Tony Tye, Post-Gazette Linda Adams, 69, of Peters, said she and her husband would rather avoid Medicare Part D but that they reluctantly signed up. Click photo for larger image.

Charles Beattie and his wife take no medications and don't particularly want to enroll in the new Medicare prescription drug program.

That's because it will cost the Elizabeth Township couple an extra $148 a month if both enroll in Part D and opt to stay with their current Medicare HMO. But if they don't sign up for coverage and later need drugs, they'll have to pay even more because of a penalty for seniors who don't join Part D by the end of Monday.

"It's like asking all 16-year-olds to buy car insurance even if they aren't driving yet -- just so they won't have to pay a penalty if they drive later," said Mr. Beattie, 75.

While the Beatties still weren't sure last week what they would do, their decision -- and those being made by countless other seniors who use little or no medication -- will have a broad impact not only for seniors who do enroll but also on taxpayers across the country. Simply put, the number of healthy people who sign up for Part D will affect not only what premiums are like down the road, but also the amount of subsidies the government must provide for the program to continue. The more that healthy seniors balk at Part D, the higher the potential costs for everyone else.

The early returns aren't encouraging.

A report this month from the Medicare trustees indicated that more healthy people are staying away from Part D than was initially projected and that Part D enrollees were, on average, sicker than expected, and therefore had higher drug costs.

But officials at the region's dominant health insurer, Highmark Inc., cautioned against drawing any conclusions yet. People who needed drugs were among those rushing to sign up, while people either not taking drugs or taking only a few have been taking their time before making a decision, said spokeswoman Denise Grabner.

Like Western Pennsylvania voters who have gone to bed on election night thinking their candidate has won only to discover a late-night rush of rural votes turned the tide the other way, it's too early to make a call on how Part D will fare. "The people [who] are signing up now ... had the time to sit back and think about the situation," Ms. Grabner said.

The penalty for failing to enroll in Part D consists of 1 percent of the average monthly premium for every month that eligible recipients lack coverage, following the deadline. For recipients who fail to sign up by May 15, the next enrollment opportunity comes in November for coverage beginning in January. At that point, most late-comers would have a 7 percent penalty added to their monthly premiums.

Healthy beneficiaries say they don't appreciate having the decision thrust upon them.

With three 5K races on her calendar in the next six weeks, Linda Adams, 69, of Peters, said she was mindful of her health and proud of the fact that she doesn't take medication. She and her husband would rather do without Part D, but reluctantly signed up due to concerns about the penalty.

"It seems like the 'Rx drug culture' that we live in today has determined that seniors need to take and spend money for drugs," she said.

Charles Lamberton, 68, of Bethel Park, says he won't enroll in the program, and thinks there's a good chance the decision won't hurt him financially. Here's why:

Right now, the average Part D monthly premium is $30. If he waits three years to enroll, he'll have saved more than $1,000 in premium costs.

Joining in 2009 would mean paying a penalty of 31 percent every month, Mr. Lamberton said. But if that adds just $10 per month to the tab, it will take 10 years for the penalty to catch up to the premium savings.

Premiums surely will grow between now and 2009, but so would the savings generated by not signing up. Plus, by the time he exhausts his premium savings, Mr. Lamberton acknowledges that neither he nor the Part D program might be around anymore.

"To reduce the cost to the government, the plan needs people like me with no claims to be paying premiums to cover those folks who already use drugs and therefore are sure to sign up," he said. "My guess is, people like me are staying out for now."

While Mr. Lamberton's numbers make sense, they carry a risk, said Jack Hoadley, the health policy researcher. Considering how expensive some medications are, he said, a sudden illness during the uninsured period could bring out-of-pocket medicine costs that make Mr. Lamberton's bet a losing one.

"It's a gamble," Mr. Hoadley said.

Dr. Judy Black, medical director for senior products at Highmark, said healthy seniors could find Part D benefits cheaper than the $32 national average. In Allegheny County, for example, a Post-Gazette survey found there were several ways to buy drug coverage for less than $21 per month.

But even that doesn't represent all the potential costs. The Beatties from Elizabeth, for example, are currently enrolled in a premium-free Medicare HMO; but if they sign up for Part D and opt to stay with their HMO, they'll have to pay both a $22 monthly fee for the drug coverage plus a $52 premium for the medical benefits.

While Dr. Black advises younger seniors who lack coverage to seriously consider buying Part D benefits, there's another group of drug-free seniors who might be an even tougher sell.

"I got a call last week from a patient who is 91 and doesn't take a lot of medication," said Dr. Black, who still treats some patients. The 91-year-old had decided the penalty wasn't an issue for her because "she's not going to be around much longer," she said.

"Had she been a 66-year-old on no medication, and the individual would say to me 'I don't think I'm going to sign up,' my role as a practicing physician would be to say: 'You need to think about this, because as you get older you're more likely to need medicines and you'll pay higher premiums.' "