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Health Care for Americans: Is There a Train Wreck Ahead? Americans’ Healthcare Derailed Thursday, March 01, 2007 Margie Metzler 916-921-5008 Website: This program operates under a grant from the California Wellness Foundation Issues Facing Americans

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health care for americans is there a train wreck ahead americans healthcare derailed

Health Care for Americans:Is There a Train Wreck Ahead?Americans’ Healthcare Derailed

Thursday, March 01, 2007

Margie Metzler



This program operates under a grant from the California Wellness Foundation

issues facing americans
Issues Facing Americans
  • The Uninsured: Insurance Company Dominance?
  • Fixing Medicare Part D (Seniors)
  • The FDA and the Pharmaceutical Industry
  • Choice vs. Complexity
uninsured americans
Uninsured Americans
  • 41 million uninsured nationally and 7 million Californians (and growing): most in working families
  • Why?
    • Companies reducing benefits to save money
    • Cost of private insurance impossible for many
    • Cost of COBRA ballooning ($1200 for a family of three)
why is being uninsured so dire
Why is Being Uninsured so Dire?
  • Emergency rooms shutting down (Hospitals are in crisis)
  • Doctors don’t take cash patients
  • Costs for cash patients way higher than cost to insurance companies
  • You can’t get insurance if you are old or sick
  • Most people let conditions worsen till they are much sicker
  • 50% of bankruptcies are due to medical expenses
california year of healthcare issues
California : Year of Healthcare Issues
  • 4 Plans:
    • Sheila Kuehl’s SB 840
    • Governor’s Proposal (no bill yet)
    • Perata Plan
    • Nunez Plan
    • Republican Plan
gray panthers supports california s sb 840 single payer healthcare
Gray Panthers Supports California’s SB 840, Single-Payer Healthcare!
  • Security - All California residents are covered for life.
  • Choice - the freedom to choose your own medical provider. Delivery of care will continue as now to be private and public.
  • Comprehensive Benefits - includes all care prescribed by a patient's health care provider, including hospital, medical, surgical, mental health; dental and vision care; prescription drugs and medical equipments, diagnostic testing, hospice care and more.
  • High Quality - The plan invests in needed health care infrastructure such as electronic claims and reimbursement systems and statewide medical databases that improve health care quality.
  • Efficient Administration - one comprehensive insurance plan saves the state, patients and providers billions of dollars each year.
  • Shared Responsibility - Payment of an affordable premium by employers, employees and individuals supports the health care system we all need at some time.
  • Fair Reimbursement & Cost Controls
what is the mma
What is the MMA?
  • The Medicare prescription Drug, Improvement and modernization Act (MMA), Dec. 2003
  • Most sweeping change in Medicare’s 40 year history
  • Administered by CMS and SSA
    • CMS: RX Program
    • SSA: Extra help for low income
structure of standard benefit
Structure of Standard Benefit
  • Monthly Premium
    • Varies: average is $31
    • Can be deducted from your SS check or paid directly to plan
  • Annual Deductible
    • In 2007, can’t exceed $265 (was $250 last year)
  • Initial co-payment
    • 25% of covered costs between $265-$2400
  • No coverage during donut hole($2401 - $5,451)
    • Still pay premiums, even though no coverage
  • Catastrophic Coverage
    • After $5451, 5% of covered costs
how does it work
How Does it Work?
  • You figure out which drugs you take now andwhich you'll need all year.
  • Go to CMS, online or by phone, to register. You research the 55 different plans offered by 23 companies (Or contact HICAP). You choose a plan based on the drugs they cover (formulary). You do this every year because the plans change every year.
  • You pay a monthly premium. If you didn’t sign up by May 15 you pay a penalty for life.
  • Donut hole: When the combined total cost (net cost, not co-pay,) reaches $2401, you are in the donut hole and for pay all costs for all your drugs for the next $2850. You are still paying your monthly premiums.
  • There is a new donut hole and new enrollment period every year. This year it ended Dec. 31: the next will be Nov. 15-Dec. 31, 2007.
  • Turning 65: you can sign up 3 months before your 65th birthday and you’ll have 3 months afterward to enroll. If you enroll after that you’ll pay a 1% penalty per month for life.
other issues
Other Issues
  • No negotiating for best prices like VA and Medicaid
  • States can’t regulate insurance plans
  • Late Enrollment Penalty: 1% penalty per month and the penalty lasts forever
  • Some retirees lost their creditable coverage for good
  • Originally, insurance companies could change prices, formularies, co-pays, deductibles at will, but you couldn’t change until Nov. enrollment period. Your complaints caused the CMS to force companies to keep you on the drugs you need until the next enrollment period.
what s new in 2007
What’s new in 2007?
  • Donut hole coverages have changed. Most companies still give no coverage, and some that do now cover only generic drugs.
  • Formularies may have changed.
  • Co-pays may have changed
  • The maximum deductible has risen from $250 to $265.
  • Premium may have changed.
  • There are more plans available.
  • Two companies (Marquette National Life Insurance Company and PacifiCare) have dropped their plans.
we deserve these improvements
We deserve these improvements
  • Waive premiums for any month a senior is not receiving Medicare prescription coverage. Those in the donut hole should not be required to pay for goods not received.
  • Count ALL drug costs incurred in the donut hole, not just expenses for those on the insurance plan’s formulary, provided by an in-network pharmacy. Every out of pocket cost should count towards catastrophic coverage.
  • Allow seniors to receive prescription drugs directly from traditional Medicare, not through an intermediary insurance company. This would reduce confusion and offer a simple, one step plan with affordable drugs.
more improvements
More Improvements
  • Eliminate the lifetime penalty for seniors
  • Increase funding to provide counseling and education to beneficiaries and caregivers
where to go for help info
Where to Go For Help/Info
  • Health Insurance Counseling and Advocacy Program (HICAP): Call 1-800-434-0222 to reach your local HICAP or go to
  • National Committee to Preserve Social Security and Medicare: (a national, nonprofit organization)
  • Social Security: 1-800-772-1213 or go to
  • Center for Medicare and Medicaid Services (CMS): Call 1-800-MEDICARE or go to
  • Low income subsidy: go call 1-800-772-1213
the fda and the pharmaceutical industry
The FDA and the Pharmaceutical Industry
  • US drug prices are the highest in the world and getting worse. We paid 81% more for brand drugs (average) than Switzerland, Britain, Germany, Canada, Sweden, France, and Italy.
  • FDA ties to Pharma (Tauzin)
who s really in charge here
Who’s really in charge here?
  • Out of control industry marketing: marketing is 30% of cost of drugs; 10-15% spent on R&D; over $4.5 B spent in 2006; ads promote drugs for new “diseases”, 50 most heavily marketed drugs accounted for 50% of increased sales)
  • Industry influence in government (Medicare Part D)
  • Quality of care compromised
  • Pharmaceutical costs out of control
  • Consumers can’s afford their drugs
rx marketing to doctors
Rx Marketing to Doctors
  • Industry spends $12 B/year on drug marketing to MDs, or $13,000/doctor
  • There is 1 sales rep for every 5 MDs
  • Gifts, lunches, trips, educational grants, entertainment, free samples
    • Even small gifts create obligation and influence prescribing decisions
    • Free samples create loyalty to brand and unwillingness to use generics (30-80% lower cost)
  • Doctors are paid to promote expensive new drugs and off-label uses
  • Negotiations and price controls
  • Opening up US prescription drug pricing to world competition and free trade (Prescription Drug Importation debate)
  • 2007 Pharmaceutical Market Access and Safety Act, HR 380 ( Emanuel and Emerson) and Senate S-242 (Dorgan and Snow + 30 co-sponsors)
2007 pharmaceutical market access and drug safety act
2007 Pharmaceutical Market Access and Drug Safety Act
  • S 242 and HR 380
  • Allows individuals, wholesalers and pharmacists to import from FDA-approved facilities in 30 countries
  • Raises drug safety with provisions against counterfeiting
  • Has provisions to stop drug companies from cutting off supply to countries
no more vioxxes
No More Vioxxes!
  • Register all clinical trials and make results public
  • Regulation of industry marketing
  • JAMA standards
  • Litigation (PAL)
  • Best Buy Drugs (
  • Drug Effectiveness Review Project (DERP): Oregon Health & Science University Evidence-Based Practice Center. Now includes 15 states and two non-profit organizations.
  • Medication Errors Panel Report (CA State Cap.)
choice vs complexity
Choice vs. Complexity
  • Choice is a good thing. Unless it overwhelms you when you are sick.
  • Choosing among 3 plans gives you options. Choosing among 55 plans gives you a headache.
  • Our current healthcare system is impossible to navigate.
federal congress people

Boxer, Barbara- (D - CA) 112 Hart Senate Office Building, Washington 20510

(202) 224-3553

Web form:

Feinstein, Dianne- (D - CA) 331 Hart Senate Office Building, Washington DC 20510

(202) 224-3841

Web Form:

Federal Congress people


Find your Congressperson: