By Christopher Lee and Susan Levine
Washington Post Staff Writers
Monday, September 25, 2006
Millions of older Americans are confronting a temporary break in their Medicare drug coverage this month that will require them to pay the full cost of their prescriptions or face the painful prospect of going without.
This is the "doughnut hole" in the new Medicare drug benefit that began in January, and advocates for seniors say there is nothing sweet about it. Some seniors knew nothing of the coverage gap until they were hit with a bigger drug bill, advocates say.
"Virtually everyone who calls to say they've been denied coverage, they're shocked," said Robert M. Hayes, president of the Medicare Rights Center, a nonprofit that helps seniors navigate Medicare. "Trying to explain that this is the way the program was created by Congress angers folks who think it makes no sense. Many people feel blindsided."
The coverage gap was one of the most contentious elements of the 2003 legislation that created the new benefit. It ends federal payments for a person's drug purchases once an annual spending limit is reached, resuming them only after the beneficiary has spent thousands of dollars out of pocket.
Proponents saw the unusual setup as a way to provide some help to all beneficiaries, and substantial help to those with catastrophic drug costs, and yet not break the bank in a federal program that is expected to cost hundreds of billions of dollars over the next decade.
Nine months into the program, as more and more seniors reach the threshold that puts them in the gap, many see it as a headache -- or worse.
Frances Acanfora, 65, had been paying $58 for a three-month supply of her five medications. But this month the retired school lunchroom aide learned that her next bill would be $1,294. She had entered the doughnut hole.
"It's not my fault that I take this medicine," the Brooklyn resident said. "I've got to take it. And they make a limit. That's not fair."
After talking to her doctor, Acanfora decided to temporarily stop taking a drug as part of her treatment for breast cancer. She hopes to obtain some free samples of eye drops for her glaucoma. Three other medicines -- for high cholesterol, diabetes and osteoporosis -- cost $506.62, which Acanfora put on her credit card.
"I pay a little bit at a time," she said. "What am I going to do? I need it. . . . Sometimes, just to think about it, I cry."
About 3 million of the 23 million Americans who receive the Medicare drug benefit are expected to reach the gap this year, officials said. That is fewer than half the 7 million cited in a 2004 report by the nonprofit Kaiser Family Foundation, which Medicare chief Mark B. McClellan called outdated.
A few more-expensive plans have no doughnut hole, and low-income beneficiaries can receive extra help from Medicare that eliminates the gap. Under the standard plan, however, the government picks up the bulk of drug costs only until the beneficiary and the government together have spent $2,250 for the year. At that point, beneficiaries must pay 100 percent of costs until they have spent a total of $3,600 of their own money. Then the federal subsidy resumes, paying 95 percent of any additional expenses.
Beneficiaries must continue to pay premiums averaging $24 a month, even in months when they are on their own. The calculation starts anew every year.
At Iona Senior Services in the District, Chris DeYoung's phone keeps ringing. On the other end are Medicare beneficiaries who have suddenly fallen into the gap and are looking for ways to climb out. DeYoung, Iona's community outreach coordinator, has only a few tips: mail-order pharmacies, diligent comparison shopping, purchases from Canada.
"For most of them, they're not going to get out of it this year," he said. "I don't think everyone really appreciated the doughnut hole, or they thought it'd be narrower than it is."
Georgetown retiree Maria Laurence, who says she selected an AARP-affiliated drug plan without doing much research, now pays "a fortune" for nearly half a dozen prescriptions. One drug went from about $84 for a three-month supply to $670.56 -- more than $7 per pill.
"It was such a shock. I had no idea," she said. "It's just a hard pill to swallow, no pun intended."
Even with the doughnut hole, most beneficiaries are better off financially than they were before the drug benefit was created, when many seniors had to fend for themselves all year long.
McClellan said seniors in the coverage gap should continue to use their Medicare drug cards to get the prices negotiated by their plans. They also can apply for prescription-assistance programs run by many states and pharmaceutical companies, he said. And they can call Medicare at 800-633-4227 for information and help.
"There are lots of places to go to get lower-priced drugs, to get additional help with your drug costs," he said.
Mark Merritt, president of the Pharmaceutical Care Management Association, stressed that the majority of seniors will not reach the gap. Many who will could delay it by more than two months by switching to generic drugs and using mail-order pharmacies, he said.
"There's been a lot of hand-wringing about it and very little information about what people can do to stay out of it," said Merritt, whose organization represents companies that administer drug benefit programs for employers and health insurance carriers.
Another thing seniors can do is choose their drug plans more carefully for 2007 when the open enrollment period begins Nov. 15. Susan Knight, director of the Senior Health Insurance Program in Anne Arundel County, said she and other workers will begin visiting centers and programs for seniors next month, the start of what is likely to be another major marketing season for companies offering prescription coverage.
Many Democrats in Congress, long critical of the gap, are not waiting until then. They dubbed last Friday "doughnut hole day," saying it was when the average Medicare beneficiary would reach the gap. They and their supporters criticized the policy at dozens of events last week, airing grievances from seniors in public forums and delivering edible doughnut holes to the office of at least one House Republican.
"This gap does not have to exist," said Sen. Debbie Stabenow (D-Mich.).
Clarice Wansley, 67, a retired county administrator who lives in Hattiesburg, Miss., fell into the doughnut hole in June. Her drug bills went from $184 a month to $387 for the eight medications she takes for cancer, heart trouble, seizures and other ailments, she said.
She paid on her own for the past few months, but recently her doctor told her she needed yet another drug, one that costs $239 a month. Now she doesn't know what to do.
"I'm not destitute, but I can't pay that and buy gasoline and food and pay the mortgage," Wansley said. "I'm scrambling around trying to find help."
Dan Wojehowski, 47, of Smyrna, N.Y., takes six drugs for disabling depression and severe back problems. Last year he was able to get five of them free through drug companies' patient-assistance programs. But when the Medicare benefit started, many of those programs sent people there instead. Wojehowski began paying $53 a month for most of his drugs. Next month, his first in the doughnut hole, he will have to pay $341.
Wojehowski, who knew about the gap, plans to continue with two medications but not the others.
"I just can't afford to buy them," he said. "Every time somebody in Washington says what a wonderful benefit this is, I think they have to look a little closer."