The most important revelation in my investigation of Plan D is that it is NOT required. I can simply choose not to subscribe. That moves the consideration to a whole new level. Also, according to the 2013 rules, a person who receives Extra Help can change companies anytime -- not just before December 7.
The most discouraging aspect of this search has been that no matter WHOM I ask for help and advice, what I get is a pitch for or against “Obamacare” -- which is irrelevant. They told me when I was doing public relations with the media that if someone asked me a question I either could not or did not want to answer, I should answer a question that was similar but not the same. I hear this strategy among politicians and even doctors again and again. Sometimes they don’t even do “similar.” Just change subjects.
I will not depend only upon the advice of doctors about which drugs I should take, the same as I will not depend upon insurance companies to tell me which policies I should engage. The influence of big pharma, the many instances of flawed studies and reversed recommendations, my hospital chaplaincy which gave me access to patient files and physician reviews, and my brief brush with statistics, have all told me that medicine is NOT magic, that what cures one person can damage the next, and simply perpetuating oneself is not the best goal. I barely managed to resist the craze for estrogen replacement at menopause. Everyone talks about testosterone as psychoactive -- try switching in and out of estrogen! It’s being thirteen again.
So, where am I? Personally, I mean. What Plan D should I choose?
1. QUALIFICATION: I'm under the poverty line as currently defined. It moves yearly. I’m on the boundary and could be pushed out in a different year, but now I get Extra Help.
2. DIAGNOSIS: My only conditions are “metabolic syndrome” and “ocular migraine”. That means age and behavior driven glucose and blood pressure levels that are marginally too high as well as tired eyes from obsessive reading and writing. These are all best managed with diet and exercise -- very minimal medication. But these latter must be monitored with formidably expensive lab tests. Much of medicine now is based on these tests rather than direct observation of the body. For a five minute conference with a nurse-practitioner, a blood draw, and multiple panels of statistics that showed the same figures as last time, I was billed $546, all paid for by Plan B. NOT Plan D.
At this “checkup” I asked for the new “shingles” vaccine but there was none on hand in the clinic (which means a new billable visit to get the shot) and no one knew whether it is covered or under which plan. Ideal levels of glucose vary in the minds of various physicians. Some say that slightly older people should maintain slightly higher levels. Others think that lower is always better and will push a person close to the danger level, I discovered from experience. One cannot relax vigilance.
3. DEDUCTIBLE: This is the amount a person is expected to pay before the insurance begins to pay. On the list I’m looking at, most companies specify a little over $300, but if one is classified as “Extra Help” (meaning poor) then the deductible drops to maybe $65. Some companies offer NO deductible. This is a good thing since the total cost of my drugs for the whole year is less than $300 -- at non-negotiated prices. The cost of my YEAR’S drugs if the insurance company has negotiated special very low prices for the meds is little more than $65. Of course, the insurance companies owned by drug store chains have a lot of leverage for deals -- probably as much as a small African country.
4. CO-PAY: Some policies ask the patient to pay part of the cost of drugs, separately from the issue of what is deductible. Co-pays, like deductibles, can be arbitrarily changed by the insurance company on the first of every year AFTER you have had the chance to change policies. There is some kind of relationship which is meant to allow the insurance company to preserve its profit. BUT a person with Extra Help can change any time. No advisor knew this, though it’s in the Medicare book, which is about the size but not the helpfulness of my MAC OSX operator's handbook.
5. MONTHLY PREMIUM: In the beginning this was the essence of the game: put your money in the pot and gamble on whether you’ll need it. Now it is the subject of negotiation and accommodation. If you are poor enough, you will get Extra Help with your premium. Extra Help also lowers your deductible. Medicare “Extra Help” will not necessarily pay all your premium, but Montana (among other states) will pay what’s left, so possibly the total covers ALL the premium. But don’t get to assuming there is NO premium, which is sort of my mistake. Someone has to cover it and you’d better check out who is doing it or risk -- as I did -- neglecting $8.50 payments until it has become a $450 debt. Since the insurance company made no fuss about it, I suspect there is some mechanism for the government to compensate for deadbeats like me. (I AM paying off this debt.) Plan B payment is simply deducted from your SSI check before you get it, leading to the illusion that there is no premium.
6. GAP COVERAGE: Another negotiating chip: as soon as this phenomenon was invented, it could be widened, discounted, redefined. The idea is that if over time you exhaust a certain amount of insurance coverage, you are suddenly not covered. Then at some late date you’re covered again. Makes no sense to me.
7. ACCEPTANCE OF GENERICS: Some plans require generics, others require name brands. There are enough small differences in formulation that some people don’t benefit from generics or vice versa. Another wiggle point that benefits Big Pharm.
8. ACCEPTANCE BY DOCTORS: Some docs will accept whatever Medicare pays and others won’t. There’s a strong sense of entitlement on the part of the docs as well as a tendency to want to push the easy stuff off onto, for instance, nurse/practitioners. When all they do is look at test scores and then follow the indicated formula, there’s not much difference, but there is a definite culture diff between the two levels of education as well as culture diffs within the medical profession, esp. if you include O.D.'s with M.D’s. Only one nurse-practitioner, a man, has ever given me a checkup by really looking at me, checking reflexes, feeling my feet and so on. Maybe one-third of docs (male or female) have done the same. But the bills for service were the same.
9. SPECIFIED FORMULARY: Whole separate booklets specify what meds the insurance company will pay for. I don’t get it. I guess some treatments are considered ineffective or dangerous. One suspects thumbs on scales. Why the fancy word: “formulary?”
10. LEVEL OF SERVICE: The constant complaint when it comes to drugs issued by free clinics, whether it’s the Indian Health Service or a public health HIV-AIDS service, is that the drugs arrive after long waits, inaccurately provided, handed over with contempt, sometimes not in stock, and so on. Of course smart drug store chains high-light good service since it is something they can require of their employees without extra investment of money. But somehow service provided to people who are needy is often given with contempt. Isn’t it reasonable to give needy people MORE kindness?
11. CONFLICT OF INTEREST: And here’s where I balk and begin to think of just going without Plan D. Big Pharma is involved with the politics of government health care and insurance -- like CareMark drug chain owns SilverScript. Also, it is forbidden for insurance salesmen to pitch their plans to Extra Help people -- so who are all these “agents” who call instantly if I pull up an insurance company on the computer? They are “licensed” -- that means nothing. Maybe passed a test. Semantics.
12. SCARE-MONGERING: Every person is in danger of dying at every moment of their lives. A flaming piano could drop out of the sky on you before supper. It’s not likely, but it’s possible. We all are held taut between wanting to risk for the possible benefits and even for a possible increase in skill and experience, but wanting to stay safe enough to risk again on another later day. Everyone has to find their own trade-off.
So I have to think about the likelihood of me needing much more expensive drugs in the future: cancer, heart, trauma. I get a coupon for being such a clean living non-risker. I also have good genes, for which I thank the precluded ancestors of myself who lived such hard, dangerous and probably defiant lives that they were killed early, thus removing their faulty genes from my pool. There’s also something to be said for my mother who believed in cod-liver oil, farm food, and donkey labor by kids.