Killer Cure

Be careful what you wish for. In the case of helping America's older and disabled people afford prescription drugs, this cliché couldn't be more apt.

The pressure is on Congress to cover the cost of medicines prescribed to people on Medicare. This gap in coverage evokes images of someone's grandmother -- not your own, there's something inherently remote and impersonal about this issue for most people -- carefully budgeting to make sure she can afford both her blood pressure pills and groceries. But if Congress passes the plan currently under consideration, that heart-wrenching scene changes only slightly. Grandma is still counting her pennies, but now she's budgeting to make sure she can afford the co-payment for her visit to the doctor and her home health aide.

And if grandma is one of those four million retired Americans who buys health insurance through her previous employer, she may lose her insurance altogether, as employers use government support for drug coverage as an excuse to drop retirees from their health plans. If the push to "privatize" Medicare is successful, grandma will no doubt feel confused and utterly frustrated. Republicans want traditional Medicare programs to begin competing with private HMOs. If passed, grandma may either have to pay the difference in monthly premiums between the HMO and the traditional fee-for-service Medicare program -- the latter preferred by her and her peers -- or she must enroll in the HMO and contend with all the restrictions -- like not being able to choose your own doctor -- which make HMOs such a hated enterprise in this country.

How did it happen that Congress is contemplating such a screwy piece of legislation -- one that purports to give people help paying for medicines yet hikes the expenses of other basic health-care services?

Moneyed Interests And Ideology

The debate over Medicare involves so many subplots it's hard to stay focused on the content of the competing proposals. There's the specter of the 2004 elections and the rush to bank the political currency gained from passing a good bill or stopping a bad bill. There's the sordid tale of internal wrangling in the House of Republicans -- er, Representatives -- in which Democrats are being locked out of negotiations. There's the money in politics angle, worthy of an episode on HBO's K Street , in which a powerful industry unleashes a sophisticated lobbying apparatus to parlay its message across editorial pages and over cozy lunches with congressional staff.

Finally, there's the ideological standoff between those who think Medicare is one Great Society program we can be proud of, and those who believe that any service -- no matter how essential -- can be better managed by a profit-making organization. The conservatives believe the principle of guaranteed coverage for America's seniors and disabled should be sacrificed on the altar of competition. While pressures other than philosophy exert greater influence over the debate in Congress, media coverage has often depicted lawmakers who call for privatizing Medicare as motivated purely by ideology, when in fact industry lobbying has more influence over them.

Despite all the dramatic overtones, getting the public to pay attention to the issues Congress is wrangling over remains difficult. What gets lost in the seemingly arcane details of the various proposals is that whatever Congress produces will be a big letdown for seniors and people with disabilities anxious for help. Numerous nonprofit organizations that promote the interests of Medicare beneficiaries and older people -- U.S. Action, Consumers Union, Medicare Rights Center -- say that the proposed plan will increase costs to beneficiaries. As counter-intuitive as it sounds, a bill created to relieve seniors of the expense of prescription drugs will actually result in higher costs in other areas in order to offset the prescription drug coverage.

In exchange for being able to say "I passed a prescription drug coverage bill," politicians are willing to overlook the fact that their plan simply shifts beneficiaries' expenses from one type of health care (medicine) to another (increased fees for doctor visits, lab services, home health care). In this shell game, the only victory belongs to the politician and the pharmaceutical and insurance industries bankrolling him or her.

Profits Over People

To understand what's driving this unwieldy effort to "reform" Medicare, consider who stands to benefit from the bills under consideration on the Hill. On Halloween, Boston University released a study that predicted the pharmaceutical industry would reap a "windfall profit" of at least $139 billion over eight years if Congress passes a drug benefit. Not a bad return on the $120 million the pharmaceutical industry's trade association, PhRMA, spent this year to lobby Congress.

The various interests in the debate over prescription drug coverage have issued enough "line in the sand" type declarations to cross hatch an entire beach. For the most conservative House Republicans, the battle over this legislation is part of a larger war to subject all senior, disabled and poor Americans to health care regulated by the marketplace, which they claim will reduce spending, despite evidence to the contrary. Nonetheless, if the final bill does not require Medicare to compete with private plans, conservatives will revolt. House Republicans wish to prohibit Medicare from using its purchasing power to negotiate with drug companies for lower prescription prices.

For their part, senate Democrats (and one independent and one Republican) have in recent weeks been equally adamant in their opposition to privatization and proposed spending caps on the program, after which more costs would be shifted to beneficiaries. In staking out their position, these lawmakers are no doubt aware that a Kaiser Foundation poll conducted earlier this year found that the majority of Americans favor giving seniors a drug benefit even if it costs taxpayers more. It would seem that Americans still believe that the younger generation has an obligation to care for the older generation.

As advocates for older people and the disabled say, Medicare works. According to the Medicare Rights Center, a nonprofit group that represents people on Medicare, the program has radically cut the poverty rate among older Americans, helped extend both the duration and quality of life of older Americans and has done so by controlling costs far more effectively than any private insurance system.

The nation needs to give older people and people with disabilities reliable health coverage without breaking the bank. But what Congress is cooking up threatens to leave a bitter aftertaste in the mouths of older and disabled Americans. Medicare was created in 1965 because private insurers found it too costly to insure older people, who consume four times as many health services as younger Americans. As we face an onslaught of retiring baby boomers, it makes sense to bolster, not dismantle, the social insurance structure of the Medicare program.

Alexandra Walker is the assistant editor of

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