[EDITORIAL NOTE: A few weeks ago, Congress voted to override President Bush’s veto of the Medicare reform bill, HR 6331. Most of the publicity about the legislation centered around staving off a 10.6 percent cut in reimbursements to physicians, but there were other provisions too that are moves in the right direction.
Saul Friedmen, the Gray Matters columnist for Newsday, published a column last Saturday clearly laying out these changes. His is one of the few mainstream media voices regularly speaking for elders. You can find more of his recent columns here.]
Now that the sound and fury is done, and a good Medicare reform bill has been passed over the president's futile veto, it's time to take stock. For the bill was not simply about stopping a 10.6 percent cut in fees for Medicare doctors; much more was at stake.
That's why the American Medical Association, which has become a staunch friend of Medicare, the American Physical Therapy Association, mental health professionals, AARP and virtually every senior and health-care advocate, joined to pressure enough Republicans into defying George W. Bush for only the third time in his presidency. And for the first time since Republicans took over Congress in 1995, traditional Medicare won a battle against the health-insurance industry.
Indeed, the importance of the bill, the Medicare Improvement for Patients and Providers Act, was underscored when Sen. Edward M. Kennedy (D-Mass.) interrupted his treatment for a brain tumor for a dramatic appearance on the Senate floor, which shamed eight Republicans into voting to break their filibuster so the bill could pass.
Among those who were relieved by the bill's passage were thousands of Medicare patients in need of outpatient physical, occupational and speech therapy, who were facing an annual $1,810 cap on the amount Medicare would pay, which is not nearly enough for most patients.
The caps were imposed years ago because of billing abuses by some private therapists. Patients who received therapy from facilities in hospitals were not affected. But Congress a few years ago authorized Medicare to adopt an "exceptions process," in which most patients in need of therapy at private facilities could exceed the cap. But that exceptions process had run out on July 1, before the new law was passed.
That meant thousands of patients faced continued pain, and setbacks in their recovery from strokes, surgery and injuries. The Medicare legislation, which has taken effect, continues the exceptions process through Dec. 31, 2009. Therapists hope the next Congress will impose a moratorium on the caps or repeal them as no longer necessary.
Similarly, the Medicare bill phases out over six years the higher co-pays for mental health services, so they are in line with the 20 percent co-pay of most other services covered by Medicare. Since Medicare became law in 1965, the program has required that patients pay a 50 percent co-pay for mental health services. Now, Congress has caught up with the times and decided mental health should be on par with physical health.
For poor or low-income beneficiaries, the legislation increases funding for the Qualified Individual program, which pays the high monthly Medicare Part B premium ($96.40) for persons with poverty-level incomes.
Many low-income beneficiaries have not qualified for some of these Medicare Savings Programs because their assets, including savings, insurance policies and in-kind household help, were too high.
The legislation increases the amount of assets one can have and still qualify for extra help in paying for Part D drug costs, as well as other Medicare savings programs that provide help in paying Medicare premiums and other costs. For example, the legislation exempts the value of a life insurance policy. It prohibits states from seeking to recover from estates the amounts paid to beneficiaries of the various Medicare saving programs.
The bill also eliminates the Part D late-enrollment penalty for persons applying for low-income subsidies. Also, as of January 2012, the bill will permit Part D coverage of drugs that have been prohibited.
The legislation makes life tougher for Private-Fee-for-Services plans. But the patient will have greater protection. Now, these plans will have to have their own networks, and must abide by the rules required of other HMOs and Medicare Advantage plans. And they will be subject to the same payment rates as other plans. Medicare advocates hope this will slow the growth of the private plans that cater mostly to the younger, healthier and more affluent beneficiaries.
Some of the most important provisions were aimed at slowing the growth of private Medicare plans, which were eroding traditional Medicare. For example, after a number of complaints about the hard-sell tactics of insurance agents, the legislation set some new rules limiting the behavior of insurance agents who sell Medicare Advantage (MA) and Part D plans (PDP), which cover drugs only.
Under the new legislation, salesmen are prohibited from door-to-door selling, cold calling and the cross-selling of non-health-related products. If you get an unsolicited telephone call, or a sales person at your door to sell you an MA or PDP, call 800-MEDICARE.
But the most contested part of the legislation was the Democratic proposal to pay for these improvements and the physician fees by cutting back slowly on the huge, $5-billion-a-year slush fund that the government pays insurance companies to offer their MA plans, so they can make record profits. This was the provision that the president, the insurance companies and Republican Medicare privatizes, opposed so strongly.
I would have liked to see Congress eliminate the subsidy, which costs 13 percent more per beneficiary than traditional Medicare. But as part of the legislative compromise, Democrats agreed to wind down the subsidy, beginning with $700 million in 2010. With a saving of $47.5 billion over the next 10 years.
As Bush feared, Congress has taken the first small step in saving original government-run Medicare. Perhaps more steps, like Medicare for All, will follow in the next Congress and administration.
You can write to Saul Friedman, Newsday, 235 Pinelawn Rd., Melville, NY 11747-4250, or by e-mail at saulfriedman @comcast.net.
[At The Elder Storytelling Place today, Granny Annie gives us Today and Yesterday, a poem she wrote in 2002 that shows how little some things change.]