Seniors approaching Medicare "doughnut hole" - Half a year into the new Medicare drug program, 3.4 million seniors are approaching the government funding gap, called the doughnut hole, which halts payments for drug costs between $2,250 and $5,100. As more seniors are affected by the gap in coverage, they may make changes in their prescription-buying habits, and the issue could become political fodder for the fall elections.

Los Angeles, U.S. July 2, 2006 (via Los Angeles Times)

The program leaves a $2,850 hole in coverage. Now half a year into the plan, 3.4 million seniors may have to decide how to pay or avoid the costs.

WASHINGTON — When Congress created the Medicare prescription drug program, it adopted an unusual idea to hold down costs: the so-called doughnut hole.

The program pays most of a participant's drug bills until expenses reach $2,250 in a year. Then it stops paying until costs exceed $5,100. That leaves a hole of $2,850 that seniors with serious prescription needs are expected to manage on their own.

Now, six months into the drug program — the first new major healthcare benefit for the elderly in decades — 3.4 million seniors are approaching the doughnut hole.

Most of them are middle-class seniors with multiple chronic illnesses. (The poor are exempt from the gap.) Some have already experienced an abrupt surge in prescription costs.

Melvin Kinnison, 65, of Huntington Beach was shocked to discover that the out-of-pocket cost to refill his prescription for antiseizure medication was jumping to $178 from $10. He left the pharmacy empty-handed.

"It hit me like a slap in the face," said Kinnison, a former Los Angeles County sheriff's deputy.

Kinnison is trying to figure out how to handle a monthly tab for heart, diabetes and acid reflux medications that has climbed to $1,000 from $80. "I thought Medicare is supposed to be helpful," he said. "It sure isn't."

Sensing a political opportunity, some Democrats are campaigning on a promise to shrink or close the doughnut hole. As November's congressional elections draw nearer, more seniors will confront the gap.

But the significance of the issue extends beyond the immediate problem. At stake is a basic approach of the Bush administration and many conservatives and business leaders for dealing with the cost crisis in healthcare. They say consumers must be made to take more responsibility for their medical affairs. Costs are growing so fast, they say, the government and private employers cannot shoulder the burden alone.

They say seniors can avoid problems like Kinnison's if they purchase a plan that covers the doughnut hole. The Medicare drug benefit is delivered through private insurance plans, which individuals choose. The plans that cover the doughnut hole — most plans don't — charge higher premiums. Of the estimated 23 million seniors enrolled in the Medicare benefit, about 2.4 million paid extra for some level of gap coverage.

Medicare Administrator Mark B. McClellan also points out: "Even among the people in plans with a doughnut hole, there are steps consumers can take" to make sure they never reach the hole, such as using lower-cost generic drugs and monitoring costs.

"What millions of these beneficiaries had before was no coverage at all for their prescription expenses," McClellan said.

He urged concerned seniors to call (800) MEDICARE to find out about generics. Medicare officials also advise seniors to carefully read their drug plans' monthly statements, which contain information on how close they are to the gap.

In the long run, some experts suggest, some seniors may wish to switch from traditional Medicare to managed care plans, which are more likely to provide coverage in the doughnut hole. Seniors can also anticipate the gap and save ahead for it.

Those strategies may help many seniors, but not everyone, critics of the doughnut hole say.

The higher premiums for blanket coverage may be beyond the reach of some. Generics are not available for all drugs. And a senior's health needs can change, making it difficult or impossible to plan ahead.

Moreover, such careful management is itself an obstacle for some seniors, whose medical and other problems complicate the situation.

Some doctors worry that vulnerable patients may fall victim to the gap, unable to pay the suddenly higher costs of their medicines.

"There is a huge amount of evidence from research and clinical experience that seniors skip medicines when the price is too high," said Dr. Joshua Sharfstein, Baltimore's public health commissioner.

"If we find that people are skipping their medications, that is a subject of concern."

### Source: Los Angeles Times