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“I am coughing up blood and I have been for days.” Even amid the hundreds of calls health care advocate Suzanne Jackson gets each day, this one stood out. The alarming voice mail, left with the George Washington University Health Insurance Counseling Project, was from Joyce Hill-Jones, a 55-year-old D.C. resident in desperate need of help in getting medication to treat an acute case of bronchitis. But like 16,000 other low-income seniors in the District of Columbia who used to have their prescriptions paid for by D.C. Medicaid, Hill-Jones was dumped from the program on Jan. 1. In its place seniors were funneled into one of 48 insurance plans that comprise the new federal Medicare drug program, known as Medicare Part D. Like many others, Hill-Jones was confused by the process and had no idea what plan she was in, if any, or whether it would cover the 10 medications she takes each day. Due to such confusion, since the beginning of the year thousands of D.C. residents like Hill-Jones have flocked to the GW program and to the District’s Legal Aid Society, looking for help and overwhelming the system. Jonathan Smith, executive director of the Legal Aid Society, compares the situation to a natural catastrophe, like a hurricane or an earthquake, one where huge numbers of people suddenly need help all at once. “The difference is that this is a man-made disaster,” he says. “On January 1 people were dropped off a cliff. That is what makes this unique.” Smith says the sheer volume of Medicare cases has forced his group to redirect its limited resources, causing a ripple effect throughout the entire legal-services community. In order to focus on Medicare, for example, Legal Aid has turned away people seeking help with food stamps or welfare problems. The problem is not limited to Washington. Barbara Frankel Siegel of the Health Consumer Center of Los Angeles says her facility got 200 new Medicare cases in just the first week of January. In New York the Legal Aid Society got so many calls on Part D it had to set up a dedicated hotline to handle the load. NEW-YEAR CHAOS Many service providers for the poor anticipated problems when Congress initially passed the Medicare prescription plan in 2003 as a way to help senior citizens pay for the rising cost of medications. Medicare had never covered prescription drugs before, and advocates worried what would happen when low-income seniors who already had drug coverage through state Medicaid programs were lumped in with other seniors. Toward the end of last year, Legal Aid and the GW Clinic, along with many other service providers across the country, made preparations for when the plan would take effect. Legal Aid attorneys contacted local law firms including Hogan & Hartson, Arnold & Porter, and Alston & Bird to recruit volunteers to advise seniors and began to educate themselves about the new program. In December they began holding Saturday walk-in clinics devoted solely to Part D participants. “We saw it as something we needed to figure out,” says Jennifer Mezey, supervising attorney at Legal Aid. “We didn’t know what was going to happen. In part we were concerned about being overwhelmed, but we were equally concerned about not getting any calls.” Initially, the main concern was not about people (like Hill-Jones) who were considered “dual eligible,” meaning they already received drug coverage through Medicaid. Instead the biggest worry was low-income seniors who didn’t qualify for Medicaid help. “We thought, as many people thought, the duals would be fine,” Mezey says. “The thinking really changed approaching December, when we realized there is just too much room for error.” On Dec. 31 all of the “dual eligibles” who hadn’t picked one of 48 available insurance plans were automatically enrolled in one. The result was chaos. GW Clinic, which usually receives 150 to 200 calls a month, received 350 the first week alone. The following Monday it got 200 in one day. The problems were mainly administrative. Many seniors had never received identification cards in the mail telling them in which plan they were enrolled. Others were placed in a plan that didn’t cover their medications, sticking them with high co-payments and deductibles. But at least 1,800 duals in the D.C. area were overlooked completely and not enrolled in any plan at all. Hill-Jones, who suffers from high blood pressure, an irregular heartbeat, depression, and severe arthritis, says she knew her drug coverage had changed, but she had yet to receive her new card when she contracted bronchitis in January. By February, when she started coughing up blood, she couldn’t wait any longer. She went to the drugstore, but her pharmacist refused to fill her prescription because Hill-Jones did not know which plan she belonged to, if any. “I got really hysterical,” she says. “I started crying and made this big, horrible scene in the drugstore, saying I was going to die, but I was afraid.” She says the pharmacist ultimately gave her a 14-day supply of her medicine and sent her home. GW’s Jackson says most of the calls she and her volunteers receive are from people like Hill-Jones who either don’t know what plan they are enrolled in or are enrolled in a plan that does not meet their needs. The attorneys must determine which plan the participant is enrolled in and then contact both the plan and the pharmacy to make sure all the records match up. In Hill-Jones’ case the plan she was originally enrolled in would only allow her to get a two-week supply of a medication at a time. Jackson found her a plan that will give her a 30-day supply, but Hill-Jones may need to pay more money for the prescription. Judith Stein, executive director of the Center for Medicare Advocacy in Connecticut, says her group received 169 calls on Part D in the week between Christmas and New Year’s. By comparison, the center got 110 calls total in the prior four months. Stein says she is still getting dozens of calls and e-mails about the new plan each day. It is not just the volume but the time it takes to resolve cases that has taxed the resources of legal-service providers. GW’s Jackson says a typical case takes about an hour, but an especially complex one can take seven or eight hours of work to straighten out. TURNING PEOPLE AWAY At D.C. Legal Aid, which has handled 165 Medicare cases thus far, two of the four attorneys in the public benefits section spend at least 75 percent of their time just dealing with Part D issues. They have enlisted the help of interns and a senior attorney who volunteers with the group, as well. Still, in order to meet these demands, some individuals seeking help with welfare and other public benefits problems that the organization would normally handle are now turned away. Smith says that even before the Medicare influx, his organization could not take every case that came in the door. He notes that in the District only about 10 percent of the poor who seek legal assistance actually get it. He says if a Legal Aid attorney can’t handle a person’s case, the lawyer will give brief assistance and refer the individual to another service provider that may be able to help. He says the group has declined to take some food-stamp overpayment and Social Security cases because his staff just doesn’t have the resources. Smith, however, could not provide specific numbers on how many other cases have been turned away because of the Medicare crunch. In addition, Legal Aid has curtailed some of its normal outreach work. For example, the group had planned an aggressive program to educate people facing welfare sanctions about their right to appeal, but that has now been put on hold because, Smith says, Legal Aid could not handle the cases that might result from that effort. Other D.C. service providers say they have seen significant upswings in the number of clients who have sought their help in recent months. But they say there is no hard evidence to definitively link the surge to problems at Legal Aid. Scott McNeilly of the Washington Legal Clinic for the Homeless says that since mid-January the average number of people attending one of his group’s weekly intake sessions has tripled. Usually they see between three to five people at each session, but last Monday, for example, 14 people showed up. The clinic doesn’t track referrals, but McNeilly says the types of cases the staff are seeing — and the fact that people list mailing addresses on the intake sheet — lead him to believe they are referred from other providers. The mailing address is one tip-off, he says, since most of his clients live on the streets or in shelters. Plus, he says the cases are in areas such as Social Security, disability issues, and even a child custody case — the types of cases his clinic does not usually see. Mark Herzog, the supervising attorney at the D.C. Bar Pro Bono Program Law Firm Clinic, says the clinic’s caseload has also shot up since mid-January. Instead of the usual five to seven disability cases they get each month, he says they have gotten about 16. While he says the number of referrals from Legal Aid has not increased significantly, he believes Part D may be creating a cascade effect. As Legal Aid deals with the Medicare problem, other service providers are in turn forced to make more referrals. Right now, Smith is hopeful that the avalanche of Medicare cases is temporary. “This will always be at some level a part of our public benefits practice,” he says. “There will always be people enrolling in the program, but there will be far fewer, so the hope is that by the first of June the intensive period will be over.”
Bethany Broida can be contacted at [email protected].

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