Mr. Speaker, Medicare Part D continues to bring problems for our Nation's seniors. As more and more reach the ``doughnut hole,'' seniors are confronted with dramatic, no-win choices. I offer my colleagues a recent article in the San Diego…
Mr. Speaker, Medicare Part D continues to bring problems for our Nation's seniors. As more and more reach the ``doughnut hole,'' seniors are confronted with dramatic, no-win choices. I offer my colleagues a recent article in the San Diego Union-Tribune--``Going to Have to Sell My House . . . or Die.'' It's past time to start over with the prescription drug benefit!
[From the San Diego Union-Tribune, July 16, 2006]
Going To Have To Sell My House ... or Die
(By Keith Darce)
Frank Harrison says he's facing a choice between his health
and his house.
When the Spring Valley retiree hit a coverage cap in his
federal prescription drug plan in early June, his monthly
medicine costs skyrocketed from about $250 to about $1,800,
largely because of two expensive immune suppression drugs
that he has taken since a kidney transplant six years ago.
The 62-year-old former computer company operations manager,
whose main income comes from Social Security disability
benefits, stopped taking one of the drugs, which cost about
$575 a month, so that he could keep paying his $750 mortgage
payment.
``What it boils down to pretty soon is that I'm going to
have to sell my house. It's either that or die,'' he said.
Harrison is among the 3.4 million seniors and disabled
Americans who have begun to fall into a gap in Medicare Part
D coverage. They must pay the full price for drugs after
they've spent $2,250 in co-payments and until their out-of-
pocket costs reach $5,100 for the year.
Those in the so-called ``doughnut hole'' are likely to cut
back on medicines to save money even if doing so jeopardizes
their health, according to some research.
``Some are being caught totally unaware,'' said Jennifer
Duncan, who manages the San Diego Health Insurance Counseling
and Advocacy Program.
HICAP, which assists Medicare beneficiaries, has fielded
calls in recent weeks from about 20 Part D enrollees who've
either hit the coverage gap or are nearing it. Medicare is
the government's health insurance program for those 65 and
older and the disabled.
The gap is the latest headache to confront those who
thought that signing up for a Part D plan would lower their
costs for expensive medications. Early glitches blocked some
from getting prescriptions because their names didn't appear
in the computer systems of the private companies selected to
operate the plans. Others tried to buy drugs only to learn at
the pharmacy counter that the medicines weren't covered by
their plans.
Still, several surveys have indicated that most
participants are satisfied with the Part D program and have
saved money during its first six months.
Congress created the Part D gap when lawmakers created the
drug insurance program in 2003. The measure was added to
reduce the program's overall cost. Lawmakers reasoned that
only a tiny portion of Part D participants would reach the
gap and most would be without coverage only for a short
period.
Many of the 22.7 million people in the program will avoid
the coverage gap, according to a recent report by accounting
and consulting firm PriceWaterhouseCoopers. They have private
supplemental insurance, are enrolled in a higher-priced Part
D plan that doesn't cap benefits, have incomes low enough to
qualify for exemptions or simply won't purchase enough drugs
to reach the cap before calculations start over on Jan. 1.
Those falling into the gap are largely middle-class seniors
who aren't poor enough to qualify for MediCal--the federal
health insurance for the poor known as Medicaid outside
California--or they are wealthy enough to afford higher-
priced Part D plans that have no coverage caps.
People who fall into the doughnut hole don't pay the full
retail price for drugs, said Peter Ashkenaz, spokesman for
the Centers for Medicare and Medicaid Services in Washington,
D.C. They pay the discounted price paid by their Part D plan
operator--about 20 percent below retail prices, he said. ``I
think people tend to forget that piece of it.''
But halfway through the first year of the prescription drug
program, the San Diego HICAP is fielding calls from
frightened seniors whose benefits are about to run out,
Duncan said.
`` `Doughnut hole' is a lousy term. It's more like an
abyss,'' she said. ``It's a soft, funny way for saying you
may not be able to pay your rent or eat this month because
you're going to have to pay for all of your medicines.''
One recent call was from a paraplegic who takes high doses
of the pain-killer morphine that cost $1,500 a month. Another
caller takes $10,000 worth of medicine each month to prevent
his body from rejecting a transplanted lung.
Even beneficiaries facing less dire circumstances could
have trouble dealing with the gap.
An overwhelming majority of Medicare recipients suffer from
chronic diseases, such as hypertension and diabetes, said
Kenneth Thorpe, chairman of the Health Policy and Management
Department at Emory University in Atlanta.
More often than not, they also are being treated and
medicated for multiple conditions, he said. ``These are very
expensive patients.''
When their drug coverage runs out, even temporarily, they
are likely to stop taking some or all of their medications,
Thorpe said.
That's what Kaiser Permanente researcher John Hsu found
when he studied about 200,000 Medicare beneficiaries in 2003
who participated in a more limited government prescription
drug program that predated Part D. The results, published in
the June 1 edition of The New England Journal of Medicine,
found that people whose drug benefits were capped at $1,000 a
year had higher rates of emergency room visits,
hospitalization and death than those with unlimited coverage.
Hsu attributed the increases to people ending drug
treatments once the insurance cap was reached. The cost for
additional medical care offset the lower drug cost savings
created by the cap, he reported.
When Harrison's coverage ended in early June, the maker of
one of his immune suppression drugs put him on a program that
delivered the medication for free. But he wasn't offered the
same deal from the maker of the other medication, and his
$1,300 monthly income is too high for him to qualify for the
doughnut hole exemption available through Medi-Cal. He's
hoping his doctors will provide an answer--perhaps an
alternative drug available at a discount or for free from a
manufacturer--when he goes in for a check-up in a few weeks.
Wendel Ott, 74, of San Diego, doesn't expect to hit the cap
until September, but already he's considering cutting back on
his eight medications.
``It's going to cost me a tremendous amount of money for
the last part of the year,'' said Ott, who takes medicines
for high blood pressure, an enlarged prostate and chronic
bronchitis. ``Let's face it, I'm not wealthy.''
While many people were aware they might face a gap in
coverage when they signed up for a Part D plan, it's clear
some haven't prepared for it, said Michael Negrete, vice
president of clinical programs for the California Pharmacists
Association.
``Most people haven't saved money to deal with the doughnut
hole,'' he said.
Once in the gap, people create a new problem for themselves
if they try to save money by purchasing cheaper drugs outside
their Part D program, Negrete said.
``When they get drugs outside of Part D, that doesn't go to
the credit they need to get out of the (gap),'' he said. ``If
they are getting their medicines from Canada or from a
discount drug service, they will never get out of the
doughnut hole.''