(Featured image courtesy of Marcelo Leal, on Unsplash)
Because of professional and personal reasons, I decided to retire from full-time ministry about 19 months before I was to be eligible for Medicare. My wife and I planned this major move ahead of time, and set aside funds to personally pay for my health insurance premium while I remained under the healthcare plan provided by my previous employer through COBRA. While I was on that commercial insurance plan, I enjoyed the adequate coverage that the commercial plan provided. In fact, due to the specific contract arrangement of a drug manufacturer with my local pharmacy, I found out that one of the very expensive medications that my endocrinologist prescribed for my maintenance dose enabled me to receive it without any co-pay! As a diabetic, I take maintenance medications, including Insulin, that are vital to keeping me healthy.
Through advanced planning, I had timed the expiration of my COBRA (18 months) to cease right at the time that I became eligible for Medicare. As part of that shift, I made the transition of all my medications to my new supplemental prescription plan under Medicare. Then some hard realities hit me. I learned more about the “contracts” that drug manufacturers have with pharmacies, primarily how uneven they are. I also learned that my prescription plan provides an “allowance” – which turns out to be really a cost threshold – that when exceeded will mean that my copay will increase to 50% of the actual cost of the drug! With the assistance of the customer representative of my supplemental prescription plan, I went through extensive research comparing the prices of my medications along 3 sources. The bottom line is this: the expensive medication that my endocrinologist really wanted me to stay on, and that I received without any copay under my previous commercial plan, now will cost me $150 a month for a 30-day supply!
I had to make the hard decision, and insisted to my endocrinologist, that I simply cannot afford to continue to take this one medication together with the cost of my other medications. With that important medication now taken off my regimen, my doctor is now calling me back to attend a new diabetes seminar with the view of planning and exploring how to move forward without that medication.
This personal account is just about my prescription medications. What does it mean for hospitalizations? Surgical procedures? Catastrophic illnesses? Are there also “thresholds?”
A recent study by West Health and Gallup (https://news.gallup.com/poll/317948/fear-bankruptcy-due-major-health-event.aspx) revealed that half of all U.S. adults are concerned that a major health event in their household could lead to bankruptcy, an increase from 45% measured in early 2019. These results also show that the percentage of non-White adults who harbor this concern has risen from 52% to 64%. This is a foreboding reality that I never imagined will apply to me. Now it does.
Clearly the certitude of adequate and affordable health care is only assured to the select wealthy among us. The cost of health care in the US is astronomical. Drug manufacturers seem to have no guard rails in setting drug prices. Our system of private, employee-tethered health insurance coverage is like a sword of Damocles hanging over the heads of the vast majority of Americans. And for the unemployed, they are bereft. If one is fortunate enough to stay employed until retirement, and be covered by employee-provided health insurance, the transition to Medicare is not without its new challenges (like in my case, and many others under the same plan). These are all major issues in the way our government is structured around these life and death matters. Restructuring it so that the entire apparatus is equitable is a daunting, vastly complex, task. And for certain, such attempts will meet stiff resistance from powerful lobbies and self-interested parties who benefit by maintaining the status quo. But it must be reformed so that health care is accessible, affordable, and just. Courageous public policy must lead the way.