Comment: Medicare + Choice plans
(This article first appeared in The Nation)
With a doctor in charge of the Senate, compassionate conservatism is well positioned to run roughshod over the issue that traditionally worked well for Democrats–healthcare. The Republicans’ parsimonious plan for a senior citizen prescription-drug benefit will be among the first issues taken up by the new Congress. The Bush Administration has signaled that it wants to link the benefit to turning Medicare over to the insurance companies–legislation that Senator Bill Frist, the new majority leader, knows all too well, since he sponsored it in previous sessions. It doesn’t matter to the privatizers that Medicare + Choice plans, the government’s pilot project on privatization, have been a disaster almost everywhere they’ve been tried. They cherry-picked the relatively healthy seniors while subjecting the frail elderly to canceled policies, higher co-payments and burdensome extra charges. Yet the Republicans are intent on using prescription drugs as a wedge for their long-term goal of privatizing the entire government-run program. Given the confusion they were able to spread about drugs during the recent campaign–fueled by the tens of millions of dollars the pharmaceutical industry poured into surreptitious advertising campaigns–they may well get their way, unless Democrats find their voice on the crucial drug issue.
Defenders of Medicare must be crystal clear about why the pharmaceutical manufacturers have been so intent on derailing the Democrats’ senior citizen drug plan. You’d think the industry would prefer a plan that spends nearly $ 600 billion on drugs in the next eight years over one that spends about half that amount. Moreover, under the Democratic plan, more seniors would be taking more drugs, because its lower co-pays and more generous benefits would encourage them to fill their prescriptions or stop cutting their pills in half to make ends meet.
There is one reason for the industry’s visceral opposition to the Democrats’ plan: It is government-run. That means the Centers for Medicare and Medicaid Services (CMS, the agency formerly known as HCFA) would begin meddling in how the taxpayers’ money gets spent, just as it currently sets the fees that hospitals and doctors receive from Medicare. (Little-known fact: Medicare costs have gone up much slower than other healthcare costs in recent years–and are well below private health insurance premiums.) CMS might one day establish lists of preferred drugs and use its purchasing power to negotiate lower prices for drugs on the list–a fate the drug industry wants to avoid at all costs.
The potential of pro-consumer government intervention in the drug marketplace was revealed in dramatic fashion in December when the National Institutes of Health (NIH) released the results of one of the most ambitious studies it has ever undertaken: an eight-year comparison of four common hypertension drugs. More than 20 million Americans, most of them seniors, take one of the 150 high-blood-pressure medicines on the market and another 20 million probably should. But which should their doctors prescribe: one of the old diuretics that have been around since the 1950s and now cost pennies a day, or one of the “new and improved” agents like calcium channel blockers that the drug industry has promoted at a cost of billions of dollars over the past decade? The results of the study were conclusive: The cheap diuretic, which few doctors prescribe, worked best.
The implications of the research go far beyond the treatment of high blood pressure. The trial is a model for the role the federal government must play in an increasingly crowded drug marketplace if it is going to provide a drug benefit for senior citizens that taxpayers can afford. Many of the drugs that have emerged from industry labs in recent years to treat common chronic conditions fall into the heart-medication pattern: They’re either variations of existing drugs already on the market or entries that seek to treat what older drugs–usually coming off patent–already treat with proven success. They’re called me-too drugs, as in, “We want an entry into that lucrative market, too.”
Congress must help seniors and physicians sort out the confusion. First, it should revise the rules at the Food and Drug Administration so that drug companies are required not only to test new drugs for safety and efficacy but also to submit data that compare them to already existing therapies. The government should then give NIH a new mandate to systematically conduct comparison trials like the high-blood-pressure trial. (Only in the rarest of cases does a drug company conduct such tests, preferring to hire a small army of salespersons to distribute the results of the latest industry-funded clinical trials and let the best marketing team win.) This is not to say that new drug approvals should hinge on proving their superiority. Industry spokespersons point out that there can be a positive side to me-too drugs–for example, some patients don’t respond well to the best drug in a class. But government-mandated comparisons would not stop a company that wants to bring an effective drug to market.
Industry will wail that the additional clinical testing will drive up the cost of approving new drugs and choke off innovation. Just the opposite will occur. A new requirement that drug companies test their latest offerings against existing medicines will force them to focus their R&D budgets on truly innovative new medicines, while NIH comparative trials will inform doctors about the best clinical practices. In the long run, that will benefit patients, the drug industry and the practice of medicine. It will also begin modernizing Medicare for its onrushing confrontation with the baby-boom generation. The program doesn’t need to be turned over to the insurance industry, which has already failed miserably at holding down healthcare costs. The government must use science and regulation creatively to give seniors the best medicine at a price society can afford.