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Medicare’s Troubling Drug Gap
The New York Times
September 2, 2008
Probably no aspect of the new Medicare drug program has caused more confusion and irritation than the notorious “doughnut hole,” a gap in coverage that forces people who had been getting their drugs cheaply to suddenly pay the full price out of pocket. Now, for the first time, an analysis has quantified what happened last year when millions of beneficiaries fell into the gap. For patients with serious chronic conditions, the medical implications were very troubling.
Congress crafted the “doughnut hole” to limit federal spending on the drug benefit. Beneficiaries pay only deductibles and co-payments, with the rest covered by their insurance plan, until their drug purchases reach a specified limit. Last year, the gap began when beneficiaries purchased $2,400 worth of drugs. Then they fell into the doughnut hole and had to pay the full cost until their out-of-pocket spending reached $3,850, at which point they qualified for catastrophic coverage.
Last year, an estimated 3.4 million beneficiaries reached the coverage gap, according to a study by researchers at the Kaiser Family Foundation, Georgetown University and the National Opinion Research Center, or NORC, at the University of Chicago. Beneficiaries taking drugs to treat such chronic conditions as Alzheimer’s disease, diabetes, depression, osteoporosis and high blood pressure were especially likely to reach the gap.
What’s disturbing is that 15 percent of the beneficiaries taking drugs in eight categories said they stopped taking their medications when they reached the gap. Another 1 percent reduced their use by skipping doses, and 5 percent switched to another drug that was cheaper but might or might not be as effective.
For the 10 percent of diabetics who stopped taking their medication after reaching the gap, the health consequences could be immediate and serious. For those with high cholesterol or osteoporosis, the harm could take longer to show up but could still be serious.
There is no easy solution short of increasing federal spending or finding a way to drive down the cost of drugs. The program has helped millions of older Americans. The next administration and Congress will have to revisit the wisdom and need for the gap.
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