Congress has not seriously dealt with the prescription drug issue in context of Medicare for more than a decade. Opposition led to the repeal of the Medicare Catastrophic Coverage Act in 1989. This was the result of pressure from pharmaceutical manufacturers and affluent elderly beneficiaries, most of whom already had drug coverage, to paying higher premiums without and accompanying benefit. Unfortunately the issue of prescription drugs for Medicare beneficiaries has not been resolved. It has become a social matter, and an election year issue.

It may be helpful to go back to 1988, when the Medicare Catastrophic Coverage law was enacted, to understand the present situation. It was also the year that the 200th General Assembly adopted a policy statement called "Life Abundant: Values, Choices, and Health Care-The Responsibility and Role of the Presbyterian Church (U.S.A)." Although Congress repealed the law the next year, the church was gearing up to pursue access, affordability and quality in a just health care system for all. The latest guidance from a General Assembly occurred last year at the 211th General Assembly (1999) when it reaffirmed and recommitted the church's charge to healing and wholeness.

Since 1988, there have been times when it seemed that our nation was on the verge of adopting universal health coverage, which would lessen the need for or complement the Medicare program. Since that did not occur, attention was again focused on Medicare. As an outcome of the Balanced Budget Act of 1997, the National Bipartisan Commission on the Future of Medicare was appointed. After meeting during 1998 and 1999, the Commission was unable to reach consensus to recommend a proposal for Medicare. A significant stumbling block was providing out-patient prescription drugs.

The Medicare benefit package, largely designed in 1965, provides virtually no prescription drug coverage. This does not mean, however, that all Medicare beneficiaries lack this coverage. In 1996, almost one-third had employer-sponsored health coverage, as retirees, that included drug benefits. More than 10 percent of beneficiaries received coverage through Medicaid or other public programs. Medicare beneficiaries seeking lower drug costs can choose to enroll in a Medicare+Choice plan with drug coverage if one is available in there are or purchase a Medigap policy. Even for beneficiaries with drug coverage, the extent of the protection it affords varies. The value of a drug benefit design, including cost-sharing requirements and benefit limitations.

There are no easy answers for providing prescription drugs for Medicare beneficiaries. Medicare+Choice, once seen as a positive alternative because it provides prescription coverage, has lost much of its luster. Created in the Balanced Budget Act of 1997, the program began with large enrollment rates as beneficiaries left fee-for service Medicare to take advantage of drug and other benefits. Recently, however, enrollment has fallen to negative increases as beneficiaries are dropped by plans leaving the program.

President Clinton gave new impetus to take up the issues of prescription drugs in his 2000 State of the Union address, pledging to "give every senior a voluntary choice of affordable coverage for prescription drugs." However, both the Administration and Congress are challenged by the prescription issue because of its cost, if for no other reason. Perhaps the most controversial element relates to how payment should be apportioned in society. As the senior population increase (it estimated that 77 million "baby boomers" will enter Medicare within the next 10 years) and pharmaceutical advances help to prolong life and the quality of life, will seniors be able to afford their medicine? What benefits should be given and who should pay?

Legislative Proposals

Is there a need again for some universal catastrophic coverage? "Catastrophic" can be define as wither based on fixed dollar amounts out-of-pocket costs (e.g. $1000 or $2000) or as a percentage of family income (usually 10 or 15 percent). An example of such a bill is the "Access to Prescription Medications in Medicare Act" (S. 841). It was introduced in April 1999 by Sen. Kennedy (D-Mass.) and a companion bill was introduced in the House by Rep. Stark (D-Calif.) (H..R.. 1495). Some features include a provision ensuring that there will be no premiums or cost sharing for beneficiaries with incomes below 135 percent of poverty; all other receive 75 percent premium subsidy. Those with employer coverage equal to or better than the drug benefit could opt to receive the subsidy for their existing coverage.

Another legislative approach is to target insurance and subsidy schemes aimed at low-income elderly persons with disabilities. Rep. Bilirankis (R-Fla.) sponsored the Medicare Beneficiary Prescription Drug Assistance and Stop-Loss Protection Act (H.R. 2925); "stop-loss" refers to catastrophic coverage. The proposal would provide full premium subsidy for a comprehensive drug benefit if income is below 200 percent of poverty, and no cost sharing below 120 percent of poverty.

Although there are a number of legislative proposals related to prescription drugs for Medicare beneficiaries, the President's and the Breaux (D-La.)-Frist (R-Tenn.) proposals have elicited quite a debate in Washington. There are similarities between them. Both provide voluntary coverage, although income-targeted subsidies are provided to encourage the purchase of drug coverage. By making the drug benefit financially attractive, the proposals seek to maximize participation and avoid "adverse selection" problems-i.e. having only high-cost beneficiaries purchase coverage that would drive up premium costs. Low-income beneficiaries would pay nothing for the drug benefit, while those earning more would pay up to 75 percent of the cost. To further minimize adverse selection, the President's proposal included, and Breaux-Frist considers, a provision limiting opportunities to select drug coverage. Both promote competition as a marketing factor.

One major difference between the two proposals concerns how the beneficiary premium would be set for those remaining in the traditional fee-for-service program. Under Breaux-Frist, there would be no separate part B premium. All plans, including traditional Medicare, would calculate a total premium expected to cover the cost of providing Medicare-covered services to the average beneficiary. The maximum government contribution would be bases on a formula. Beneficiaries would pay no premiums if they chose plans costing 85 percent or less than the national enrollment-weighted average premium. Beneficiaries would pay an increasing portion of the premium for plans with higher ones. The traditional fee-for-service program could still be chosen as a plan. Therefore the monthly amount beneficiaries would pay to enroll in it would depend upon how expensive it is relative to the private plans.

In contrast, under the President's proposal, the beneficiary premium for traditional Medicare, the part B premium, would continue to be set administratively. As under Breaux-Frist, all other plans would submit competitive premiums. The maximum government contribution to private plans would be set at 96 percent of the average spending per-beneficiary in traditional Medicare. Beneficiaries who joined plans that cost less than that amount would pay reduced or no premiums. Beneficiaries who joined more expensive plans would pay higher part B premiums.

The House plans to vote on a drug bill this summer tentatively called the Medicare Prescription Drug and Modernization Act. According to a draft document, the new drug benefit and the current Medicare+Choice plans would be run by a new agency within the Department of Health and Human Services called the Medicare Oversight and Management Administration. However, the draft does not include a cost for the proposal or the amount of stop-loss coverage beneficiaries would receive, a feature likely to affect the attractiveness of the plan to beneficiaries.

A group of panelists representing Congress, the Administration and the biotechnology industry predicted that the Republican leadership in the Senate would resist such efforts. Although unlikely, congressional action could be produced if House Republican leaders proceed with a vote and Republican senators facing re-election in states neighboring Canada or otherwise in political trouble force a vote in the Senate. This is because all House seats are up for re-election and senators from states bordering Canada are particularly vulnerable because of the ability of seniors to buy less expensive drugs in Canada than in the United States.

The senators most affected include Gorton (R-Wash.), Abraham (R-Mich.), Santorum (R-Pa.), Jeffords (R-Vt.), Ashcroft (R-Mo.), and Finance Committee Chair Roth (R-Del.).

On May 15, Texas Gov. George W. Bush (R) laid out six principles for Medicare reform that reflect the Medicare reform agenda of most Republican lawmakers. The principles include preserving seniors more choice of health plans, providing financial help for low-income seniors, increasing access to medical technologies, avoiding raises in Medicare payroll taxes, and creating a more accurate measure of program solvency. Bust said Medicare beneficiaries must continue to receive benefits automatically as opposed to means testing, and should be able to choose a health plan that best suits their needs, including those providing prescription drug coverage.

The Democrats and the White House are more unified on the prescription drug issue, nonetheless, not all Democrats are supporting the party's proposal. This was revealed when Senate Minority Leader Dachle (D-S.D.) was unable to line up all 45 Senate Democrats to back the lead Senate Democratic drug proposal, S. 2541, which would amend title XVIII of the Social Security Act to provide a prescription drug benefit for the aged and disabled under the Medicare program, enhance the preventative benefits covered under such program, and for other purposes.

Conclusion

There should be no illusions about how complicated Medicare reform will be. Although principal elements have been lifted up, "the devil is in the details." This will surely be a challenge for lawmakers, but it also challenges social justice advocates, especially people of faith. As out nation prepares for presidential campaign and congressional elections that will provide leadership for the next four years, citizens must claim their responsibility for "neighbor" and self.

The need to care for and the need to be cared for calls for mutually interdependent accountability. The PC(USA) Washington Office encourages people of good will to speak truth to power. Nicholas Lash asks: " How might the kind of 'people' that Christians (like Jews) confess themselves to be, acquire the discipline, sustain the culture, that would render us capable of "speaking truth to power"? Will your voice make a difference in how this nation brings about Medicare reform?

Suggested actions:

It is believed that a prescription drug bill will not be passed before the end of the current legislative session, which is considerably shorter this year. The target date for adjournment is October 6. There seems to be neither bipartisan nor bicameral support in this election-charged year. This could be, however, a good time to let lawmakers know about your concerns related to prescription drug benefits.

1. Contact your Senators and Representative to let them know of you concerns related to the need for Medicare beneficiaries to receive prescription drugs. IF you know a personal story that reinforces your concern, please describe it briefly. Let them know you will also be communicating with their opponent in the coming election. Ask your lawmakers; position on who should be eligible for coverage, how and who would pay for benefits, and what should be the role of the federal; government. If you agree with their response, thank them in a future correspondence. If you disagree, let them know why, but be polite.

2. If your Senator or Representative is retiring after this session of Congress, you should contact the candidates for that office using the same strategy described above. The following members of Congress have announced their intention not to seek re-election in 2000:

Senators
Connie Mack (R-Fla.)
Richard Bryant (D-Nev.)
J. Robert Kerry (D-Neb.)
Frank Lautenberg (D-N.J.)
Daniel P. Moynihan (D-N.Y.)
House
Bill Archer (R-Tex., 7th)
William L. Clay (D-Mo., 1st)
Bill Barrett (R-Neb., 3rd)
Owen Pickett (D-Va., 2nd)
Herbert Bateman (R-Va., 1st)
Bruce Vento (D-Minn., 4th)
Charles Canady (R-Fla., 12th)
Helen Chenoweth-Hage (R-Idaho, 1st)
Tom Coburn (R-Okla., 2nd)
Thomas Ewing (R-Ill., 15th)
Tillie Fowler (R-Fla., 4th)
William Goodling (R-Pa., 19th)
Rick Hill (R-Mont., at-large)
John Kasich (R-Ohio, 12th)
Jack Metcalf (R-Wash., 2nd)
Ron Packard (R-Calif., 48th)
Edward Pease (R-Ind., 7th)
John Porter (R-Ill., 10th)
Matt Salmon (R-Ariz., 1st)
Mark Sanford (R-SC., 1st)

House Members Seeking Election to the Senate
Tom Campbell (R-Calif., 15th)
Ron Klink (D-Pa., 4th)
Bob Franks (R-N.J., 7th)
Debbie Stabenow (D-Mich., 8th)
Bill McCollum (R-Fla., 8th)
Robert Weygand (D-R.I., 2nd)

3. Seek a way to express your concern about prescription drugs to the presidential candidates. If you attend a campaign meeting where they are present, try to voice your opinion. Also try to contact the local or regional Democratic or Republican party leaders and ask that they relate your concerns to the offices of the presidential candidates. This will be more effective if done before the party conventions this summer.

General Assembly Guidance:

The 211th General Assembly (1999) adopted two reports from the Advisory Committee on Social Witness Policy: "Heath Care: Policies and Activities" and "Managed Care." Concerns for beneficiaries of Medicare are addressed in both.