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John Elias, my patient, has a dilemma. He can't afford to buy his medicines and also pay his rent. I'm sure he won't give up his apartment just to keep his veins filled with my chemical suggestions. But he is willing to take whatever free drug samples I provide. Luckily, drug company representatives visit my office regularly and drop off oversize, brightly colored boxes of pills, one or two pills per box. Sometimes I can fill a plastic bag with enough medicine to supply a patient's needs. Still, my sample closet is not as well stocked as the local pharmacy.

The explosion of samples occurs most often when two drug companies are competing over a similar product. When I have one set of pills, it's Elias's diabetes that's treated; when I have another set, it's the hypertension. He does not die, but his blood pressure goes up and down, and his blood sweetens with rising sugar, which lowers whenever I happen to have the right pills. Elias leaves my office smiling, more comfortable with his predicament than I am.

"See you in a month, Doc. And don't worry. I got enough pills here to last me a good ten days."

I do worry--about the remaining twenty days, about his risk of a heart attack or a stroke--but samples arrive at the drug company's rate, not in response to my urgent requests.

Elias is disabled, the result of a spine operation that didn't go his way. He has Medicare, but like millions of other disabled and elderly Americans, he's unable to afford the secondary insurance that would include a drug plan. He earns too much in his part-time clerical job to qualify for Medicaid, which also covers prescriptions, or to be accepted into a drug company's "Share the Care" program. He does qualify for New York State's EPIC plan, which allows some Medicare patients to fill all their prescriptions for under $100 per month, but he says he can't afford even that. He says he won't consider leaving his job to get Medicaid as others have done; he's proud of the fact that he can still work.

Elias lives in his wheelchair; the levers and locks are extensions of his arms, the wheels his legs. He navigates the street outside my office, leaning back on two wheels to jump the curb. His arching wheelies are another man's sidestep. But he has not managed to navigate his other diseases the way he has his paralysis. When I tell him the dangers of not controlling his diabetes and his high blood pressure, his smile fades. "When you're out, then I'm out," he says simply.

Meanwhile, the same company that makes his diabetes pill offers to fly me, all expenses paid and with a $1,000 stipend, to a frolicking weekend in Naples, Florida, where I would hear lectures for three hours a day on a drug I already prescribe, before adjourning to the surf and a sightseeing sunset booze cruise. The competitor invites me to the corporate box at the ballgame, with a lobster buffet and a live calypso band to entertain us between innings.

The drug salesman infiltrates the somber atmosphere of my medical office, trailed by a huge sample case on tiny wheels. It's uncanny: He knows how much of his drug I prescribe, and he wrongly assumes that I will respond to his enticements. He provides catered lunches to my office staff where the only apparent cost is listening to him harp on about a product that he freely admits I know more about than he does.

Despite the money spent on massive advertising, the manufacturers insist that exorbitant drug prices are the result of research and development. Several of the industry's best researchers are former professors who have been wooed away from the universities for higher salaries and better laboratories, and for every participant in the drug pipeline, from discovery to production, the excitement is almost palpable. New medicines for arthritis, hypertension, high cholesterol and diabetes improve the quality of life with fewer side effects. However, the new drugs are sold in Canada and Europe for a much lower price--a $15 pill in Detroit may cost $5 across the river in Windsor, Ontario--and there are foreign chemists producing these drugs in the laboratory and companies selling them for a fraction of their cost in the United States.

The more expensive the drug, the more difficult it is to determine how it is going to be paid for. Recently, a new wonder drug for arthritis became available in two formulations, one oral, the other intravenous. The choice of which form to use illustrates a basic problem in reimbursement. Since Medicare pays only for the more expensive intravenous, patients are being hospitalized unnecessarily to receive it.

As a doctor, I'm frustrated by the current system's inability to consistently provide for a patient's medicinal needs. Clearly, there is a need for government to intervene, but it's crucial that this intervention include an understanding of inflated costs and a plan for combating this inflation. As Medicare expands to cover pills, will the federal government drive a hard bargain and negotiate a lower price per pill the way HMOs, hospitals and other countries already do? I don't see how taxpayers can avoid being penalized if the government agrees to pay top dollar.

This year, after many insufficient attempts to maintain his health with samples, Elias wheels into my office with, if wheels were legs, an almost detectable swagger. All his years in service as a clerk have finally paid off. He is now the recipient of secondary insurance with a drug plan. He is one of the lucky ones. Now all his medications will be covered, at least for the moment.

"I'm ready to be healthy," he says with a grin that reveals his neglected teeth. "Lay those prescriptions on me."

Single-payer healthcare is favored by the public, yet the insurance industry has too much to lose if it is enacted.

Foundations formed when nonprofit hospitals became for-profit are often not living up to their obligations.

The number-one healthcare issue facing the country is not which prescription drug plan is best for seniors or whether a handful of patients will be able to sue their HMOs. It is the 44 million people, or nearly 20 percent of the population under age 65, who have no health insurance and, for many, no healthcare at all. The myth that emergency rooms provide all the care the uninsured require continues unchallenged. But the emergency room is not the place to get primary care, follow-up care or care for chronic conditions, which most people need. Federal law requires emergency rooms to stabilize patients. After that, they are sent on their way, especially if they have no money to pay for further treatment. When they are given prescriptions, 30 percent of the uninsured don't fill them because of the cost.

Rationing specialty care for the uninsured is common. In Washington, DC, the uninsured wait four months for an MRI and two months for a CT scan. In California, some counties have money to screen women for breast cancer but no money for treatment. During the four to seven years following an initial diagnosis of breast cancer, one national study shows, uninsured women are 49 percent more likely to die than women with insurance. Community clinics that treat the uninsured rarely have specialists on their staffs and resort to begging area physicians to help out--not always with success.

The Bush and Gore solutions do little to help the uninsured and a lot to keep the healthcare system safe for insurance companies, the AMA, employers and the pharmaceutical industry, all of which have shoveled money into their campaigns. Bush proposes an annual refundable tax credit (that is, one that's given even if a person owes no taxes) of up to $1,000 for individuals and $2,000 for families. His campaign literature makes tax credits sound ideal: "If a family earning $30,000 purchases a health insurance plan costing $2,222, the government will contribute $2,000 (90 percent)." Trouble is, most families can't buy insurance for $2,222. The average premium for a family policy is $6,740 and for an individual, $2,542. Gore calls for a credit equal to 25 percent of the premium. Using the average premium as a benchmark, that's about $1,700 for family coverage; a family wanting a policy would still have to cough up more than $5,000.

Tax credits, moreover, leave intact the ability of insurance companies to select good risks and exclude sick people who will cost them money. That, of course, is what the industry wants to protect--and is part of the payoff for its campaign largesse.

Both Bush and Gore would also fiddle with the Children's Health Insurance Program (CHIP) to boost coverage. CHIP has brought health insurance to some 2.5 million kids, but 10 million still have none. Bush's solution: Give the states more flexibility in administering the program. But many states have not even spent federal dollars already earmarked for them, and could be tempted into using the money for something other than insurance. Gore's solution: Stretch the eligibility rules to include children whose families have incomes up to 250 percent of the federal poverty level, or $41,000 for a family of four. But what if a family's income is above 250 percent, say $43,000? Gore's answer: tax credits.

Then there are medical savings accounts, which Bush likes and Gore doesn't. Congress now allows self-employed people and employees in small companies to buy MSAs, which are a combination high-deductible insurance policy and tax-deferred savings account. But at the end of 1999, only 45,000 policies of the 750,000 Congress authorized had been sold. Still, Bush wants to let more people buy them, a move that will spark interest mainly among the healthy, who won't need the savings account to pay for care, and the wealthy, who can assume the costs not covered by the large deductible and who will simply get another tax break.

The major battleground in healthcare, though, is over a prescription drug benefit for Medicare beneficiaries, with pharmaceutical companies replacing HMOs as this year's healthcare villains. Under Bush's scheme, the very poorest seniors would get help paying for the entire cost of a drug benefit. Individuals with incomes greater than $14,600 and couples with incomes up to $19,700 would get a partial subsidy. Bush would pump $48 million into the state pharmaceutical assistance programs to give free drugs to those with the lowest incomes. But more than half the states have no programs, and those that do lace them with restrictions.

Under Gore's plan, Medicare would cover 50 percent of the cost of prescriptions, first up to $2,000 and later up to $5,000, for seniors willing to pay a premium that would start at $25 a month. As with Bush's plan, seniors with very low incomes would get help. Both candidates offer help for those with catastrophic expenses: Gore's benefit would kick in after seniors have spent $4,000 on drugs, Bush's after they've spent $6,000 for all services. Neither, however, includes a way to control pharmaceutical prices. Controls of any sort are anathema to the drug companies.

The fight over whose plan provides the bigger benefit obscures the real fundamental Medicare issue, and that is the future structure of the program itself. Under the guise of "consumer choice," Bush wants to transform Medicare from a social insurance program with a defined benefit available to everyone into a voucher plan under which seniors would be given a fixed amount to buy whatever insurance they could afford. Even if a voucher were sufficient to pay for a policy today, there is no assurance that it would do so in the future. In effect, the Bush proposal could make seniors, rather than government, bear the cost of healthcare inflation. Gore speaks of putting Medicare in a lockbox, which presumably means he wants to maintain it as a social insurance program.

Unresolved in the candidates' discussions is the larger question: Is healthcare a right in America or a commodity available only to those who can pay? On this the public may be way ahead of its leaders. When the Kaiser Family Foundation asked people earlier this year if healthcare, like public education, should be provided equally to everyone, 84 percent said yes. The candidates, however, are listening to the special interests, whose money speaks louder than the people.

We have the Bill of Rights and we have civil rights. Now we need a Right to Care, and it's going to take a movement to get it.

Research support for this article was provided by the Investigative Fund of The Nation Institute.

With his recent speech on healthcare, Bill Bradley has moved the
worsening plight of the uninsured back into the spotlight.

In early December 1984, an undercover police officer named Marcellus Ward met with a pair of heroin dealers above a candy store in southwest Baltimore.

The single-payer system, it was said,
Has faults that go beyond the fact it's Red:
If any faceless bureaucrat decreed
That surgery the doctor says you need

Almost three times as many people, most of them in tropical countries of the Third World, die of preventable, curable diseases as die of AIDS.

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