My patient John Elias, with a fixed income from Social Security and a small pension, is a perfect candidate for prescription drug coverage. Yet under the new Medicare plan, he is faced with high deductibles, $420 in yearly co-pays and the prospect of $3,600 coming out of his pocket just to receive $1,500 in coverage before a more complete coverage kicks in. But Elias doesn't take his medicines to begin with, because he doesn't have the money to buy drugs. When I explain the new plan to him, he simply shakes his head. "Not for me, Doc," he says.

Elias is paralyzed from the waist down. He suffers from diabetes and hypertension, and he relies on the free samples in my closet to treat these conditions. When I run out of samples, his blood pressure shoots up. His blood sweetens and unsweetens, depending on whether I can offer him his diabetes pill or not. Product samples come in flashy boxes, a few pills per box, designed to lure patients and doctors into using these drugs. Elias swallows the lure, but he wriggles off the hook.

This past fall the New York Public Interest Research Group (NYPIRG) published a survey of 100 pharmacies. It revealed that cash consumers of prescription drugs pay 100 percent more on average for their medicines than the government pays for Army or veteran supplies, and 130 percent more than Canada pays. The problem is that the uninsured and those caught in the gap have no one doing their negotiating for them, no one who can buy in bulk for them. But the new Medicare plan, rather than using that negotiating power to force more reasonable prices, will force the government as well as the poor and those in the gap to pay retail prices for drugs. A large new cohort will be brought to the prescription drug trough, but on drug- company terms.

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