Medicare Part D: D is for Disaster!

1. Medicare Part D: D is for Disaster! Thursday, Oct. 12, 2006 PROGRESSIVE WOMEN'S COMMITTEE Jackson, California Margie Metzler 916-921-5008 margiemetz@hotmail.com Website: www.gpcal.org This program operates under a grant from the California Wellness Foundation

3. Issue that Resonates: Medical Care • We pay more than other countries and get less • We are sicker on average than other countries • We are the only country where business provides coverage • US Businesses realizing they can no longer compete with countries with universal health coverage

4. Can this issue engage voters? • It’s a life and death issue! • Medicare Part D provides a visible example of how privatization fails! • Everyone will get Medicare at some point (if they don’t destroy it…)

6. Five key reasons why Medicare works • Automatic and reliable coverage; health security • Good choice of doctors and hospitals • Negotiated and reasonable prices • Affordable protection from the financial risk of needing costly health care services • The same cost and coverage regardless of where you live or your health status

7. Overview of the Presentation • What is the Medicare Prescription Drug, Improvement, and Modernization Act of 2003 (MMA)? • How was it designed to work? • How was the rollout? • What’s wrong with the program? • Where are we now? • What can we do?

8. What is the Medicare Prescription Drug, Improvement, and Modernization Act of 2003? • Designed to Support Pharmaceutical and Insurance Companies • Forbids Medicare from negotiating drug prices with the pharmaceutical industry • Gives drug companies power to charge high prices under Part D • Forces you to pay high costs for drugs • Gives billions of dollars to HMOs and other Medicare private health plans

9. Basics • The Medicare Prescription Drug Improvement and Modernization Act (MMA) was passed in Dec. 2003 • It was the most sweeping change in Medicare’s 40 year history, and the most chaotic • Administered by CMS and SSA • CMS: Rx Program • SSA: Extra help for low income people • Provided by private insurers (not regulated by any state) • Private Drug Plans (PDP) • Medicare Advantage -- Prescription Drug (MA-PD)

10. Structure of Standard Benefit • Monthly Premium • Varies: average is $25 • Can be deducted from your SS check or paid directly to plan • Annual Deductible • In 2006, can’t exceed $250 • Initial co-payment • 25% of covered costs between $250-$2250 • Catastrophic Coverage • After $5100, 5% of covered costs, or $2 generic/$5 brand name

11. How was the Rollout? • How come a Senior plan, 25% Internet users, was completely designed for the Internet? • How come we used the most vulnerable non-computer users in our country as a test group in January? • How come no one thought of hiring more people to answer phones etc.? • How come nobody thought abut the blind, homebound, non-English speakers, TTY users, people who are functionally or cognitively impaired?

12. How Does it Work? • You go to the CMS Website or call them to register. You research all the CA 48 plans (and their tiers). Or contact HICAP. • You choose a plan based on the drugs they cover, so you need to know what illnesses you will have during the year. • Administered by CMS and SSA: • CMS: RX program • SSA: Extra help for low income • You pay a monthly premium. • If you didn’t sign up by May 15 you pay a penalty for life. • You pay a co-pay for each drug. • You pay 100% while in the annual doughnut hole.

13. More on Enrolling • Compare plans in your state • Check your Rx and your preferences, and do the math! • Pharmacy in your area? • Are your prescriptions in their Formulary? • Premiums? • Deductibles? • Co-pays? • Coverage gap?

14. What’s not Fully Covered? • Some Drugs are specifically prohibited by MMA • Over the counter, cosmetic and weight loss • Benzodiazepines and Barbiturates • PDPs may offer a prohibited drug as an extra benefit, except for Benzodiazepines and Barbiturates • PDPs can place other restrictions • Syringes etc. not covered

15. Other Limitations • Prior Authorization (PA) – the PDP can require approval of a prescribed medication before it can be filled • Quantity Limits (QL) – the PDP can restrict the number of doses of a drug for which it will pay • Step Therapy (ST) – the PDP can require the patient to try a lower-priced drug before approving a higher-cost one

16. What else is wrong with the MMA? • No negotiating for best prices! • States can’t regulate • Late Enrollment Penalty: 1% penalty per month and the penalty lasts forever • Some retirees lost their creditable coverage for good • You are supposed to have choices, but get few tools to help you be informed • Originally, insurance co’s could change prices, formularies, co-pays, deductibles at will, but you couldn’t change until Nov. enrollment period. Your complaints caused the CMS to change this.

17. How are we now? • Five months past the May 15 deadline • Nov. 15 to Dec. 31 is new enrollment period (Really, Dec. 6) • 90% of Medicare recipients now have some sort of coverage. Most always had creditable coverage. • The 2 most popular plans are United Health Pacificare, AARP’s plan, and Humana, the cheapest. • 4-5 million seniors still don’t have coverage; of those, 3 million could qualify for low income coverage

18. More Surfacing Issues • The appeals process is awful (S 1335 would help) • Marketing misconduct (Blue Cross and Secure Horizons) • Fraud • Pharmacists financial hardships • Doctors Spending Hours Contending with Medicare Part D - Patients Confused and Concerned - Limited Number of Drug Companies Viewed as Helpful According to The J. Scott Group:http://www.genengnews.com/news/bnitem.aspx?name=2314775 • Medicaid recipients: proof of citizenship requirements as of July 1

19. Don’t Blame the Pharmacist! • Pharmacists are on the frontlines: paying co-pays and other costs. • Many of them are working hand-in- hand with the rest of us advocates. • They are going out of business (esp. independents)

20. We want legislation that… • Allows seniors to receive prescription drugs directly from Medicare • Requires Medicare to negotiate with drug companies: reduce confusion, and money saved could eliminate subsidies to insurance companies and close the donut hole. • Waive premiums when there is no coverage. • Donut hole: count all drug costs incurred, not just expenses for those on the insurance plan’s formulary. • Or… eliminate the donut hole

21. Give us legislation (2) • Eliminates the lifetime penalty for seniors until the whole plan is overhauled. They currently face up to a 7% penalty • Liberalizes the assets test so more are eligible for extra help. (60% of those who applied were ineligible due to the stringent test.) • Increases funding to provide counseling and education to beneficiaries and caregivers. • Revisits the income-based premium structure that “means tests” Medicare for the first time • Easier enrollment

22. Give us legislation (3) • If Dr. prescribes it, you can have it • Eliminates co-pays for duals • Provides a system for resolving issues “at the counter” • Provides open enrollment any time the plan makes changes to formulary • Provides a single standardized appeals process, widely publicized • Monitors plans and sanctions them if they do not comply • Makes prices public

23. Where is such legislation?? • 55+ bills have proposed which provide parts of the previous changes • Not one of these bills has been allowed by committee heads to be discussed, let alone voted on • Read about all of them at www.gpcal.org/documents/fedleg.pdf • Talk to every Senator, Representative, and candidate and press for change

24. Where You Can Go For Help • National Committee to Preserve Social Security and Medicare: http://www.ncpssm.org/medicare/ (a national, nonprofit organization) • Health Insurance Counseling and Advocacy Program (HICAP): Call 1-800-434-0222 to reach your local HICAP or go to www.calmedicare.org • Social Security: 1-800-772-1213 or go to www.ssa.gov • Center for Medicare and Medicaid Services (CMS): Call 1-800-MEDICARE or go to www.medicare.gov • CMS Region IX, San Francisco: Part D plans, (415) 744-3628; Advantage Prescription Drug Plans, (415) 744-3617 • Low income subsidy: go towww.ssa.gov/prescriptionhelpor call 1-800-772-1213 • Medi-Cal Emergency Drug Benefit: http://www.medi-cal.ca.gov • Medicare Advantage—Medicare Managed Care Manual, Ch. 2: http://www.cms.hhs.gov/manuals/downloads.mc86c02.pdf • The Health Consumer Alliance: http://healthconsumer.org

25. Senators http://www.senate.gov/ Boxer, Barbara- (D - CA) 112 Hart Senate Office Building, Washington, 20510 (202) 224-3553 Web form: www.boxer.senate.gov/email.html Feinstein, Dianne- (D - CA) 331 Hart Senate Office Building, Washington DC 20510; (202) 224-3841 Web Form: www.feinstein.senate.gov/email.html Representative http://www.house.gov/ Dan Lungren http://www.lungren.house.gov/feedback.shtml http://www.lungren.house.gov/index.shtml Or…. Bill Durston, http://www.durstonforcongress.org/ 916-622-VOTE (916-622-8683) Mail: Durston for CongressP.O. Box 190Rancho Cordova, CA 95741 Fair Oaks Office 4142 Sunrise Boulevard Fair Oaks, CA 95628(916) 961-2866 Federal Congresspersons

26. What do we need? A Real Drug Benefit: • You can use your Medicare card to get the drugs and doctor and hospital services you need at a reasonable and affordable price • A simple, fair and cost-effective way to ensure that every American with Medicare who needs medications gets them

27. CIRCULATE & ADVOCATE • Contact your Senator and Representative in Washington • Contact the Media! “Only media attention gets change.” • Talk to others about the problems with Part D and urge them to join the fight • Legislation: Over 55 bills have been put forward to fix problems; go to http://www.gpcal.org/documents/fedlegpartd.pdf for a complete list. Some of the best include HR 3861, the Medicare Informed Choice Act (Stark, Schakowsky) to extend the deadline; HR 752 (S 873 in Senate) (Stark, Berry) the Medicare Prescription Drug Savings and Choice Act, to create a uniform drug benefit in Medicare and require that Medicare negotiate for the best possible prices; S. 1335, the Justice for Medicare Beneficiaries Act of 2005 (S. 1335), (Christopher Dodd, John Kerry, Edward Kennedy and Jeff Bingaman) ensures that Medicare beneficiaries who are denied health care benefits can appeal these denials in a meaningful way. • To track legislation: http://www.govtrack.us/ • Library of Congress site for Legislation http://thomas.loc.gov/ • Don’t vote for anyone unless they support this fight!

28. Let’s Change our Language (Lakoff-ian Stuff) • Don’t blame Medicare, blame privatization! • Don’t talk of “enrolling” in a program, talk about buying insurance. • HSA’s: they’re not savings accounts; they’re High Deductible private insurance plans • Remember, health care is a value. Talk it up!