One of the challenges with government services of any kind, is once it’s out there, it’s very difficult to get back. People come to expect it as something that’s their right — that’s why we use the word “entitlement.” This has caused budgets to spiral out of control in way that has made funding the government in the future increasingly difficult.
Yet oddly, the Powers That Be want to mess with a program that’s actually saving taxpayer money.
Medicare Part D is one of the most successful and popular programs in the federal government. It has provided outpatient prescription drug coverage for more than 43 million seniors and people with disabilities. An outlier in Washington for coming in under cost, Part D gets patients prescription drugs sooner to stave off more expensive treatments (and suffering).
President Bush’s best domestic achievement, Part D has been a shining example of how conservatives can apply free market principles to policy so the government works better and cheaper. Patient satisfaction is nearly 90 percent and it’s come in under budget — gasp — by as much as 40 percent. One of the reasons for its popularity is that its formulary for treatments is bigger and delivers the best solutions to patients. Which is why many veterans supplement care from the Department of Veterans Affairs with Part D plans.
No other government program does this well, but alas a new rule could threaten this.
In November, the Centers for Medicare & Medicaid Services (CMS) released a proposed rule that will impact the Part D program and six protected classes of treatments — threatening coverage for some of Part D’s most vulnerable populations. It should be withdrawn.
As it stands now, Part D plans must cover all (or almost all) drugs in six protected classes, including:
- anticonvulsants (which fight epilepsy)
- antineoplastics (which fight cancer)
- antiretrovirals (which fight HIV/AIDS)
- immunosuppressants (to help with organ transplants)
These classes were created to protect affected patients from discrimination. Moreover, patients who fall within these classes often need specialized care and a range of medications; protecting them gives providers the flexibility to prescribe the most suitable treatment options.
CMS’s new rule aims to create significant exceptions which could lead to fewer protections and more limited formularies for patients. Under the proposed rule, affected patients may regardless lose access to their current regimen of medications as well as new breakthrough medications.
Troublingly, this new rule could restrict new formulations of existing drugs. Doctors and researchers aren’t just coming up with new drugs, but they’re coming up with new ways to use and combine them (called formulations). The proposed rule would change allowances for Part D to cover such formulations, which would both restrict patients’ access to them and disincentive researchers from finding new ones.
Even worse, the rule could allow plans to replace working treatments with prior authorization and step therapy. This could disrupt the current treatment regimens for millions covered under Part D, potentially forcing patients to change treatments even if they are effective. This is bad news because one-size-fits all approaches to treatment don’t account for individual circumstances. Furthermore, disrupting treatment reduces patient adherence to their treatment plan. For beneficiaries with serious conditions such as HIV/AIDS, maintaining adherence is essential for positive outcomes.
The rule could also restrict coverage based on inflation, measuring price increases not according to medical inflation, which usually increased much faster than general inflation.
Medicare Part D is one of the best innovations the federal government has come up with. For more than 10 years, private insurance plans have competed with one another for Medicare enrollees under Part D. Whereas monopolies in other entitlement programs create a perverse incentive to overcharge, Part D has driven insurance companies to keep their costs reasonable and push for bargains with drug companies.
Despite this success, Democrats have made previous proposals to make the Part D formulary more like the one used by the VA — including government negotiation of drug prices, which is effectively a price control. There are relentless, necessary demands to reduce the federal budget; disrupting Part D is not the place to start.
The proposal to limit the protected six formularies will have a similar effect. Like government drug negotiation and price controls, limiting the six protected classes may seem to some to be a good idea to save money in the short-term. Indeed, in this misguided effort to save money, this change would make the program less effective by denying seniors, veterans, and the disabled access to the best possible care, increase expenses and suffering for those patients long term.
Jared Whitley is a long-time politico who has worked in the U.S. Congress, White House, and defense industry. He is an award-winning writer, having won best blogger in the state from the Utah Society of Professional Journalists (2018) and best columnist from Best of the West (2016). He earned his MBA from Hult International Business School in Dubai. To read more of his reports — Click Here Now.
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