Much has already been written about how awful the new Medicare bill is - the big winners are HMOs (who get huge handouts to encourage them to "compete" with Medicare) and drug companies (Medicare is prohibited from negotiating bulk drug discounts for members, and re-importation of drugs from other countries is banned). Patients, on the other hand, are in trouble - and every day we're identifying new reasons why.

The latest: the Medicare bill bans Medigap policies, add-on insurance plans which cover the difference between what Medicare will pay and the actual cost of care. And that difference can be considerable - under the new plan, patients will be responsible for a $250 deductible, 25 percent of all their drug costs from $251 to $2,250, and then - strangely - all of the next $2,850 in drug costs. The goverment is supposed to pick up everything after the patient has paid $3,600 in out-of-pocket expenses, but the catch is that the $3,600 doesn't include payments for drugs that aren't on the insurance company's formulary. Seniors might end up with considerably more than that in out-of-pocket, unreimbursed expenses, and they're forbidden to buy additional insurance to help out.

Why on earth? - Because studies have shown that patients with Medigap coverage tend to have higher usage of care and greater overall medical expenses. Supposedly this is because their good coverage makes them "insensitive to the costs of care." But I'd want to see proof that it's not because (1) sicker patients are more likely to need, and therefore buy, Medigap coverage, or (2) in the absence of Medigap coverage, cost concerns lead patients and doctors to make less-expensive but also less-optimal care choices (such as substituting an older, cheaper drug with more drawbacks for an expensive new drug).