Tough choices for the elderly:  Food or medicine?

With Congress tinkering around the edges of Medicare reform, making prescription drug coverage a part of the health care program for America's 39 million elderly is one of the key stumbling blocks. Until you've been there, or until you've seen your parents' prescription bills, you have no idea just how big a bite medicine can take out of the typical senior's monthly budget.

It's a paradox. Medical science makes one discovery after another extending our lifespans, but with older age comes the need for more and more medicines to make those added years tolerable. We have seen an explosion of new drugs to treat arthritis, heart disease, mental illness and other ailments that have helped Americans live longer, healthier lives.

Seniors, on average, spend about 18 percent of their income on health care, with a large chunk of that going to prescription drugs. Medicines make up the second-largest category of expenses, after housing. It is not unusual for Medicare recipients to face a choice between drugs and food. Nor is it rare to find seniors who play prescription roulette: splitting dosages, skipping days or undermedicating to stretch a prescription to save on costs.

Basic Medicare coverage does not include coverage for outpatient prescription drugs. Never has. Today about 65 percent of Medicare beneficiaries receive some drug coverage through what are known as "medigap" policies, through a Medicare HMO or under coverage provided by a former employer.

That coverage may not amount to a hill of pills, though. According to the American Association of Retired Persons, two of three medigap policies that do cover prescriptions have an annual cap of $1,250. The third has a limit of $3,000. These policies require beneficiaries to come up with 50 percent co-pays and cost about $1,000 a year or more. Medicare HMOs typically cover prescriptions, but some insurers have fled the Medicare market because they claim to have made little profit in it. The cost of prescription drugs in America rose from $55.2 billion to $78.9 billion between 1994 and 1997. That's an increase from 5.8 percent to 7.2 percent of total health care costs. Drug companies caution that capping the price of drugs could lead to cutbacks in research and development of new therapies--an outcome that would not serve any group well.

Because some of the newer, more innovative drugs carry hefty price tags, there are concerns that adding a generous drug benefit will overtax Medicare just as the baby boomer generation is about to place still more demands on the program. Others point out that effective drug therapies help keep older people out of hospitals and nursing homes, thus saving Medicare money in the long run.

The debate swirls in Congress. Measures to provide seniors with the drugs that put quality into a longer life split over funding as much as over philosophy.

In Senate testimony, the AARP cautioned Congress not to "rush to judgment" on plans to reform Medicare. Noting the complexity of the program and the diverse needs of its recipients, Esther "Tess" Canja, the president-elect of the nation's powerful senior citizens group, called for a "careful and thorough examination of a full range of issues" that would affect those who depend on Medicare for their health care.

At the top of AARP's list of Medicare reforms is a call for a defined set of health care benefits, including prescription drug coverage. The group also wants to see adequate government contributions keep pace with growing program costs and a rejection of a higher eligibility age.

Earlier this year, the Medicare Reform Commission, headed by Sen. John Breaux (D-La.), was unable to agree on an official recommendation on Medicare changes. Breaux is working on his own proposal. He has now indicated that public pressure forced him to drop the idea of raising the eligibility age from 65 to 67. He also now favors a drug subsidy for all recipients.

According to the AARP Bulletin, Canja expressed reservations about the Breaux proposal. His plan, she noted, would create a powerful new federal board with authority to alter Medicare benefits. Without more details and serious deliberation, AARP would be forced to "alert [its] members of the dangers in such legislation and why we could not support it," she said. Clearly that was a thinly veiled message that the wrath of the organization's members could be brought down on Congress.

Most observers think that unless there is movement on Medicare reform within the next few months, this important issue will fall victim to the political realities of the 2000 election cycle.