Medicare doughnut hole traps seniors

By John D. Dingell

Detroit Free Press

September 22, 2006

Nine months ago the Medicare prescription drug program sputtered to life. Millions of seniors faced problems getting their prescription drugs and making sure the new plan paid for those medications. Thousands of pharmacists and volunteers worked diligently to prop up this complex program. Yet many problems remain.

One of the largest is the so-called doughnut hole. In the coming days and weeks, many more seniors will begin to fall into that hole.

Under the current Medicare prescription drug formula, beneficiaries receive coverage until the total cost of their prescription pharmaceuticals reaches the $2,250 limit. Once it has reached this limit, seniors will receive no help from their drug plan to pay for their medications until they have spent $5,100 in total drug costs. This is called the coverage gap or doughnut hole. Seniors must continue to pay premiums while in the doughnut hole, but get no coverage for their prescription drugs.

After the prescription drug benefit went live, Americans slowly began falling into the doughnut hole. Now a steady stream of seniors must pay for their prescription drug out of their own pocket. The disturbing part is those most threatened by the coverage gap are sicker than average, need more costly medicines and spend more on drugs during the year.

During the debate on the prescription drug benefit, I offered the Democratic alternative to the plan that is now law. That bill would have provided a simple, straightforward, stable plan that would have cost the government about the same amount as this complex and insufficient program.

Now, we must fix the program that is in place. Two pieces of legislation that would go a long way are the Medicare Prescription Drug Savings and Choice Act and the Medicare Prescription Drug Emergency Guarantee Act. The first bill would provide the savings necessary to fill in the doughnut hole by allowing Medicare to negotiate for better prices on medications. The second would ensure that seniors will not leave their pharmacy empty handed because of an insurance company snafu, protect patients and pharmacists from insurance company gamesmanship that would deny coverage, and give seniors better information about filing grievances when their plan denies needed medicines.

We must implement these fixes before the second year of the program begins, ensuring that seniors get the prescription drug coverage they deserve.

The doughnut hole has been a problem since the legislation was first considered in summer 2002. For the last four years, this problem has lingered. As many of our seniors begin to become more familiar with their Medicare prescription drug benefit, they find out that they think they have insurance only to find out that they don't. That is a statement worthy of Yogi Berra. Unfortunately, it's the truth.

JOHN DINGELL, D-Dearborn, is the longest-serving member of the U.S. House of Representatives and presided over the debate when Congress originally enacted Medicare. He is unopposed in his bid for a 27th term. Contact him in Washington at 202-225-4071, or in Dearborn at 313-278-2936.