Like all other beneficiaries who have paid Medicare taxes through their working lives, low income elders and people with disabilities deserve to receive their prescription drugs through Medicare. Because they are costly to serve, however, they have been treated badly in the current debate, as Robert Pear’s July 21 article in the Times pointed out. Since this discrimination belies the underlying purpose of Medicare, it is time for Congress to repudiate its present stance and return to its historical recognition of Medicare’s universality.

Most low income beneficiaries are eligible for both Medicare and Medicaid. These nearly seven million individuals, known as "dual eligibles," receive their primary health care coverage through Medicare, with Medicaid filling in the substantial coverage gaps, including the two big-ticket items of prescription drugs and long-term care. Dual eligibles are substantially more in need of health care services than other Medicare beneficiaries. For instance, they have a higher prevalence of chronic conditions and are three times more likely to have significant limitations in activities of daily living. Not surprisingly, they are also major users of health care services. While dual eligibles comprise only 17% of Medicare beneficiaries, they account for 24% of Medicare spending. Similarly, they represent 19% of all Medicaid enrollees but use 35% of program resources. About 6% of all Medicaid spending goes for prescription drugs for dual eligibles.

Although dual eligibles most need the guarantee and stability of federal health programs, the Senate’s Medicare "reform" legislation excludes them from its prescription drug benefit. Under that version, they would be left instead to the vagaries of 51 state Medicaid programs with 51 different sets of eligibility rules and 51 different packages of prescription drug coverage. Moreover, states will have a significant financial incentive to reduce Medicaid eligibility levels for the elderly and those with disabilities in order to force dual eligibles out of Medicaid and into the Medicare drug benefit. This reaction will harm not only dual eligibles, who will lose all Medicaid coverage, but also those who are only eligible for Medicaid and therefore do not have Medicare to fall back on.

One argument offered for excluding dual eligibles is that insurance companies prefer to keep them out of the risk pool because of the estimated $10-$15 billion per year cost of prescription drugs for dual eligibles. But this is a reason to include rather then exclude them: Congress created Medicare in 1965 precisely on the sound insurance and public policy principle of spreading risk over as large a group as possible. If we intend to honor the view of Medicare as what President Bush called "the binding commitment of a caring society," then we must include those who are most in need of health care services.

Another stated reason for the exclusion is the alleged difficulty of administering the benefit between the two programs. It is true that administration of a drug benefit with both primary and secondary coverage will be complex, for retirees with employer-sponsored health plans as well as for dual eligibles. But Connecticut’s experience with coordinating dual eligibles’ long term care between Medicare and Medicaid demonstrates that the process can be simple and place no burden on beneficiaries. After the provider decides which program to bill, the state reviews the claim to determine if there might, in fact, be Medicare coverage and pursues appropriate claims. Over a period of 17 years this program has returned $200 million to Connecticut’s Medicaid program.

In recent years, however, the federal government has placed roadblocks in the state’s pursuit of these Medicare dollars. Most recently, Connecticut settled litigation against the federal Department of Health and Human Services, impelling rescission of its 1999 policy that had brought the state’s system to a standstill. If the federal government were to embrace coordination, the same principles utilized in Connecticut’s administration of coverage for its dual eligibles could be applied in the drug benefit context.

Everyone in the country has a stake in Medicare, directly as a beneficiary or indirectly as a beneficiary’s relative -- and generally as a citizen with a social, ethical, and financial interest in ensuring the availability of quality health care. The poor are especially well served, for Medicare puts them closer to parity with better-off Americans than does any other national program. Neither the high-risk status of dual eligibles nor the difficulty of coordinating drug benefits between Medicare and Medicaid is a valid reason to deprive them of full participation in Medicare. It would be unconscionable for Congress to diminish Medicare’s universality by excluding nearly seven million of the country’s most vulnerable people from the prescription drug benefit.

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By Gill Deford, Patricia Nemore, and Judith Stein.  The authors are attorneys with, and Ms. Stein is the Executive Director of, the Center for Medicare Advocacy, Inc., a national organization with offices in Connecticut and Washington, DC, that works to ensure that elders and people with disabilities have access to Medicare and quality healthcare. The Center for Medicare Advocacy has represented thousands of individuals who are eligible for both Medicare and Medicaid.