Sam Uretsky

Puzzling Out Medicare Drug Card Maze

Sen. Charles Grassley, R-Iowa, chairman of the Senate Finance Committee, said of the new Medicare prescription discount card, "The drug discount card program has been the target of a deliberate campaign to discredit it and confuse seniors about how it works.'' What Sen. Grassley overlooked is that most of these critics are the seniors who have tried to decide which card to select.

One of the classic Aesop fables is the one about the fox and the stork. In the fable, the fox invites his friend the crane for dinner and serves soup in a shallow bowl, convenient enough for the fox, who can lap at the soup, but impossible for the bird, who can do no more than wet the tip of his long beak. The discount plan was, with what seems to be typical Republican efficiency, designed to benefit the insurance companies, with no particular regard to the elderly. The system is rather like programming a VCR to record a show that immediately follows a football game &endash;- it's a lot of work with no guarantee that you'll get what was promised.

Selecting a plan to enroll in is itself unduly complicated. In theory, competition brings prices down. In practice, the so-called competition just leads to confusion. The Internet system that's designed to help people select which plan to join offers representative prices for a list of supposedly representative drugs. This may be useful for anybody who is taking these drugs, and only these drugs, assuming that the prices are accurate, the list of participating pharmacies is accurate and that the patients can assume they will be taking the same drugs for a full year and that the prices will be held constant for a year. This is clearly one of the administration's faith-based programs. The only certainty is that anyone enrolled in a specific plan has to stay with that plan for a full year. Medical necessity (or physician's whim) may force a change of drugs, the insurer may change the prices as often as once a week, the local pharmacy may go out of business, but the patient is locked into one plan, and only one, for a full year. The technical name for this is "bait and switch." No wonder people don't understand the plan.

Nietzsche once wrote, "He who has the power to name has the power to slay," and George Bush, or perhaps Karl Rove, has taken this to heart. The "Clean Skies Act" helped encouraged increased air pollution, the "No Child Left Behind Act" harmed education, "Operation Iraqi Freedom" replaced homegrown martial law with an imported version and the Medicare Prescription Benefit Plan benefits not the elderly but the insurance companies.

This is a reflection on both the current state of government and the insurance industry. In a truly competitive environment, one of the key elements of competition would be in responsiveness to customer needs. Price is one form of competition, but courtesy and service matter too. A thoughtful clothing manufacturer, faced with an aging customer base, might leave just a bit more room in the seat without relabeling the size. A car manufacturer might make wider doors, a watchmaker might put on larger numbers and an insurance company might use smaller words in a larger typeface. But the neocons manage to believe in private industry without necessarily believing in competition. These are the people who gave Halliburton the deed to Iraq without inviting anybody else to bid. They're the people of the Boeing tanker-lease deal, the ones who rewrote the Clean Air Act in a way that wiped out 10 of FirstEnergy's 11 violations. The New York Times reported that employees at 28 firms and their parent companies certified by Bush administration to be national distributors of discount prescription drug cards contributed $1.8 million to Republican candidates in this year's election, including $275,000 to Bush's re-election campaign. Corporations no longer need to be pioneering when they can become Pioneers.

It's an article of faith among the neocons that government programs are bad and private industry is good. There may be some things that private industry does better than government, but the simple reality is always going to be that government has an edge when it comes to shared risk and responsibility programs. That's because government is better at getting the maximum number of people into a pool.

Health benefits are shared risk; everybody pays a small amount, and those who are sick get the benefit. Since government can get the largest number of people to pay in, as with traditional Medicare, the risk is shared most widely and the cost for any single person is lowest.

Insurance companies deal with smaller groups of people. This drives up each person's share of the risk and the administrative costs. According to American Medical News, in 2003, Dr. John Rowe, CEO of Aetna, received a compensation package worth $18,227,653. This sounds like a lot, but falls behind such luminaries as Larry Glasscock, CEO of Anthem, at $24,969,719 and Dr. William McGuire of United Healthcare who received a total package worth $94,180,531. The average health insurance CEO, collecting salary, bonuses, stock options and other goodies, went home with $22.6 million last year. Salaries like that are part of the shared risk that policyholders have to assume. Economically, it's better to be in an insurance pool with 12 people who need liver transplants than get stuck with a share of the cost of a single insurance company CEO.

A prescription drug plan under Medicare could have been a real benefit for the elderly and edged our nation marginally closer into line with the rest of the civilized world, where health care is a right. Instead, we're given a system that continues to reward CEOs and shows little concern for the welfare of the claimed beneficiaries.

As many people have already pointed out, the best drug discount card is still a bus ticket to Canada.

Sam Uretsky is a writer and pharmacist living on Long Island, N.Y.

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