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AMBULATORY CARE New Medicare Drug Coverage Proposed For Low-Income Beneficiaries Almost half of Medicare enrollees currently have no prescription drug coverage. Unable to afford supplemental insurance, low-income patients frequently stretch existing medications to the point of ineffectiveness or choose not to fill expensive prescriptions, putting their health on the line. Stephen Soumerai (r) and Dennis Ross-Degnan propose a joint federal–state program to cover outpatient prescription drugs for low-income Medicare beneficiaries. In the March 4 New England Journal of Medicine, drug policy and health services experts Stephen Soumerai and Dennis Ross-Degnan describe the economic and clinical consequences of medication underuse and outline an incremental federal and state policy reform that would improve low-income Medicare patients' access to key medications. The Drug Coverage Gap In Medicare's 34 years of existence, the basic federal health insurance program for seniors and disabled people has never paid for outpatient drugs. Medicare beneficiaries who are not covered by a supplemental drug insurance plan, corporate retirement program, Medicaid, or a Medicare HMO must use their own money for prescription drugs taken outside the hospital. Soumerai and Ross-Degnan propose a joint federal­state program to cover poor, near-poor, and low-income Medicare beneficiaries, not eligible for Medicaid, with incomes up to about $16,000 for a single person. Such a program would target about 4 million elderly and disabled people with the greatest economic and clinical need, and would build on the best existing federal and state pharmacy assistance programs. Their plan also includes federal financial contributions to states to encourage their participation; lower patient charges for the lowest-income enrollees; access to a comprehensive list of effective drugs; and enhanced education of physicians to reduce over- or under-use of medications. Soumerai and Ross-Degnan's proposal comes at a time when drug coverage is fast moving up the agenda in Washington. Congress is starting to consider controversial plans from Sen. Edward Kennedy (D-Mass.), Rep. Pete Stark (D-Calif.), and others to offer universal Medicare drug coverage as well as another bill introduced by Rep. Tom Allen (D-Maine) to control drug prices. And the National Bipartisan Commission on the Future of Medicare extended its March 1 deadline so members could try to devise a major new benefit covering prescription drug costs. Drug Benefits Cut, Health Costs Rise New data in the article show that among Medicare beneficiaries with incomes less than $10,000, almost two thirds have no drug coverage and purchase only half as much medication as those with employer coverage--despite being sicker. With drug expenditures continuing to escalate, Medicaid programs and managed care organizations across the U.S. have capped some drug benefits. Limits on prescription drug benefits have made it more difficult for the low-income elderly to afford the prescription drugs they need, which often increases health care costs and may result in poorer patient outcomes. For example, in New Hampshire, a Medicaid policy change curtailed unlimited drug coverage to a limit of three prescriptions per month. While the cap was in effect, excess nursing home and hospital stays cost Medicaid more than the statewide savings in drug expenditures. "Coverage gaps are causing millions ... to reduce their use of clinically essential medications." --Stephen Soumerai "Our studies suggest that coverage gaps are causing millions of low-income elderly and disabled to reduce their use of clinically essential medications," says Soumerai, HMS associate professor of ambulatory care and prevention at Harvard Pilgrim Health Care. "Our previous research has demonstrated clearly that not only does this make people sicker, but there are increased hospital and nursing home admissions, and more costs to the health system as a whole." The number of Medicare beneficiaries is projected to grow from 38.6 million in 1997 to 56.3 million in 2017. "Without timely federal and state Medicare policy reform, the problem of inadequate coverage for costly prescription drugs among low-income elderly and disabled Americans will soon become a human and economic catastrophe," says Ross-Degnan, HMS assistant professor of ambulatory care and prevention at Harvard Pilgrim. The proposal outlined in the New England Journal of Medicine would cost an estimated $4 billion, which the authors argue is more achievable than other proposals currently before Congress. --Peta Gillyatt Back to Top