Never trust the recipe for roast pork in a Kosher cook book. It's not that the Republican Party can't design a social benefit program, it's just that they tend to forget whom they're trying to benefit. Given the competing voices of the insurance industry and the pharmaceutical manufacturers, along with the doctrine that the private sector is always somehow smarter and better than the government, the needs of the elderly got drowned out.
Like the kid's game Fanny Dooley, Republicans like government money, but they don't like government programs. The result is a giveaway that rivals the Halliburton no-bid contracts in Iraq, with, if possible, less justification.
Perhaps one sign of the problem can be found in Slate's report (Slate is an online news magazine owned by the Washington Post), written by a former assistant editor who is now working as a social worker in Seattle. Commenting on a New York Times report on people having trouble understanding the Medicare plan, the writer went to the Medicare site, typed in the name of one drug, Seroquel, and was given five plans available in the Pacific northwest that cover the drug. While he admits to being a bit more "tech-savvy" than the average Medicare recipient, he concludes that "at first glance the law may not be quite as needlessly bureaucratic as the Times piece implies."
What part of "Medicare recipient" doesn't anybody understand? The demographic includes 65-year-old engineers who take one or two drugs for hypertension, but it also includes older people, taking a collection of drugs for hypertension and arthritis and Type II diabetes. It includes people whose familiarity with new technologies stopped at the abacus.
Beyond that, the demonstration of how to use the on-line resource requires Windows XP and Internet Explorer. According to the Washington Post, only 23% to 30% of seniors go on-line anyway. These people are faced with a bewildering array of choices, covering different drugs at different prices. Compared to this, picking a barbecue sauce at a high end supermarket is a snap.
According to the Kaiser Family Foundation, only 20% of eligible people have expressed the intention of enrolling in the plan, while 43% have yet to decide. The Kaiser report indicates that only 5% of the seniors surveyed understood the number of choices they would be faced with.
The report finds seniors evenly split in their opinion of the program: 37% have an unfavorable view, 31% view it favorably and 31% don't know. Beyond that, a small majority of seniors assume that their physicians and pharmacists will help guide them in selecting a plan.
This is simply unrealistic. Health professionals, if they've taken the time, may be familiar with the details of the program, but not with the details of each individual plan. That's one of the problems with the system as it exists today, and will only get worse if things are left alone. Every insurer sets up its own rules, including a formulary, a list of drugs that may be eligible for a lower co-payment, or in some cases, the only drugs that the insurer will pay for at all.
These formularies are generally rational -- although they can be seriously flawed -- but the details often aren't available until after an insurance claim has been placed and then rejected. When an octogenarian has gotten somebody to take her first to the physician and then to the pharmacy, it can be a real hardship to be told that she has to get a prescription for a different drug than the one prescribed because the insurer can save a few cents. Sometimes the rejection notice will say that the insurer won't cover the 25 milligrams tablet, but they can prescribe the 50 milligram tablet and the consumer must cut it in half.
The first observation is that those who designed this plan never gave much thought to the needs of the elderly. The second is that those who should have known better weren't thinking.
The legislation for this boondoggle was helped by the endorsement of the American Association of Retired Persons, the AARP, which said it was "a start." Even the New York Times has suggested that the flaws in the plan can be repaired by additional legislation. But the reality is that Part D is in place, guarded by about $30 million in campaign contributions from the drug companies in 2002, 75% of which went to Republicans. After paying that kind of protection money, the corporate beneficiaries don't have much to worry about.
Medicare can be fixed, and the US can have an efficient, single-payer healthcare system just like the rest of the developed nations. Unfortunately, it may be necessary to take a few steps back to achieve that goal. The first step towards improved health care for all Americans may be campaign finance reform.
Sam Uretsky is a writer and pharmacist living on Long Island, N.Y.