Health: Take Two Aspirin and Read This Now

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Thankfully, no one is waiting for another slow-motion catastrophe to unfold. Governors of more than 20 states have pledged emergency funds to help people, at least temporarily, pay for drugs they are having trouble getting. Insurers say they expect to have any remaining problems fixed in the next two weeks, although patient advocates are skeptical. And in response to the bipartisan outrage, House Republican leaders are considering a proposal, initially suggested by Democrats, to extend the deadline for signing up for the new benefit from May 15 to Dec. 31, a House G.O.P. aide tells TIME. The difficult transition, though, is more than just a product of bureaucratic fumbling. It is a significant step in the march of U.S. health care toward a free-market system governed by choice and risk. President George W. Bush is expected to make that movement a central element in his State of the Union address next week and to emphasize its promise. The patients, families and pharmacists caught up in Part D know its price, at least in the short term.

The fundamental goal of Medicare Part D is hard to argue with. Medicare has no drug benefit; Part D provides one. When Medicare was established in 1965 as a Great Society health-care program for seniors, prescription drugs were a minor planet in the universe of medical treatment. They now account for 11% of every health-care dollar spent. But more than a quarter of the 42 million people on Medicare had no drug coverage at all last year.

The law that was passed in 2003 is not really an expansion of Medicare, which is an entitlement with standardized care. Part D, although funded by Medicare, is actually private insurance, similar in design to high-deductible health policies that shift more of the costs to members in an effort to make them more conscious of what they're spending. "People are used to it being an entitlement, but [Part D] wasn't the same sort of generous benefit that Medicare is," says David Scrase, president of Presbyterian Health Plan, a Part D provider in Albuquerque, N.M.

The array of selections available under Part D--even Alaska, with only 53,000 eligible recipients, has almost 30 plans, all with different premiums, deductibles, co-pays and covered drugs--has bewildered seniors trying to choose. But that confusion is only part of what has gone wrong. The main reason for the problems of the past three weeks is that the vast majority of enrollees--20.4 million of 24 million--already had some kind of drug benefit, in many cases Medicaid, and were automatically switched to Part D. Their information had to make its way through several layers of private and public bureaucracy for the new system to work. Medicare allowed people to sign up for Part D until Dec. 31 for coverage on Jan. 1, but insurers couldn't process their enrollment cards fast enough to be ready by then. People eligible for both Medicaid and Medicare were assigned to plans randomly, in many cases to plans that did not cover the drugs they took. Insurers are supposed to cover 30-day emergency supplies of medicines that are not included in their plan, but many companies are stonewalling on fulfilling that guarantee. So many seniors have had to pay out of pocket for their drugs or go without. Medicare promised subsidies to poor people for their co-payments and deductibles, but insurers still do not have complete information on who is eligible for the extra help.