Statement of Therese Emerick

Thank you for the opportunity to submit my testimony regarding the implementation of the Medicare Part D prescription drug program. I appreciate the steps that Congress and the administration has taken to ensure that people with Medicare have access to medically necessary medications, including the extension of the 2006 transition period and the special enrollment period for people who qualify for the Extra Help low-income subsidy program.

While I do not officially represent an organization, but I know that I am not alone in my sentiments or experiences. The comments below arise from my own experiences with the new Medicare prescription drug program.

At the age of nine, I began having grand mal seizures. For the next eight years, I tried numerous anti-convulsants, none of which controlled my seizures.  Once, I even had a toxic reaction to a then commonly prescribed anti-convulsant.  At age 17, my seizures were finally controlled by the following regimen:  Dilantin  Dispense as Written (DAW), Tegretol (DAW), and Phenobarbital. With these medicines, I was able to go about my life in a normal way. I graduated high school and completed my bachelor’s degree from Wayne State University in Detroit, Michigan.

At age 31, I sustained a traumatic brain injury on the job leaving me unable to continue working. Shortly thereafter I was deemed eligible for Social Security Disability and Supplemental Security Income (SSD/SSI) making me eligible for Medicaid and two years later Medicare. My monthly income is approximately $620.00 per month which includes my SSD and SSI.   In addition to that, I receive approximately  $100.00 per month in food stamps, and currently hold a Section 8 housing voucher. 

I am one 6.2 million people moved overnight from Medicaid prescription drug coverage to a private Part D prescription drug plan.

Prior to January 1, I had good, affordable, reliable health insurance coverage through Medicare and Michigan Medicaid.

The Transition to Part D

In July 2005, I received a form letter from the Michigan Department of Community Health (MDCH form B 05-05) that read:

“The federal government is changing how your drugs will be covered. Starting January 1, 2006, Medicare will pay for your drugs instead of Medicaid.  Look for information that Medicare will mail to you.  Your costs will depend on which plan you are enrolled in.  Later this fall Medicare will assign you to a drug plan.  You can then:

“1) Stay in the plan that Medicare assigns to you; or

“2) Pick a different plan that covers your drugs.

“Help is free and a phone call away.

“The letter then referred any questions to 800 numbers to the following agencies:

“Michigan Medicare/Medicaid Assistance Program, Medicaid Beneficiary HelpLine,

1-800-MEDICARE or the Medicare Web site at www.medicare.gov.”

I contacted of the all agencies listed in the letter. I looked at the Medicare Web site. I received no clear answers about how this would affect prescription coverage under Medicaid.

When I asked my caseworker, she told me that “We are still waiting for the details of how this is going to work.” When I contacted my state and federal representatives and I similarly was told that the details have not been worked out.

In November, I received a letter notifying me that I was enrolled in PacifiCare’s Part D plan. Per the letter’s instructions, I called the plan repeatedly to determine whether or not my prescriptions would be covered, but I was unable to get through to a counselor.

When I finally did speak to a representative, I was told that I had to check my medicines on the plan’s Web site. At the time, my computer was being repaired, and, access to the Internet at the public library is restricted, leaving me unable to check my medicines with those listed on my assigned plan’s formulary.

Further complicating this transition, in December, I caught a virus that had the symptoms of a severe cold.  Even though I was sick, I continued to call the Medicare helpline and my plan repeatedly to find out more about the Part D coverage that I was assigned to. Again, there were long hold times. In many instances, I hung up in frustration. I tried calling these help lines at different times of the day in order to reach a real person, but I was unsuccessful.

Finally, I went to the Family Independence Agency and discussed the situation with my caseworker.  With her help, I reached a plan representative who explained I would be receiving a card in the mail.

I did not receive my card until the first week in January, a couple of days after I had called in my prescriptions for January. The pharmacy needed to see my membership card before they would dispense my medicines so I had to wait two days until my enrollment packet arrived in the mail. Luckily, I had stockpiled some of my medicines, so I did not have to go without.

The thought that I might have to go without my medicines was terrifying.

Currently under Part D

For now, I am receiving all of my prescriptions through my Part D plan. I pay $8.00 in copayments every month.  That amount is more than I paid prior to the transition.  Previously, I paid $1.00 per prescription.  The increase in price may seem like a small amount to most.  Due to the amount that I receive monthly ($620.00 SSD/I), I have had to make hard choices including, but not limited to, paying my utilities bills late or making partial payments (resulting in my incurring repeated late charges), eating and medicine. 

I will not go without the necessary medicines that is needed to control my epilepsy. The consequences of going without could  invoke a condition called "status eppillepticus.”  Status epillepticus is non-stop seizures that require immediate hospitalization.   It is often fatal.

Recent Correspondence From PacifiCare

I recently received an Explanation of Benefits (EOB) from Prescription Solutions from PacifiCare.  It reads in part:

• Amount Paid For Prescriptions

“You and/or others who have paid for your prescriptions have spent $334.47 in co-payments and/or co-insurance this year.  In addition, this amount also includes any extra help that you get paying for your drugs.  This amount may include payments made by your current or former employer/union, other insurance plan or policy.  This counts toward your initial coverage limit.

Prescription Solutions from PacifiCare has paid $288.67.  These payments count toward your initial coverage limit. 

Together $623.04 has been paid by Prescription Solutions from PacifiCare, you and/or others.  This is the total that counts toward your initial coverage limit.”

The different amounts listed cause me a great deal of concern.  I have received information from multiple sources providing me conflicting information about whether or not I will fall into the donut hole--pay 100% of my prescription drug costs.

I do not understand why three different amounts are listed in the correspondence from PacifiCare.  Nor do I understand other terminology that is being used in the letter and how it applies to me.  

Solutions

Part D needs to be reformed so all that are eligible will receive the medically necessary prescriptions at an affordable cost.

First, an extension in the enrollment period is needed for those who are eligible. Determining which of the many plans offered best suit their needs and budget require a detailed understanding of computer/intenet use, the technicalities of pharmaceuticals and the regulations on each policy.  In addition, those who are eligible for Part D should not be forced into choosing a program that may not suit their needs out of the fear of increased premiums, or lack of coverage until the next enrollment period.  Finally, an example of the penalty information was listed on the medicare.gov Web site as opposed to the penalty formula. (http://www.startribune.com/484/story/400980.html)

Second, the  donut hole must be eliminated.   Michael Leavitt, Secretary of Health and Human Services, gave a reason for the elimination of the donut hole.  He recommended that “insurance companies to allow patients to have more than a month’s supply of prescription drugs on hand at a time, in case of emergency.”

(http://www.casperstartribune.net/articles/2006/03/11/news/wyoming/0af12a4b085e81da8725712e000501c8.txt)

It is impossible for those on a fixed income after they reach the donut hole, to obtain their medicines, as their prescriptions are unaffordable.

Third, the heavy reliance on "step therapies" that were described in reports by Rep. Henry Waxman should be not applicable to those who have a documented medical history in which step therapies prolonged an illness.

 Fourth, the insistence on the use of generic drugs must be waived if it has previously been documented in one's medical history that generics do not alleviate symptoms of a serious medical condition.  A second reason for this is the situation that many prescription drugs do not have a generic equivalent. Yet another reason would be if a person had previous medical documentation of a sensitivity/allergic reaction to a generic drug.  Extensive medical expenses can be incurred in determining if, in fact, any other type of medication/a different course of treatment would suffice.

Fifth, the appeals process needs to be streamlined and standardized, with the goal of its elimination. Many who currently have Part D have been taking the same medications for years.  Sudden changes or withdrawals from certain medications can cause serious health risks that can be fatal.

Part D must provide coverage for all necessary medications.   It is not the place of any insurance carrier to second-guess medical advice.  It is the function of a Part D insurance carrier to provide reliable prescription coverage at an affordable price.  

According to a BBC report, dated June 27, 2003, President Bush made the following claim.  ”Seniors have waited too long for morechoices and better benefits, including prescription drug coverage, similar to the kind now enjoyed by federal employees and members of the Congress.” 

(http://news.bbc.co.uk/2/hi/americas/3026856.stm)

Due to the five restrictions/limitations on Part D, it is not similar to the benefits and prescription coverage “now enjoyed by federal employees and members of the Congress.”

Elected officials are public servants, representing their constituents.  In effect, their constituents are their employers.  One of the essential functions of a job description could read: to represent the will of the people in this country and to vote their concerns on issues that have a direct impact on their health and well being.

Taking that analogy a step further, it is necessary to ask a question.  Why should the employee be compensated with a better health care package that is paid for, in tax dollars, by the employer, with many of the employers having substandard, if any health coverage?

The answer is that establishing a single payer health care system, including prescription, dental, and vision/optical coverage is necessary.   This would result in the savings of approximately $286 billion in paperwork alone, according to Physicians for A National Health Program  (PHNP). (http://www.pnhp.org/news/2004/january/national_health_insu.php)

The ideal single payer health care system would not require prior-authorizations for prescriptions, would eliminate pre-existing conditions and/or other regulations that interfere with the best medical advice of his/her physician when determining the necessary course of treatment.

To achieve the goal of a single-payer health care system, it is necessary to recall the words of the late Walter Reuther, to the American Public Health Association, in 1968:

"We must first free ourselves of the illusion that we really have a health care system in America. What we have is a disorganized, disjointed, antiquated, obsolete non-system of health care. Consumers are being required to subsidize a non-system that fails to deal with their basic health care needs and the cost of that system is continuing to skyrocket." (http://www.uaw.org/atissue/atstory.cfm?atId=129 )