay $182.40
Month 10 You Pay $514.44

Month 7 is when the total Rx costs (for all drugs) enter the Donut Hole, only partial help from part D.

Month 10 she would be paying full cost for all Rx's until she spends over $3600 when Part D would come into effect again.

(Everyones costs would look different depending on what drugs are being purchased.)

So, that $75 looks decent compared to what she's paying using the drug discount card right now. She'll be paying over $500 at the end of the year when she's in the Donut Hole where Part D doesn't cover Rx's.

Overall, for all her drugs, this plan's annual costs save about 4% versus the prescription drug card, but if she's not saving now for the higher costs later in the year, it's the old Food vs Rx dilemma.

Lots of people will be paying full cost for Rx's when the elections come around.

Posted by: fracas_futile on January 19, 2006 at 3:57 PM | PERMALINK

From Hiltzik's column:
It's worth remembering that the prescription drug program was born in an act of fraud. The Bush Administration sold it to Congress in 2003 by estimating its cost at less than $400 billion over 10 years. Scarcely a month after its enactment, the White House issued a new estimate: $535 billion. That figure might well have killed the bill, which had passed the House by a razor-thin margin even with the lower price tag.

It soon came to light that Richard Foster, Medicare's chief actuary, had known of the higher estimate - but had been told he'd be fired if he warned Congress before the vote. (The current estimate is $700 billion.)

As written, the legislation complied with a drug industry demand that Medicare be prohibited from negotiating with manufacturers for lower drug prices. Among those helping the industry make its stand was Rep. Billy Tauzin (R-Louisiana), whose committee on energy and commerce oversaw Medicare. In an odoriferous development, Tauzin soon quit Congress to become president of the Pharmaceutical Research and Manufacturers of America - Big Pharma's Washington lobbying group.

Bush lovers, over to you.

Posted by: craigie on January 19, 2006 at 3:57 PM | PERMALINK

Sorry, Will. Medicare was going broke before Bush was elected, or Clinton, for that matter, and it would be going broke no matter who was in the White House now.

Any additional drug benefit, either the Democratic plan or the Republican one, just adds to the load.

Posted by: tbrosz on January 19, 2006 at 4:30 PM | PERMALINK

And, as we know, invasions of defenseless countries are much more important than drugs or benefits to American citizens.

Posted by: MRB on January 19, 2006 at 5:06 PM | PERMALINK

Indeed, tbrosz and mimikatz, that was the chief problem with simply adding a drug benefit to traditional Medicare: the program is already burdened by runaway costs. It certainly could have been done, though, given the political will and enough of the taxpayers' money. Can you imagine, though, what the Repugs would have said (screamed?) if Dems had proposed $535 of additional government spending to add a prescription drug benefit to Medicare? Yet, that would have been a sensible alternative compared to this bureacratic nightmare they've created.

Such a program could be administered at the state level, but states have been afraid to tackle the problem because of the huge potential costs; nonetheless, something of this sort was accomplished by Howard Dean, when he was governor of Vermont. Sorry, I'm short on details, but I understand that he began by expanding the state Medicaid program to include all children. He then continued on in a patchwork way until they had cobbled together some form of health care coverage for every citizen of the state (not necessarily prescription drug coverage, though, for those outside traditional Medicaid). As noted upthread, a more ambitious program was proposed for California, so such projects can be undertaken at the State level (or the Federal, for that matter) by intelligent, progressive people who are pragmatic and have good intentions.

That was not the case here. Remember that this is the Republicans second try at replacing traditional Medicare with a managed care product. The first time, most of the MCO's lost money and bailed out. They are great at collecting premiumsfrom healthy young people and then denying covered benefits, but when it came to actually providing medical care to sick, older people who really need it they fell flat on their faces. Young people are where the profit is; old people are where the costs are. This time, the Republicans are using the sugar coating of the prescription drug benefit to get people signed up (plus the explicit threat of financial penalties if they don't enroll RIGHT NOW -- how reprehensible is that??). In addition, they've sweetened the pot for the MCO's by increasing the subsidies (what they pay per enrollee) beyond what standard Medicare pays now (that is: care in the vaunted private sector will actually cost the taxpayer more). The whole deal is greased with a half-trillion dollars of our money, borrowed from China with IOU's that are to be paid back for the rest of the foreseeable future out of working peoples' paychecks.

Sweet.

I'm sure that their ultimate goal is to push everyone off traditional Medicare through some combination of sticks and carrots, then shut the program down forever. Whatever happens after that is someone else's problem.

Medicare is actually quite efficient at delivering care, compared to managed care. Does it have structural problems? Yes. Can it be fixed? Probably, but first you have to be interested in making the program work. They aren't. They want to kill it.

Posted by: Galen on January 19, 2006 at 5:25 PM | PERMALINK

"The sky is falling! Medicare is going bankrupt!"

Medicare's costs are spiraling out of control no faster than anything else in our healthcare system. In fact, Medicare's costs are spiraling slower.

You want to fix Medicare, you have two options: fix the healthcare system, or let old people die.

But Medicare isn't the real problem. The healthcare system is--for years, we've spent money to appease every speical interest group from pharma to insurers. Better care can be provided for less money. It just takes the political will to get it done.

Posted by: theorajones on January 19, 2006 at 6:27 PM | PERMALINK

"But Medicare isn't the real problem. The healthcare system is--for years, we've spent money to appease every speical interest group from pharma to insurers. Better care can be provided for less money. It just takes the political will to get it done."

Exactly. Couldn't agree more. Can't say it better.

Posted by: Galen on January 19, 2006 at 6:52 PM | PERMALINK

>>Newspaper accounts from the '60s back him up. Under the headline "medicare takes over easily," a Post writer described the program's first day as "a smooth transition, undramatic as a bed change." Three weeks later, the Times affirmed that "medicare's start has been smooth.">>

Well of course! That was just liberal media selling another big-gov't preempt of private enterprise.

Posted by: csp on January 19, 2006 at 7:07 PM | PERMALINK

"Political will" is a nebulous concept, and I've seen some awful things done in its name. Got any details on how "political will" would reduce medical costs?

One rational idea I have seen involve standardized recordkeeping. Maybe there are others. But if we're heading for chopping doctor's salaries, or nationalizing medical industries, you might have a problem.

MRB:

And, as we know, invasions of defenseless countries are much more important than drugs or benefits to American citizens.

Just for perspective, if we spent what Canada does on health care (about $3,700 per capita last time I looked, in U.S. dollars), our annual bill for a similar system would be about $1.1 trillion dollars.

Some people have said that the war in Iraq will eventually cost a trillion dollars overall. That's one year of universal health care for the U.S. And then there's the next year, and the next...

Posted by: tbrosz on January 19, 2006 at 7:17 PM | PERMALINK
Just for perspective, if we spent what Canada does on health care (about $3,700 per capita last time I looked, in U.S. dollars), our annual bill for a similar system would be about $1.1 trillion dollars.

Just for perspective, if we spent what the US does on health care ($5,670 per capita in 2003), we'd be spending a lot more than that ($1.67 trillion in 2003). source.

Some people have said that the war in Iraq will eventually cost a trillion dollars overall. That's one year of universal health care for the U.S.

Or, looked at a different way, given your assumptions, less than two years of the cost savings from universal healthcare versus the status quo system.

So, if you want the economy to be able to support the kind of military interventionist foreign policy the Right seems to favor, the smart thing to do would be to adopt universal healthcare to pay for it.

Posted by: cmdicely on January 19, 2006 at 7:25 PM | PERMALINK

smart thing to do would be to adopt universal healthcare to pay for it.

Posted by: cmdicely on January 19, 2006 at 7:25 PM | PERMALINK

Its going to take more than legislation to get US costs down to Canadian levels.

I'd say doctors and nurses earning Canadian wages would be a start. And a Canadian tort system next.

So how do you pay off a US med school debt earning a Canadian medical wage?

Posted by: McA on January 19, 2006 at 10:59 PM | PERMALINK

oddly enough, according to payscale.com, I would make more in toronto as a pediatrician than is average for california ... and approx 20% lower than NYC. ...

I can't vouch for this site, and I actually don't know any canadian MDs which I can get anecdotal evidence from, but on first pass, the pay scale for PCPs seems fairly equal accross the board and accross borders. It's an interesting question, and one which I will look into, and see how it is affected by location, specialty, and subspecialty.

... and regardless, we'd eventually pay it back. the discrepancy clearly isn't so large that any MDs are going to starve.

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Posted by: 免费电影 on January 20, 2006 at 9:38 AM | PERMALINK

If a medication is not listed in a plans drug list, you can request that it be included. I called AARP on behalf of a friend, and asked if they would cover a specific drug he needed. The rep said, You have to sign up for the plan, and then we inform you of our decision.

I told him that was insane, and he said that was the policy of ALL the plans.

Well, THAT had to be hard-sell bullshit, so I called three other plans, and by golly, hes right!

Oh, the companies can also eliminate any drug from their covered list at any time.

Any questions about who wrote this law?

Posted by: Jay on January 21, 2006 at 12:21 PM | PERMALINK

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