Resist changes to Medicare, Medicaid limiting drugs


Amidst the flurry of television advertisements for Christmas bargains, Medicare ran a series of its own, pushing Advantage Plans over traditional Medicare. Why was the government advertising for big insurance companies? And what else was the Centers for Medicare and Medicaid Services doing while we were preparing for the holidays?

For one thing, it didn’t oppose the lawsuit against the Affordable Care Act brought by 18 states. Ten days before Christmas, millions of Americans heard that a Texas judge ruled the Affordable Care Act unconstitutional. The Texas ruling — which even President Trump has tweeted will not go into effect immediately — throws panic into people with pre-existing conditions, millennials who had coverage under their parents’ plans until they reach 26, and people who received Medicaid or federal assistance to buy policies.

What a merry holiday season!

But there’s more.

In late November, in what seemed like an effort to lower prescription drug costs, CMS head Seema Verma proposed giving Medicare Part D and Medicare Advantage plans the option to limit coverage of drugs in six categories known as “protected classes” in a bid to save the government nearly $2 billion. Sounds good, but currently, Part D plans must cover all drugs in the six classes, including all cancer medicines, antidepressants and HIV drugs. Under the proposal, plans could refuse coverage of a particular drug within a category as long as they cover at least two drugs within the same category.

In short, the government would save $2 billion, but you might incur greater expenses. If you are being treated by a drug not in the company’s formulary, you will have to make a case for it no matter how old you are. You have the right to appeal, but the demon of prior authorization will eat up your doctor’s time while feeding insurance company profits.

If you are a patient with an illness that requires psychotropic drugs, for instance, and the medication that works for you is no longer in your insurance company’s formulary, you will just have to appeal and your doctor will have to write a letter for you (or several letters), and you may have to pay out of pocket in the meantime. If you are getting cancer treatment with a drug not in the formulary, you may be in a life-threatening position.

What can you do about these developments? You can go to the public comment section of CMS and voice your concern about the prescription drug plan (CMS 4180) before Jan. 25, and you can urge your local state senators and Assembly members to vote (as they have pledged to do) for the New York Health Act, which will give you the prescription drugs your doctor thinks are best for you.

You will have universal, comprehensive, affordable coverage.

Now that we have a Democratic majority in the state senate and Assembly, your state representatives will have to resist the pressure from big pharma and big insurance who spend $1.6 million a day on lobbying, and a third of their profits on advertising. They will organize a campaign of false news against single-payer.

In fact, advocating for New York Health is the best medicine for your life. Keep the pressure up.

Barbara Estrin,