Discretionary Deeming: How Libby Montana Got Improved Medicare With Free Drugs

By Kay Tillow, Unions for Single Payer

Buried deep in the health reform law is Section 10323. It amends the Social Security Act to extend Medicare coverage to individuals exposed to environmental health hazards in the region defined by the Emergency Declaration of June 17, 2009. That declaration limits this benefit to the area around Libby, Montana.

Section 10323 of the Affordable Care Act (ACA) calls it “deeming of Individuals as eligible for Medicare benefits.” People do not have to be age 65, or wait two years following disability, or to have paid into the Medicare system. The victims of asbestos in Libby were simply “deemed” to be eligible for Medicare. It was described as “discretionary deeming.”

Senator Max Baucus, Chair of the powerful Senate Finance Committee, who hired insurance executive Liz Fowler to write the health reform act, slipped Section 10323 into the law assuring that all those with asbestos-related conditions in the community around Libby, Montana get into Medicare, our single payer program for all those over 65. Further, for this designated group of Montanans, Baucus arranged additional special benefits not normally available to Medicare patients.

It’s true. Senator Baucus “deemed” single payer off the table during the 2009 health care debate. He had physicians and others arrested for insisting that single payer be included in the nation’s discussion. Baucus effectively locked out any consideration of such a plan. But he gave our country’s single payer program, Medicare, to the people of Libby. And they got free drugs, too.

The victims of asbestos exposure in Libby, regardless of age, are eligible for traditional Medicare, plus, under an additional program that Baucus included in the ACA, the government also pays for services not included under Medicare, such as home care, medical equipment, counseling, help with travel, and medications not covered by Medicare prescription plans.

Coverage of drugs can be crucial. Outrageous drug prices continue to threaten all who depend on costly medications. While the ACA bars health insurance plans from refusing to cover those who are sick, insurance companies have found ways to keep patients with cancer, Multiple Sclerosis, AIDS, and other conditions out of their plans. Some insurance companies have made the co-pays on the drugs needed by such patients as high as $1,000 to $6,000 a month, effectively excluding those with pre-existing conditions.

Goodness knows the people of Libby deserve to have Medicare—with free drugs and home care and medical equipment and help with travel and much more. After all, the W. R. Grace company whose vermiculite mine poisoned their entire region left thousands, not just the miners, suffering and dying.

But the senator who helped Libby also made certain that all the rest of us would be left out—that the nation could not even consider the merits of HR 676, the Expanded and Improved Medicare for All Act, that would free our country from the health insurance companies that continue to hold us hostage.

As health reform rolls into a new stage where some who have been left out find help but millions more, both insured and uninsured, find the costs of care still beyond their means, let us look to the Libby solution, publicly-funded single payer, for the answer.

Medicare spends more than 98 cents of every dollar on actual health care, while insurance companies spend only 80 to 85 cents on health care. Under the ACA insurance companies still victimize all of us as their narrow networks deny us access to the doctors and hospitals we need. The insurance companies retain their power to deny tests, procedures, and treatment making life miserable for both patients and doctors.

The United States spends about twice as much per person on health care as the rest of the industrialized world. Yet our life expectancy, infant mortality and other health outcomes lag far behind. As the policy experts of Dartmouth and MIT search in vain for ways to cut health care costs while retaining the profit makers, let us keep in mind that unless we remove the private for-profit insurance companies from our health care, any cut in costs means a cut in care.

To expand care while cutting costs, we have to go to a single payer plan—like HR 676, Expanded and Improved Medicare for All, a bill introduced into every congress since 2003 by Rep. John Conyers, Jr. (D MI). With HR 676, we could save over $500 billion a year while expanding coverage to everyone and improving care to assure dental and eyeglasses and hearing aids and drugs and long term care and all the things we need that are not normally covered. And this coverage would remove all co-pays and all deductibles.

Health care would be paid for publicly and in advance with no payment at the point of care. Patients will choose their doctors and hospitals. When we seek care, the question will not be “How will you pay?” but “Where does it hurt?”

This simple legislation would fix our damaged health care. Medicare was rolled out in six months with only index cards in the time before computers. No need to ask how much you make—it is available to all. That’s what we need–not the twisted double-dealing that wins something special for a few, but, instead, a magnanimous, simple, bold, inclusive plan that finally will allow all of our people to enjoy the life-giving benefits that a wealthy and compassionate nation can offer.

Let us dedicate this new year to building the single payer movement that will make this plan possible.

1. http://www.nytimes.com/2009/12/21/health/policy/21healthcare.html?pagewanted=1&_r=3&hp

2. http://www.spokesman.com/stories/2009/jun/17/epa-declares-health-emergency-libby/

3. http://beta.congress.gov/bill/111th/house-bill/3590/text?q={%22search%22:[%22Patient%20Protection%20and%20Affordable%20Care%20Act%202010%22]}

4. http://my.firedoglake.com/kaytillow/2011/06/15/how-libby-montana-got-medicare-for-all/

5. http://pnhp.org/blog/2009/05/08/why-we-risked-arrest-for-single-payer-health-care/

6. http://missoulian.com/news/state-and-regional/article_f46c85e6-eddc-11de-a34f-001cc4c002e0.html

7. http://www.ssa.gov/libby/

8. http://missoulian.com/news/local/baucus-meets-with-libby-asbestosis-patients-physicians/article_7d5d0a7e-1e4f-11e2-a916-0019bb2963f4.html

9. http://www.pnhp.org/news/2013/december/insurers-using-high-drug-cost-sharing-to-scare-away-patients-with-expensive-chron

10. http://pnhp.org/blog/2013/02/19/important-what-are-medicares-true-administrative-costs/

11. http://prescriptions.blogs.nytimes.com/2009/08/12/questions-for-dr-marcia-angell/

12. http://pnhp.org/blog/2013/07/31/friedman-analysis-of-hr-676-medicare-for-all-would-save-billions/


  1. Sumitra on January 16, 2014 at 1:22 am

    Great article–I would change one thing in the following:

    ‘When we seek care, the question will not be “How will you pay?” but “How can I help?”‘