David Post: Game of ‘gotcha’ on health insurance

  • Posted: Monday, March 17, 2014 12:16 a.m.
David Post
David Post

Seniors, others grapple with gap in drug coverage

Congress has this way of providing benefits ... sort of. Or maybe it’s a big game of “gotcha.”


In 2006, Congress passed Part D to add drug benefits for seniors on Medicare. Before that, Medicare provided coverage for hospitals and doctors, but not for drugs. Similarly, the Affordable Care Act, or Obamacare, requires private insurance companies in the “Marketplace” to provide drug coverage.

As health care costs have risen over the past several decades, enlightened insurance companies — as well as federal and state governments — are realizing that the most expensive drugs are those not taken. For those with chronic illnesses, drugs that cost hundreds or even a thousand dollars a month are cheap compared to the cost of a hospital visit.

Since Social Security is the primary source of income for two-thirds of all seniors, many seniors simply lack the money to pay for their drugs. (In fact, without Social Security, almost half of seniors would live below the poverty level.)

While the goal of Medicare Part D is to provide seniors with access to drugs, thereby reducing hospital costs and the global cost of health care by, two tripwires arose.

First, Part D covers most of the first $3,000 per year, but seniors can then fall into the infamous “donut hole” requiring them to pay the next $2,000 before insurance steps in again. Come August or September or whenever that first $3,000 runs out, many seniors lack the ability to pay the full cost, stop taking their drugs and get sick as a result.

Second, because Part D is handled by private insurance companies, each plan developed its own “formulary,” or a list of covered drugs. Informed seniors shop around each fall during “open season” to make sure their policies include their doctors and their drugs. Those who don’t re-examine their policies can discover that their doctors or their drugs are not covered. They must wait until the following year to find another plan that works.

As the Affordable Care Act unfolds, the fine print is emerging. Most people made sure that their doctors were covered by their new insurance plans, but many “marketplace” insurance policies cover only a limited formulary of drugs. As people are using their new policies, more and more are learning that their plan does not cover their drugs.

Among those hit hardest are non-profit assistance programs that serve people with high-cost chronic illnesses such as hemophilia, black lung disease, HIV, tuberculosis and child cancer. These organizations have been devotingd their scarce resources to buy insurance for the people they serve. They are now learning that many of the marketplace policies — which didn’t become effective until a month or so ago — exclude the life-saving drugs their clients need. In fact, in some states, none of the marketplace policies cover these high cost but life-saving drugs.

A fundamental requirement of the Affordable Care Act was that insurance plans could not exclude those with pre-existing conditions. Now, children with cancer or hemophiliacs have access to insurance. But, they lack access to the drugs that kee them alive. How is that different than refusing coverage for having a pre-existing condition?

As divided as the nation is about health care, surely no politician intended the cruelty of that game of “gotcha.”

David Post serves on the Salisbury Planning Board and operates MedExpress Pharmacy.

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