Zonia Acosta takes eight prescription drugs each month to keep her diabetes and related medical complications in check. The 52-year-old Alameda County woman lost part of her right leg and has impaired vision because of the disease. After paying rent and other household expenses, she finds that her $1,104 monthly income -- from Social Security disability payments and a small pension from her job as a licensed family therapist -- leaves only $170 to pay for food, medicine and transportation. She belongs to a Medicare HMO, which pays for prescription drugs, but those benefits cease if her drug expenses exceed $1,000 a year.
Acosta reached her $1,000 maximum in September and will have to pay for the drugs herself until January. Two of her medications -- an insulin-control drug and test strips to monitor her blood sugar -- together cost $159 a month. She has refilled only three of the eight. "I don't have the money to fill them," she says. "I am trying to get help."
Finding help can be difficult for Acosta and others among the 312,000 Medicare beneficiaries in California -- and 5.8 million in the United States -- who are disabled. This group, the fastest-growing segment of the Medicare population, is expected to reach 7.6 million nationwide by the end of the decade.
Paying out of pocket
The typical disabled person on Medicare is a man about 50 years old, although this group ranges in age from the very young to the elderly. As a group, the disabled Medicare population is sicker, has lower incomes, requires more prescription medications and pays more out of pocket for them than Medicare recipients age 65 and over.
"These people are very ill and in tough straits. They need a drug benefit more than anybody," says Becky Briesacher, a research director at the University of Maryland School of Pharmacy who recently completed a study about the drug needs of disabled persons. Despite the large number of disabled people, little attention was paid to their specific problems during last summer's debate in Congress about whether to provide a drug benefit for all Medicare recipients. (The traditional, non-HMO Medicare program does not cover prescription drugs.) Though efforts have been made to make drug coverage more available to the disabled, the programs often come up short, and people fall through the cracks.
The difficulties begin with the Medicare program itself, which requires that only people with a serious disability be eligible for benefits. So someone must first apply for Social Security disability payments, meet strict rules, then wait 29 months before receiving Medicare benefits. In the meantime, they must pay for their own care.
After the waiting period, a person can buy a Medigap policy that covers prescription drugs. In Los Angeles County, for example, premiums for the most generous policies covering drugs cost at least $3,500 a year. It's unlikely that disabled people, three-fourths of whom have annual incomes of $17,000 or less, can pay such a hefty price.
For a lower premium, they can join an HMO that offers drug benefits. But these plans usually offer limited coverage that may prove inadequate for seriously ill people, such as Acosta, who need several expensive medications. Most Medicare HMOs have a $1,000 yearly cap on drug benefits, though some set the maximum at $2,000. With drug prices rising quickly, however, even the more comprehensive plans are scaling back benefits in 2003.
No HMO option for some
Also, the HMO option is unavailable to disabled people living in 24 California counties, most of them rural areas, in which no health plans offer Medicare programs. Nationwide, nearly 30% of disabled beneficiaries live in rural areas.
Disabled people face another problem: Although their incomes tend to be fairly low, they are often too high to qualify for Medi-Cal, California's version of Medicaid, the federal-state program that pays medical expenses for the poor. Medi-Cal provides drug coverage, but a single person typically must have income of $969 a month or less to qualify for free drugs. Pharmaceutical companies sometimes have special programs to provide free medication to the poor, but those programs have strict income limits. Not long ago I interviewed a house painter in Michigan who needed a $42 inhaler to ease symptoms of emphysema. One drug company he contacted said he didn't qualify because his $12,000 annual income exceeded the company's $9,000 income limit.
If people applying for free drugs are covered by any insurance program, including Medicare, they don't qualify either. That leaves a 1999 California law that requires pharmacies to offer Medicare beneficiaries the same discounted price for drugs that the state pays to buy drugs for Medi-Cal recipients.