The much-debated health care reform bill apparently headed for a Christmas Eve vote in the Senate could eventually close the "doughnut hole" in Medicare prescription coverage that exists for 3.4 million, or about a quarter of the nation's Medicare prescription program beneficiaries.
According to medicare.gov, the "doughnut hole" refers to a gap in prescription coverage that generally exists for eligible seniors when their annual drug costs reach a threshold of about $2,700, after an initial deductible of no more than $295 and co-payments of 25 percent. Once seniors reach that gap, they must pay all prescription costs until their total annual out-of-pocket spending reaches $4,350, then Medicare kicks in again with co-payments at 5 percent.
An amendment proposed by Sens. Jay Rockefeller, D-W.Va., and Bill Nelson, D-Fla., would gradually close the doughnut hole in yearly phases, narrowing the gap with $100 billion from pharmaceutical companies that have already pledged $80 billion of that amount toward a health care overhaul. Democrats in the House and the Senate have vowed to eliminate the coverage gap as part of President Barack Obama's proposed health care reform, though the exact method has yet to be finalized.
Jim Kattell, of Marietta, said his 86-year-old mother-in-law purchases nine separate prescription medications a month. She reaches the doughnut hole in August or September every year.
"Then she has to pay $400 to $500 a month," Kattell said. "We just know she'll have four to five months out of each year that she will have to pay 100 percent for her prescriptions. And some of her medications cost $210 a bottle for one month's supply."
Because she falls into the lower middle-income bracket, his mother-in-law is not eligible for assistance provided to low-income seniors who essentially experience no gap in their Medicare prescription coverage.
Muskingum Drive resident Arthur Jones, 78, said his prescription costs reached the gap for the first time last year.
"Last year I paid a co-payment for drugs, until I reached my doughnut hole," he said. "After that I was paying street prices - probably triple the amount I paid before I reached that gap.
"I don't think many people would object to plugging the doughnut hole," Jones said.
Rick Hindman, assistant executive director of Buckeye Hills Hocking Valley Regional Development District and director of the Area Agency on Aging, applauded the proposed amendment.
"The doughnut hole definitely affects our seniors," he said. "I hear stories all the time about people who have reached the gap begging their doctors for samples and maxing out credit cards because they can't afford to pay for the prescriptions. And this really threatens the independence of our seniors."
Hindman said seniors are now questioning whether they would be better off to just leave Medicare as it is, or if the proposed health reform bill should be enacted with Medicare cuts, but seal up the doughnut hole.
"I've had some seniors complain that the government is cutting their Medicare, but others say there's a need to cut the waste out of the program," Hindman said. "I think our biggest challenge is educating people about the Medicare prescription program. That's the issue. There are all kinds of plans for prescriptions - but it's so complicated."
Robin Collins, social services director at the O'Neill Center, agreed the gap in the Medicare prescription drug program is a major concern for seniors.
"I get calls constantly from people who say they've reached the doughnut hole and ask if we can help," she said, noting that some reach the gap as early as March each year.
"We can sometimes help, if they meet certain eligibility guidelines," Collins said. "But they must contact us as soon as they know they're approaching the gap. We can't help everyone, but we'll do what we can."
She added that eligible low-income seniors qualify for extra help from Medicare, and will never hit a doughnut hole in their coverage.
"But the middle-income level seniors who reach the gap are the ones that are falling through the cracks," Collins said. "Those are the ones who often say they're not taking their medications because they just can't afford it."
Williamstown Pharmacy owner Sylvia Miles sees a lot of folks who depend on the Medicare prescription program.
"But we shouldn't forget that the program was created so people who participate would have to be conscious of the costs of medical prescriptions," she said. "And if people will work with their pharmacists and doctors, they often don't have to get caught in the doughnut hole."
Still, Miles said the gap could be narrowed a little, and people with severe chronic medical problems should be covered.
"But we need something in place so people will be responsible. And they should be rewarded for diligently watching their health care costs," she said.
