Saturday, September 13, 2014

The Doughnut Hole: Still Going Strong, Still Killing People

Oh Happy Day!
The Doughnut Hole is Finally Gone!
Right? It's gone now, right?

Some of us may have thought that the infamous "doughnut hole" had finally been "defanged" by the Affordable Care Act's successful implementation. That idea would be partially correct. The ACA's implementation has begun to mark the end of the thing -- it is scheduled to be phased out gradually over the next few years. In the meantime, again thanks to the ACA, some, but not nearly all, of the most injurious features of the imposed limit on prescription coverage -- mainly the ones with the "worst bite" -- will be gradually reduced until the "doughnut hole" reaches its final, apparently permanent, minimum state in 2020.

Having said all that, today's "doughnut hole" is still quite alive and dangerous -- especially to old people.

Last Night's Activities
 at Short Current Essay's
Galactic HeadQuarters
Please pass the pill splitter...

About this time every year MeanMesa has to gather the prescription bottles here -- there are four or five which are to be taken daily -- and begin the rather awkward task of deciding which are so cash maintenance" and which can be reduced or "set aside" altogether until the Medicare Part D "annual year" end in January. Usually the black pit of this "doughnut hole chasm" arrives a little later in late October or November, but this year it's arrived in full force at the beginning of September.

That means that there will be around four months of "doughnut hole" level of austerity insurance coverage under Part D for MeanMesa's prescriptions. During that time, it will be necessary to prioritize and economize prescription medicine consumption to "shoe horn" what's left of the insurance coverage into a Social Security income budget. This is all very far removed from the bellowing ideological debates" our masters dutifully conduct in the Congress -- between vacations, of course.

MeanMesa staff at HQ [Galaxy Patrol]
The process described here is a lonely one taken up as each year draws to a close. Part D's "doughnut hole" means three months of fall and winter with much less daily medicine than what is ordered on prescriptions. It means even more months with much less medicine for tens of millions of other older Americans trying to live of even smaller Social Security checks than MeanMesa's.

There should be no confusion here at all. Two of MeanMesa's prescriptions are terminated at once. There is no possible way these two can be purchased for cash with the drastically reduced insurance coverage Part D offers those in the "doughnut hole.". A third prescription is marginal. Its use may also need to be terminated depending on what the monthly cost will look like with the greatly reduced coverage. In the meantime, the pills from the third prescription will be split in half to see if that can work.

The prospect of reducing the last three to half doses is pretty scary, so the cost for maintaining those at their full dosage will just have to be covered with adjustments to the grocery bill, if necessary.

MeanMesa is an old geezer in fairly good health. But naturally, as one passes across the Social Security and Medicare age requirements, a few things here and there have begun to, shall we say, wear out a little. Medicare itself has worked quite well with respect to providing good insurance coverage for doctor visits and tests. Thanks to that program, MeanMesa has a good collection of HMO doctors on what is called a "health care team."

To further illustrate the point of this post, we can take another, closer look at that "third prescription" mentioned above. The medication deals with a mild bladder problem which wakes MeanMesa in the middle of the night. The prescription was written by MeanMesa's endocrinologist, Dr. R. Administered at a half dosage, the medication still continue to works somewhat but definitely not the way that a full dose works.

Now, Dr. R might have, herself, changed the dosage on "prescription three" based on MeanMesa's condition, symptoms and so on, but Dr. R had nothing to do with this change in medication. In fact this change in medication had no relation whatsoever to any change in symptoms or any complaint by this patient about side effects of interactions. Finally, the change to this new half dosage rate for this medication had no overview or monitoring by Dr. R. or any other medical professional.

Now, MeanMesa can afford to refill this prescription so long as the dosage has been halved, doubling the length of time before the next refill. Additionally, MeanMesa is probably not going to die because of this necessary change. It will, in fact, most likely amount to nothing more than a few extra bathroom trips throughout the night.

However, the point of this post directs out thoughts to precisely whom it was who, actually, made this decision necessary. This is where the tale becomes far more interesting, and, hopefully, this will be the part which might serve to educate and enlighten this blog's valued visitors who had previously assumed that this problem was, in a deliriously happy fashion, a thing of the past.

That interesting "whom" mentioned above turns out to be a grisly troop comprised of salivating Congressional Republicans, lobbyists from the huge, already quite profitable pharmaceutical corporations, Dick Cheney and, of course, the "auto-signature President," George W. Bush.

The real story of those split pills began long ago when Part D benefits were just first "being born" in the Republican Congress under George W. Bush, so let's take a look at that part of the story.

Medicare Part D's Painful "Birth"
Hmmm. That was awfully fast.
Perhaps we over lubricated this legislation...

First of all, the passing of the Part D legislation was shockingly different from the passing of the Affordable Care Act. In the latter case Big Corporate Pharma and the Big Corporate Health Insurance companies fought tooth and nail for years to sabotage, murder, deform or exploit what became known as ObamaCare. In fact these freedom loving "corporate free enterprise entities" poured around $1 Mn per week into the promotion of an entirely fictitious, incendiary advertising campaign including everything from death panels to care rationing as if these were, somehow, something more material than simply the gaseous, yet egregiously over compensated detritus from the corporations' wholly owned think tanks.

Part D, on the other hand, "slid" through the GOP's normal stranglehold looting in the House and Senate in an eerily graceful, arcane choreography entirely scripted by literally thousands of lobbyists -- each equipped with a dripping check book chuck full of "campaign contributions" for the obediently sold out GOPCons on the receiving end.

Of course there were plenty of Congressional voters who were horrified at the gigantic give away to the lobbyists' bosses Part D in its final form had become. All medication covered by the plan would be blindly purchased -- without any negotiation whatsoever -- directly from the Big Pharma Corporations at literally any price they wished to charge. In fact shortly after Part D became law, additional legislation made it illegal to try to negotiate pharmaceutical prices in any fashion.

Because of the "divided sentiment" in the GOP controlled Senate, the actual floor passage of Part D became a drama as close as any heavily lobbied, Republican sponsored, Republican written, major looting legislation headed for a Republican President could ever possibly become. At 6 P.M. there were not enough Senate votes to safely bring it to the floor. At 12:00 A.M. there were still not enough votes to pass it. It was not until around 3:00 A.M. that enough deals had been made [...enough Senators bought off...] to draw the votes for the Part D bill to a tie. At this point Vice President Dick Cheney took his seat as "tie breaker" in the Senate, and the thing was headed for the desk of President George W. Bush where it arrived hours later.

Not even many of the "safety net hating" conservatives liked this one -- probably because they didn't get in on the Congressional pay offs available while it was being written. The following article was authored by a very conservative writer for publication in the New York Times recently.

[This article is excerpted. Read the original article  here.]

New York Times

Medicare Part D: Republican Budget-Busting

[Before reading this excerpt from the original article, it is important to know a little more about the author. About Bruce Bartlett: Bruce Bartlett held senior policy roles in the Reagan and George H.W. Bush administrations and served on the staffs of Representatives Jack Kemp and Ron Paul. He is the author of “The Benefit and the Burden: Tax Reform — Why We Need It and What It Will Take.”]

Ten years ago this week, Republicans enacted the largest expansion of the welfare state since the creation of Medicare in 1965 by adding a huge unfunded program providing coverage for prescription drugs to the Medicare program.

For years, responsible critics had said it was a system flaw that Medicare did not pay for prescription drugs along with hospitalization and doctors’ visits. By 2003, strong bipartisan support existed for expanding Medicare to include prescription drugs.

Republicans were keen to make sure that the legislation enacted was theirs, because the Democrats were certain to include cost containment for drugs in their legislation. It was widely believed that if the federal government used its buying power to pressure drug companies to cut drug prices, the cost of providing drugs to Medicare recipients would be substantially reduced.

But forcing down drug prices would diminish the drug companies’ profits and Republicans were adamantly opposed to that. Consequently, despite their oft-repeated opposition to new entitlement programs, they got behind the new drug benefit, now known as Medicare Part D, and made sure there was no cost-containment provision.

George W. Bush strongly supported this effort. Looking ahead to a close re-election in 2004, he thought a new government giveaway to the elderly would increase his vote share among this group. According to exit polls, those over age 65 gave Mr. Bush only 47 percent of their vote in 2000, with 51 percent going to Al Gore.

From the beginning, Republicans decided to forgo dedicated financing for Part D. Except for trivial premiums paid by recipients, the entire cost would fall on taxpayers. Moreover, Republicans refused to raise the Medicare tax or cut spending to cover Part D. Hence, the deficit increased by virtually the entire cost of the program.

Through 2012, Medicare Part D added $318 billion to the national debt (see “General Revenue” on Page 111 in the 2013 Medicare trustees report). That same report projects that Medicare Part D will add $852 billion to the debt over the next 10 years.

[Bruce Bartlett wrote an interesting article for FORBES dealing with the same topic. FORBES: Republican Budget Hypocrisy in Health Care]

[Note: Even through the eyes of this typical conservative writer, the absence of negotiated pricing with drug manufacturers was clearly a scam. The potential for controlling Part D's over all cost impact was to be found primarily in negotiating drug prices with the manufacturing corporations.]

The "trivial premiums" noted in the article are "trivial" precisely because of the fundamental target for Part D's benefits -- otherwise uninsured, older Americans relying primarily on Social Security income. Roughly $135 per month is deducted from MeanMesa's Social Security benefit as a "trivial premium" for Medicare -- including Part D. If this deduction were much higher than than, it would place Medicare beyond the affordable range, contradicting the intent of the Medicare program.

Nonetheless, when we consider the "fundamental target for Part D benefits" and "the intent of the Medicare program" as compared to the apparent priorities built into the obscure, lobbyist authored language of the Part D section, we begin to see why Congressmen not receiving lobbyists' checks found it so despicable.

There's "Cost Containment,"
 and then there's "Cost Containment"
Actually, the tattered remnants of the "free market" 
were at work...

Of course, there's no way to accurately estimate the thoughts running around in the mind of the editorialist who wrote the article [above], but the idea of "cost containment" when interpreted by "little people," such as this blogger, means controlling the cost of what it takes to operate something like Part D. After all, the article was quite right -- the main burden of the program lands on the tax payers.

When "little people" are considering the purchase of anything this expensive, they want to negotiate the price if at all possible. In the case of Part D the main thing landing on tax payers is the bill for all the pharmaceuticals purchased and provided under the plan. Policies determining co-payments and monthly premium amounts certainly play a role, but one almost inconsequentially small and  insignificant when compared to the gargantuan cost of paying for the actual prescriptions.

So, right away, we see that the sold out Congressional GOPs immediately set aside the best and largest opportunity to "contain" Part D costs by outlawing price negotiations with manufacturers. But, where exactly does the "free market" crack come into this picture?

Not to worry.

Start by recalling who all was there in the Congress when the bill was being written: Republicans as the majority Party in both houses, hundreds of K Street lobbyists working for very generous Big Pharma corporations, Dick Cheney and President George W. Bush who was, as a political creature, obsessed with squeezing a few more votes out of the older American voting block.

The "free market" side slips into the picture through the "back door."

Yes, Part D amounted to a "no holds barred" $ multi-Trillion Christmas present to Big Pharma. The policy would extract vast sums of tax payer money and direct it to the corporate pockets of the billionaires -- every dollar for every prescription at what ever price they decided to charge. However, although billionaires are traditionally "short sighted" -- especially in the proximity of glacial flows of Federal money -- in this case an unanticipated road block appeared on their "hard working road to paradise and prosperity."

If the Feds spent too much on Medicare Part D expenses, there simply wouldn't be enough billions left over for their very most favorite, specially designed, pharmaceutical corporation tax breaks!

The normally good natured oligarchs' think tankers and lobbyists froze in their busy little Part D tracks. Although the initial scheme had already  been cravenly greedy -- so much so that the billionaires had grudgingly become willing to actually partially "subsidize" medicine for the country's old people so long as the profits were absolutely awesome, the plan now needed a good dose of tightening up and "cost containment" before things went forward in the Congress.

Happily, Big Pharma had some really smart schemers at work in their think tanks. Literally clusters of "great ideas" were rolling out in no time. Naturally all the corporately delightful "cost savings" would fall to the pharmaceutical corporations, while the "not so pleasant" cost increases and benefit decreases would land on Medicare Part D beneficiaries, you know, on old people.

Saving Pennies for Corporate Tax Cuts
Just think of it as a complicated geriatric economic principle.

With Big Pharma's sudden concern for "austerity" in the Congressional budget, this resulting "flood of new ideas" became stranger and stranger. In fact the only "common thread" which could be discerned as running through all of them was that each one either limited or eliminated some part of the original Part D "benefit package" while holding the drug manufacturing corporations' profits harmless.

The "doughnut hole" concept was one of these "new ideas" which was ultimately incorporated in the bill's final form by the "cost containing" Big Pharma lobbyists and think tank "legislation writers."

Meanwhile, the drug companies were already attempting to forecast the utterly stupendous profits the bill's scheme would provide in their corporate futures. It should be no surprise that they have been fighting to maintain Part D in its original, high profit version -- the version authored by the Big Pharma lobbyists -- everyday since the instant George W. had finally finished bumbling with the signing pens.

The concept of the "doughnut hole" is somewhat misleading. The righties' pundits, always eager to indulge their apparently genetic appetite for conveniently "oversimplifying" things, often imply that there is simply a limit on the amount of "free" medicine the plan will provide to the "moochers and takers" who benefit from it.

Of course, matters in the real world are significantly different. Plan D beneficiaries pay around one third of this cost in co-payments. Further, although it might seem logical that Plan D would enter the "doughnut hole" after Medicare had paid a certain amount, the fact is that entry into the "doughnut hole" isn't based on how Medicare has paid -- it is based on the total of what Medicare has paid AND what the Part D beneficiary has paid.

It doesn't matter if MeanMesa is "spending" Medicare Part D money or simply forking out cash to cover the co-payments, every dollar that is spent by anyone brings MeanMesa's Part D "total drug costs" one dollar closer to hitting the "doughnut hole."

Of course the "debate" in the Congress about Part D amounted to little more than a fast descent in a goose greased slippery slide with Big Pharma's lobbyists impatiently fidgeting in the, heh, heh, lobby. However, when ACA was being "debated" [Remember the threats of care rationing and the ghostly death panels?], there were all manner of good ideas which could have permanently repaired the Mad Hatter system.

The sold out Republicans wouldn't touch any of them with a stick.

Although these "plutocratic GOP puppets" spent a month of two harping about "jobs, jobs, jobs" right after their bosses had hollowed out the economy, they finally had to concede that they had no idea what to do about the wreckage of the economy. At that point the "new order of the day" became a maudlin drama about deficit reduction -- the billionaires who call the shots for the GOP began to hate Part D even though they had originally loved it.

The following cartoon will be a good place to stop this post.

Conservatism is a racket. [image source]

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