Last week, I asked my grandmother why she wasn’t eating her pasta. “Oh, you know my stomach, the acid just gets to me. I can’t eat anything anymore. ” This sparked a long conversation about her health problems, and how she manages them. With over 9 medical conditions and twelve medications, not including vitamins and over-the-counter drugs, I wondered, how does my grandmother possibly afford her medication?
These prescription expenses should place my Grandma in the coverage gap, or the “donut hole” of Medicare Part D. In this plan, prescription expenses up to $2,830 are reimbursed up to 75%. After this amount is reached, enrollees are somehow expected to pay the full amount out-of-pocket until they reach $6,440 of drug costs. Then, after this point of “catastrophic coverage,” costs are suddenly reimbursed again up to 95% (4).
Luckily, in the Patient Protection and Affordable Care Act, enrollees who hit the coverage gap this year will receive a $250 rebate and 50% off all brand-name prescription drugs, assuming pharmaceutical companies cooperate (1). To prevent enrollees from facing high out-of-pocket costs when they hit the coverage gap, 75% of their drugs will end up being reimbursed by Medicare, no matter what (1). Low-income enrollees will be also given additional support. And if all goes well, the act will entirely eliminate the coverage gap by 2020.
This portion of the ACA is terrific for those who know about it. When I asked my grandmother how she is able to afford her medications with the donut hole in place, she gave me a blank stare. Perhaps this is because my grandmother is lucky—she does not pay for most of her medication. She instead relies on the goodwill of her physician, who has granted her with a constant supply of free samples for over twenty years.
It’s too bad that not everyone is as fortunate. Millions of Medicare recipients struggle to pay for medication out-of-pocket once they enter the coverage gap. But it seems that millions of Medicare enrollees are uninformed about the new gains headed their way. According to a recent survey, just 2 out of 10 Medicare enrollees are aware of these changes and how they will benefit (2).
It is critical that enrollees understand how the transformation of the donut hole affects them. This dismal policy puts all types of patients at a disadvantage and costs all of us money. Enrollees with chronic diseases such as diabetes are more likely to be admitted into a hospital when they reach the coverage gap because they cannot afford their medication (3). Additionally, patients with co-morbid disorders are more likely to suffer and have to seek emergency care if they fall into the donut hole (3).
Hospital admission in the U.S. is an unnecessary expense in an already astronomically expensive healthcare system. In 2007, about 3.4 million Medicare Part D enrollees reached the coverage gap (1). With this many people at risk, it is not surprising that the U.S. spends so much on health care. In order to keep patients on their medications, the costs cannot be so high and the coverage gap must be eliminated.
Thankfully, the changes to the donut hole in the ACA hold promise. Right now, they elicit positive responses from the majority of Medicare enrollees (2). Most people who are aware and affected by the bill are enthusiastic about the prospect of saving money. With recent antagonistic opposition to the bill, it is becoming more and more important to accentuate the positives. More people need to educate themselves about the ACA and its effects. This way, those who are content with the changes can ensure the bill’s support in future elections.
This overall lack of knowledge is troublesome. With so many people like my Grandma swimming in a sea of medical problems, these effects are essential to grasp. If people do not comprehend the ACA, how will it gain approval? And as lack of knowledge prevails around the country, is it really possible for people to take advantage of their rights? We all need to make efforts to educate ourselves regarding what will affect us in the ACA. If we find resources online, ask our health care providers, and talk to our friends and family members, we can spread the word to others.
1. Kaiser Health Reform Gateway: Health Reform and Health Insurance Reform
Analysis, Data and Information. (n.d.). Kaiser Family Foundation. Retrieved from http://healthreform.kff.org/
2. KRC Research (2010). Senior’s Opinions About Medicare Rx: Fifth Year Update. KRC Research. Retrieved from http://www.krcresearch.com/pdfs/KRC_MedicareTodaySurveyofSeniorsMedicareRx.pdf
3. Scott, M.A. (2007). Hospital admission associated with Medicare Part D “doughnut hole.” American Journal of Health-System Pharmacy, 64, 1029-1030.
4. What Will Happen Under Health Reform–And What’s Next? The Commonwealth Fund, Columbia Journalism Review, May 2010 supplement.
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