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 Now that the new federal Medicare drug program has been enacted, state prescription assistance programs (SPAPs) will make important eligibility and coverage policy decisions. Many will likely choose to become secondary, "wraparound" payers to the Medicare drug benefit for those limited income Medicare patients who are income-eligible for the SPAP.

While state Medicaid programs appear to be prohibited by the new law in most, if not all, cases from offering secondary, "wraparound" drug coverage to "dual eligibles" [those Medicare patients who are also poor enough to be on Medicaid too] this is not so for SPAPs. They're allowed to be secondary, "wraparound" payers if they choose to do so. Given state budget problems, some may propose terminating SPAP programs to save state funds, on the [disingenuous] grounds that the new Medicare drug benefit makes the state program unnecessary. But either way, enactment of the Medicare Part D  drug benefit means enormous savings to SPAPs---in addition to the savings states will get from Part D displacing some state Medicaid drug expenses.  For example, Pennsylvania was predicted to save $150 million just from the preliminary Medicare interim $600 drug discount card program; New Jersey’s savings were to be $90 million; Connecticut’s were to be $15 million; and all SPAPs will save proportionately at least as much when the full, permanent Part D program becomes primary payer in 2006.  

States with SPAPs will engage in, and perhaps complete, policy and budget decision-making in response to Part D’s enactment by late 2005. So it is now important for state-level disability (and aging) advocates to press states to make wise decisions:

1.Since they'll realize enormous savings anyway, states should retain their own SPAPs to offer secondary, "wraparound" coverage to modest income patients who won't get all necessary drugs from the possibly-limited formularies that the privatized Part D Medicare drug plans will establish---and to help pay high cost-sharing that Part D plans will still impose (in spite of some low income protections) on limited-income patients---especially the 15% coinsurance for those with incomes between 135% and 150%  of poverty.

2. With such great state budget savings at hand, those states with limited formularies or annual benefit caps---such as Delaware, Illinois, Indiana, Kansas, Missouri and Rhode Island---can and should now cover all FDA-licensed drugs and remove any benefit caps.

3. With such large savings imminent, those state SPAPs which now cruelly exclude the disabled under age 65---Florida, Indiana, Kansas, Michigan, Missouri, Nevada, New York, North Carolina, Pennsylvania, Rhode Island, South Carolina and Wisconsin--- should use a small part of the savings to finally cover them in the SPAP.

4. Not only should all state SPAPs now cover the disabled---they must be attentive and compassionate enough to expressly cover those disabled who are still in their two year Medicare waiting period. These newly-disabled persons---who suffer from the recent onslaught of a serious illness or injury that usually requires even more medical care than longer-term, "stable" disabled  persons, have just had a catastrophic drop in their incomes from having to stop working, and yet many of them get Social Security Disability checks just above state Medicaid income levels---while not being covered yet by Medicare. States need to expressly tie their SPAPs' eligibility rules to being "over 65" or "disabled" --rather than simply being “Medicare-eligible" (which still excludes those in the two year waiting period).

5. There may well be legal grounds to challenge state SPAPs that exclude the disabled. Not only do the Americans with Disabilities Act  (ADA) and Section 504 of the 1973 Rehabilitation Act ban discrimination against the disabled in programs that, like these, are now arguably even more federally-related than before Part D’s passage; many states themselves have state constitutions, statutes, regulations or court decisions prohibiting discrimination against the disabled generally or in state programs. See, for example, "Exclusion from Services and the Americans with Disabilities Act" in Clearinghouse Review  (October, 1996; pp.608-615).  See also outlines of each state’s laws imposing state and local responsibilities for indigent health care under “State and Regional” at www.healthlaw.org .   

Some state officials might unjustifiably fear the costs of continuing state prescription programs--and be particularly concerned with the supposedly high costs of adding coverage of the disabled. However, some key facts easily disprove these fears:

a. Disabled Medicare patients are only one-sixth the number of aged beneficiaries (see  Table 2-2, page 2-6, of 2004 Green Book at  www.waysandmeans.house.gov )

b. In the most on-point study of the issue, "Health Insurance Coverage Among Disabled Medicare Enrollees" in the Health Care Financing Review  (Vol. 12, No. 4, pp. 27-37, Table 1 at p. 31), an official publication of HHS' Centers for Medicare and Medicaid Services, reported that 41% of disabled Medicare patients already have  secondary private health insurance. The accompanying text makes clear that this is almost always as covered dependents in the job health plans (with drug benefits) of their working-aged, healthy spouses; aged Medicare patients, by contrast, are typically married to other elderly, retired spouses and so neither spouse has employee health coverage anyway. Hence, nearly half of the disabled won't even need to apply for state SPAP coverage.

c. Demographic data tables on veterans by age band for 2001 at www.VA.gov and the 2000 census figures for all male age bands over 65 at www.census.gov , read  together, indicate that over 60% of men over age 65 are military veterans---meaning that, if they have honorable or general discharges and income under about $30,000, they're eligible for prescriptions for $7 each from the VA ! (And, by getting their health care from the VA, limited income patients would actually be much better off  and even  avoid high, unaffordable Medicare deductibles and co-pays, since the VA has few--and very low—co-pays itself.) Even though-- because they are state-funded and subject to the states' own eligibility rules---SPAPs can insist that applicants who are VA-eligible go there for drugs instead, they have unaccountably so far failed to do so, even though they’d save many millions. If  they began doing so, they could shift large costs to the VA instead---and thus be all the more able to afford covering the disabled under age 65!

(The Kentucky AIDS Drug Assistance Program [ADAP], which serves a quite younger population, with many fewer veterans than are found in  SPAPs---because, since its 1973 abolition, the draft hasn't been there to force many younger men to serve, even though it did force most older men into the military when they were young---still was able to identify a full 10% of its caseload as VA-eligible simply by asking clients about military service. (Email Lisa.Daniel@mail.state.ky.us for details.) SPAPs, if they asked too, could find even more of their clients to send to the VA instead---and they'd thereby save more than enough money to cover the disabled.

d. Although it's possibly not an argument that should be made publicly---for one thing, it's not likely to influence some more conservative state officials---keeping current state SPAPs operating, and expanding them to cover the disabled too (including those in their two year waiting periods) where they currently fail to do so, will make these SPAPs more widely available to needy disabled AIDS patients also. That would lessen the growing, unfunded burden on hard-pressed state ADAPs, many of which have been forced to place ill, uninsured applicants on waiting lists.