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Hope For Closing The Medicare "Doughnut Hole"

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It’s an annual 'lump of coal' for millions of seniors living on fixed income

By Chris Levister –

Retired Perris educator Everett Franklin, recently found himself pleading with his doctors for free drug samples and maxing out his credit cards when he wound up in the dreaded “doughnut hole”.

“It’s damn humiliating to have to beg for medicine,” said Franklin. He’s coping with diabetes and complications from a stroke.

The doughnut hole refers to a costly gap in the Medicare Part D prescription drug coverage plan.

The plan currently covers up to $2,700 per year in prescription drug payments, then stops.

Coverage does not begin again until the recipient’s drug costs exceed $6,100 annually, thus leaving the recipient responsible for paying all drug costs between $2,700 and $6,100.

It’s a gap President Barack Obama says “is placing a crushing burden on many Americans who live on fixed incomes and can’t afford thousands of dollars in out-of-pocket expenses.”

Franklin entered the donut hole, this year in November. At that point his health plan stopped paying 75 percent of his prescription costs. A 90-day supply of his medications costs $2,582 when he’s in the donut hole, said Franklin. He pays a $50 annual insurance premium. His monthly income is a little over $1,700.

Advocates for seniors say the gap in coverage drives many older Americans to resort to the potentially life-threatening option of splitting pills or taking only half of their medication thus reducing the drugs’ effectiveness.

“All year you save and cut back on essentials like eating out or vacationing. You do everything right. At the end of the year, you get a lump of coal in your Christmas stocking,” said Franklin.

The prescription benefit was proposed by former George W. Bush and passed by a Republican-controlled Congress. The gap, intended as a cost saver, was unpopular from the beginning –and hard to understand. AARP, the seniors lobby, says the dreaded gap is the one issue it hears about most from its members.

“Although the benefits have proven popular, you can’t hold a town hall meeting or address seniors on Medicare without hearing complaints about the doughnut hole. It’s a major pocketbook issue,” says Nancy LeaMond, executive vice president for social impact at AARP.

Because the size of the hole is indexed to increases in drug costs, every year it grows more rapidly than the income of most seniors.

The Democrats’ plan would put that into reverse, gradually shrinking and ultimately eliminating the doughnut hole.

The gap in Medicare drug coverage was needed for the government to be able to pay for the program, says Senate Majority Leader Harry M. Reid (D-Nev. ).

“Final passage of the health reform bill will forever end this indefensible injustice for America’s seniors.”

Democrats and President Obama insist that the doughnut hole would disappear gradually over 10 years. Proponents say the government can afford to eliminate the gap because drug companies would foot the expense for the phase out. Critics argue that ‘less’ than half of the $80 billion that drug makers agreed to provide during healthcare reform negotiations over the summer, would be used to fill the gap.

Rep. Dave Camp (R-Mich.), a ranking Republican on the Ways and Means Committee is skeptical.

“They’re shielding the true cost by phasing it in.”

Meanwhile at this Perris senior center holiday party, people like Sharon Engles are keeping up the pressure on lawmakers to close the not-so-sweet doughnut gap.

“It’s disgusting. I ran into the doughnut hole last month. I had to pay $602.03 for one prescription and did not get another one filled.

I couldn’t afford it. I need my asthma meds. But I don’t have the money.”

Tye Dean Carter also of Perris hit the doughnut hole in August.

“A July summary from my plan showed that my meds cost $432.87. My share of that was $39.00. When I went back to pick up the prescription in August, the cost to me was $900,” said Carter.

“How come when a person reaches the doughnut hole, the cost goes wacky? Even with the 50% discount I wouldn’t be able to afford my medications. In my eyes, it’s a big shell game with the drug companies at the steering wheel.”

There is help for people with limited income and resources. If you qualify, Medicare will pay for almost all of your prescription drug costs. For information call Social Security at 1- 800-772- 1213 (TTY 1-800-325-0778) or visit www.socialsecurity.gov on the web.

Medicare seniors with low incomes are spared from having to deal with the gap. But about one-fourth of the other beneficiaries – 3.4 million people – fall into the gap.


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+1 # Guest 2010-06-17 02:28
10 years to faise out the donut hole? great news for someone who will be around in 10 years . But what about those of us who rely on our drugs to stay alive NOW? I just found out about the donut hole yesterday when I went for my monthly perscription refills. I was floored. I will now have to sit down and try and figure out which drugs to take and which to drop. I surely cant afford 100 percent out of pocket. The company NEVER explained this donut hole when I signed up. Had they explained it, I would have NEVER dropped my wifes employee insurance for part d coverage. Now I cant sign back on with my wifes coverage again untill next year. And they wonder why people climb water towers with high powered rifles
0 # Guest 2010-06-04 22:10
Well said.
+1 # Guest 2010-03-19 05:11
Who runs medicare? The government not drug compannies. Can we nor expect this same whacky cost system? With the new health reform. Since they did not get it right the first time. My bet is yes we can.

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