July 19, 2002 | WebMemo on Health Care
Members of the Senate are trying to outdo each other in offering senior citizens a prescription drug benefit under Medicare. In this feverish process, many policymakers are drafting badly designed legislative proposals that lack the serious structural reform necessary to improve the Medicare program -- guaranteeing an explosion of new costs that further jeopardizes the program's future.
There is no disagreement about the need to integrate prescription drug coverage into Medicare's benefit structure. Since Medicare's inception, the pace of medical innovation has been dramatic. There has been a revolution in the ability to diagnose and treat illnesses, and much of that improvement has come from the development of effective pharmaceuticals-true wonder drugs that can extend and improve the lives of millions of people. But Medicare's benefit structure has not kept pace with these improvements in modern health care.
The national debate, then, is over the best way to deliver the drug benefit. Instead of trying to craft a complicated and highly regulatory Medicare drug program, Congress could give direct and immediate assistance to those senior citizens most in need who do not now have access to drug coverage, primarily those with lower incomes. Congress could do this simply by combining a prescription drug discount card with a generous federal subsidy to cover senior citizens' routine drug costs, coupled with a plan to provide private financial protection against the high drug costs facing some seniors. This not only would solve the problem of senior access to drug coverage, but also would be a crucial first step toward Medicare modernization.
Why the Leading Senate Drug Proposals Would Make Matters Worse
There is more at stake in the policy debate than simply making pharmaceuticals more affordable for seniors. Decisions made about the way that benefit is delivered can affect the nature of health care in this country. Will patients and their doctors continue to have an ability to choose the best medical treatment? Will researchers find new cures and continue to develop new drugs with fewer side effects to treat patients more effectively? Can the Medicare program remain financially sound with the addition of an expensive new benefit?
The Graham-Miller-Kennedy Proposal.
The prescription drug benefit proposed by Senators Graham (D-FL), Miller (D-GA), and Kennedy (D-MA) raises precisely those questions. Their bill proposes a massive government-controlled drug benefit that is scheduled to end in 2010. This program sets drug prices for seniors at $10, $40, or $60, and the federal government would pay all costs once a beneficiary has used $4,000 worth of drugs. Unlike other proposals, the stop-loss provision is triggered by a beneficiary's total drug spending, not just the amount spent out-of-pocket.
The proposed program would exacerbate Medicare's managerial inefficiency and waste, and could drive the price of prescription drugs to new heights. There would be little incentive for the benefit administrators to drive a hard bargain for discounts from pharmaceutical manufacturers since the government would pay them dollar-for-dollar for the costs of the drugs. Drug prices are likely to increase under this plan, since every dollar saved by the administrators would reduce their payment by a dollar without adding to their profits.
The Graham-Miller-Kennedy bill would likely cost taxpayers about $650 billion over the next decade without the 2010 sunset provision, making it the largest single benefit expansion in Medicare's history. That estimate could, in fact, seriously understate the program's true costs.
And for this, a highly diverse class of Medicare beneficiaries would get a one-size-fits-all drug benefit. Premiums and benefits would be uniform nationally, and beneficiaries would not be able to select a less expensive drug plan. They would also have first-dollar coverage, which would blunt any incentives for efficient use of prescription drugs.
It is unlikely that the Senate could enact such a benefit without resorting to price controls. Price controls and burdensome regulation are virtually inevitable if-or when-Medicare's prescription drug costs spiral even higher under the Graham-Miller-Kennedy bill.
Congress was faced with just such a cost spiral 20 years ago in Medicare Part B, the part that pays physicians. So Congress established a complicated fee schedule that sets prices for more than 7,000 individual physician services in all of the nation's local markets, and imposed a cap on physician charges. In implementing this system, the Medicare bureaucracy issued thousands of pages of directives to doctors to regulate what they do and how they do it as a condition for reimbursement. Meanwhile, not only have Medicare physicians' payments been constrained under this system, but doctors are also facing Medicare payment reductions. And newly retired seniors are having difficulty finding a doctor willing to see them.
Using this failed model in a financially troubled system for the drug benefit would be a serious mistake. Government price setting could distort market incentives, leading to shortages of particular drugs. As costs would inevitably rise, access to the newest drugs could be restricted. Such policies would discourage pharmaceutical research and innovation to discover new cures and better medicines, with serious consequences for everyone's health.
Why Alternative Senate Proposals Fall Short
Two other proposals under discussion in the Senate represent more prudent approaches to a Medicare drug benefit. The Tripartisan proposal offers a comprehensive drug benefit through competing private prescription drug plans. A less costly proposal, sponsored by Senators Hagel (R-NE), Ensign (R-NV), and others, would provide drug discounts and federally sponsored catastrophic coverage. Both of those bills contain elements that are positive, but they also contain elements that are problematic and could lead to serious problems for Medicare in the long term.
The Tripartisan Proposal.
The Tripartisan proposal requires that beneficiaries pay a significant share of their prescription drug expenses, including a $250 deductible and half of the cost of their prescription drugs between $250 and $3,450. A benefit "hole" above $3,450 keeps federal costs down. Once a beneficiary had spent $3,700 (counting only out-of-pocket expenses), the federal government would pay all costs. Like many other Medicare drug proposals, the Tripartisan approach is somewhat complicated and is not easily explained to seniors and other taxpayers.
The Tripartisan proposal adopts many of the market principles of the House-passed bill, H.R. 4954, although it offers more generous coverage and a lower monthly premium. Under both plans, competing drug plans would have an incentive to manage costs and negotiate favorable prices with pharmaceutical manufacturers. Plans would be permitted to pass on the savings to beneficiaries through lower premiums, which are expected to average about $30 a month in 2005.
The proposal would also establish a new fee-for-service option that would give seniors both greater financial protection against high medical expenses and additional preventive care benefits. That new option would limit the total out-of-pocket costs paid by beneficiaries for all Medicare services to $6,000 a year. It would eliminate separate deductibles for hospital and physician services, replacing them with a combined deductible of $300, and adjust other cost-sharing requirements. Preventive services would be made available without any cost-sharing requirements. Such changes would improve the financial protection afforded to enrollees in the enhanced program.
In addition, beleaguered Medicare+Choice plans would be given somewhat greater flexibility than is now permitted. The administered pricing scheme for those plans would be replaced by a limited bidding system.
The Tripartisan bill's drug benefit would increase federal spending by about $340 billion over the next decade. Other enhancements to Medicare's benefits would require an additional $30 billion in federal spending.
The proposal would introduce some new elements of competition into Medicare and provide additional incentives for more efficient use of health care resources, but it doesn't go far enough toward Medicare modernization. Although it is less expansive and more economically efficient than the Graham-Miller-Kennedy proposal, the bill would still impose substantial new costs on an already over-burdened program. This level of spending would compromise Medicare's long-term solvency without the aggressive new efforts needed to reform the program.
The Hagel-Ensign Proposal.
Senators Chuck Hagel (R-NE), John Ensign (R-NV), and others propose a catastrophic drug benefit that combines a discount prescription drug card with catastrophic coverage. The bill, estimated to cost $160 billion over 10 years, incorporates an idea that mimics the President's discount drug card program to give seniors access to privately negotiated discounts.
The bill also would provide catastrophic coverage triggered by income and drug expenditures. For example, catastrophic coverage would begin when out-of-pocket drug expenditure hit $1,500 a year for those with incomes below 200 percent of poverty and $5,500 for those between 400 percent and 600 percent of poverty.
But the taxpayers, not private entities, would bear the risk of the catastrophic coverage. That means that the Hagel-Ensign bill is a government drug benefit program that simply triggers at a higher level. This is not real Medicare reform and does nothing to harness free-market forces to keep drug costs down.
How the Senate Could Build On a Better Idea
Independent analysts, including those with the General Accounting Office and the Congressional Budget Office, have repeatedly advised Congress that a drug benefit should be crafted within the context of serious Medicare reform. President George W. Bush also has repeatedly expressed the Administration's support for principles designed to inject competition and choice into the Medicare program, based on a reform plan developed by Senator John Breaux (D-LA) and Representative Bill Thomas (R-CA). That proposal would give seniors the freedom to choose from among competing, private health plans, just as federal workers and retirees do in the Federal Employees Health Benefits Program (FEHBP). Those plans would incorporate prescription drugs as an integral element of their medical benefit packages.
As an interim measure, the President has proposed offering Medicare-endorsed prescription drug discount cards to seniors. Discount cards are already available to consumers from pharmaceutical companies, retail pharmacies, drug benefit managers, and health plans. Those cards often offer discounts of 10 percent to 20 percent (or more) off the retail price. Under the President's proposal, seniors would pay a fee to participate, much like a buyer's club membership fee.
The President's discount card proposal, however, is flawed: It would hand-select a few players from a limited field, and it has predictably invited lawsuits by groups who say it is anti-competitive and by pharmacists who fear the entire discount will be drawn from their dispensing fees.
Creating a Drug Security Card.
A new drug benefit must include elements of broader program reform, or it will endanger the financial stability of Medicare. An innovative proposal called the Prescription Drug Security (PDS) Card plan offers meaningful drug coverage to seniors most in need while promoting efficiency, innovation, and consumer choice. It also provides a way of testing market-based reforms that are key to Medicare's long-term survival.
The PDS plan combines a drug discount card with a cash subsidy for low-income people, a tax-deferred saving option for others, and catastrophic insurance protection.
This plan would target immediate financial assistance to low-income seniors to assist in purchasing routine medications while also providing private catastrophic coverage for large drug expenses.
Low-income seniors without drug coverage would get a PDS card with $600 a year from the federal government to help them with routine drug purchases and could roll over any balance to the next year, when another deposit would be made. Seniors who did not qualify for a low-income subsidy could make tax-deductible contributions to a PDS account. All seniors enrolling in the program would be protected by catastrophic coverage that starts when their drug spending hits $2,000.
Seniors would be able to choose from among competing, private plans that would track their card balances, negotiate discounts on their behalf, organize the catastrophic coverage, and provide other services to improve patient safety.
Administration of the PDS card program would be modeled after the FEHBP. The administering agency would provide broad direction to individual plans on required benefits and other policies, negotiate with plans on their premium offers, and provide information to Medicare beneficiaries on their options and the performance of individual plans. Price controls and over-regulation would be replaced with flexibility and a consumer focus.
The PDS plan would allow Congress to focus on seniors who lack drug coverage and not disrupt the good coverage that millions of others have now. This plan also would allow seniors and their doctors to decide what drugs are best for them, and would actually put in place a foundation for changes that could save Medicare in the long run.
Congress should do the right thing for both senior citizens and young working families who finance the bulk of Medicare costs. President Bush has promoted a drug discount card without success, but Congress can put resources behind it to target needy seniors and make it work effectively. The Prescription Drug Security Card could provide meaningful help for low-income seniors who do not have access to drug coverage. These seniors should be the priority for Washington policymakers, who can-and should-provide this help while creating a framework for expanding drug coverage in tandem with overall Medicare reform.