A TGB READER STORY: Ah, Look at All the Lonely People
Millie Garfield is 93 Years Old

Living in the Medicare Part D Donut Hole

Now and again I am reminded of how many TGB readers live in countries other than the United States so let me first supply a short definition of the evil donut hole.

Part D is a supplement to standard Medicare health coverage which itself does not provide prescription drug coverage. Part D is a voluntary purchase for which consumers pay an extra premium but the cost doesn't stop there.

Without going into arcane details, in general, when the consumer's total out-of-pocket payments for drugs reach $3,750 in a calendar year, the “donut hole” kicks in during which the consumer pays a higher percentage for the drugs until his/her out-of-pocket cost hits $5,000.

After that milestone, the insurer pays all but five percent of the drug costs until the accounting starts over again from scratch in January of the following year.

Until I was diagnosed with cancer last year, the only prescription drugs I had taken were antibiotics now and then, the price of which was paid for by my health insurance so I had no idea how expensive many drugs can be.

I sure do now, having entered the donut hole about two months ago and from which I will emerge, if my calculations hold up, fairly soon.

Quick story: At the beginning of my chemotherapy treatment last fall, I was handed my first month's supply of the oral drug along with a piece of paper with a figure of $5,000.

At first I felt the blood drain from my head and then I laughed. “You're kidding?” I said to the pharmacist. “I'll have to skip this treatment and hope for the best.”

As often happened during my year-long cancer ordeal, I got lucky. “Oh, I'm sorry,” the pharmacist said. “I didn't mean to scare you. That's the actual price the computer spit out but you don't pay anything.” (Long story, not worth the effort here today.)

The chemotherapy finished in January but the price of the four prescription drugs I take now are, if nothing like that oral chemo treatment, scary enough while I've been in the donut hole - they've busted my small budget all to hell.

That's the thing about money, it's relative. If you've got enough, all good. If not, you could die.

Here's the story I really came here to tell you today.

Three or four weeks ago, I was next in line at the pharmacy to pick up a prescription and although I was behind the separator that gives customers privacy while talking with the pharmacist, I could clearly hear most of the conversation at the window.

The customer, older than I by a decade I guessed, did not have enough money to pay for her prescriptions. I overheard the phrase, “donut hole.”

There are some programs that can help certain low-income patients with payment but apparently none were available in this case and the two women – one a young-ish professional, the other knocking on frailty's door – were at an impasse, neither knowing what to do or say next.

Something came over me and without thinking it through, I marched up to the window, gave the pharmacist my credit card and said, “Use this.”

There were some “oh no, I couldn'ts” and “please don't mention its” between the older woman and me but we sorted it out and I was relieved to see – having realized by then what I might have gotten myself into - that at a couple of hundred dollars and change, it was nowhere near that oral chemo price.

This story is not to tell you how wonderful I am. There are plenty of people in the world who will tell you otherwise and they are not wrong. Not to mention the voice in my head that day yelling, “What are you doing, screwing up your budget that's already a mess from the price of your own drugs?”

But nowhere near as much a mess as that old woman's. Here's the real problem:

No one should go without health care of any kind – treatment or drugs – because they don't have enough money. No one.

Some small help for prescriptions drugs is due soon thanks to former President Obama's Affordable Care Act which included a provision, when it was enacted in 2010, to gradually close the donut hole by year 2020, now changed to 2019, although some healthcare experts suggest the insurance companies will increase premiums and/or deductibles when it happens.

That prediction is of a mindset with the many politicians who want to cut Medicare, Medicaid, and Social Security too. President Trump campaigned on a promise not to do that but if we didn't know before, we surely do now that you can't count on anything Trump says.

It would be a good thing for all Americans, as we make decisions about which candidates to vote for in the midterm election in November, to think about increasing moves toward universal healthcare or Medicare-for-all that are stirring in some enlightened political circles.

Would it be difficult to do? Yes. Would it take a long time to happen? Yes. Would it be expensive? Yes. Would our taxes go up? Yes. But the time has come, it is the right thing to do and we have a lot of examples to study and learn from: just about every western democracy already has such a system.

Excuse me now while I go worry about what will happen with that old woman next time she needs to fill her prescriptions and is still in the donut hole.



Comments

I believe the donut hole threshold includes payments made by one’s insurer, as well as the individual’s own out of pocket costs. This makes it particularly evil...

I’m looking at not refilling a certain expensive type-2 diabetes drug because it’s untested long-term, I can’t see that it’s doing me any good, and it will place me at the brink of that gaping hole.

Going to try diet and exercise using my Silver Sneakers membership that has been languishing since I turned 65 for years ago.

Just, "Thanks."

You were a dear to do that...and yes, we seriously need single payer universal healthcare!

Wow. Am I uninformed. Never heard of this. I thought buying “gap” insurance covered everything.

It’s covered all of my medical cost for years, but then my out of pocket prescription drug cost is way less than a thousand a year, closer to 500.

Using insurer’s mail order prescription service saves a lot of money on my take it forever prescription.

The drug companies and insurance providers are in cahoots, too. I have outstanding medical coverage and, for now, I can choose my pharmacy. But, and it's a big BUT, the outstanding medical coverage provided through my employer has decided I shouldn't be allowed to choose the local, neighborhood pharmacy that gives such wonderful service but rather a large, mail-order conglomerate who offers NO SERVICE except to package and send the meds to my doorstep where who knows could steal them.

I'm hanging on to the local pharmacy as long as I can, standing my ground, and saying I don't want a year's worth of drugs delivered to my doorstep. Hope I win.

"Would it be difficult to do? Yes. Would it take a long time to happen? Yes. Would it be expensive? Yes. Would our taxes go up? Yes."

~~~ But our premiums would go down, and the cost of health care in general would go down once the insurance companies are no longer taking their "bite" out of everyone's cost.

Yes - Medicare for all!

Bless your heart! I, too, will be in the donut hole when/if I make it to 65 with a serious condition. Or, any condition that needs expensive drugs to give relief. I also believe we need universal health care.

Once profit for a private entity enters the picture the price goes up and the care does down.

There are many studies that disprove the fallacy that single payer will be more costly. Logic backs that up. Not only do we (individual and government) spend more for our inadequate health insurance than any other industrialized country, but we are near, or at the bottom in results.

We have the template of how other countries provide the best medical care, but do it in a cost efficient manner. There are different methods, but they are all less expensive than our "for profit" insurance. We could take the best one, or a combination of the best, and provide health care for everyone and it would include vision, dental and hearing.

The ones blocking any legislation that would move the U.S. into an enlightened and more humane system cry the old bugaboo "SOCIALISM" . Then they spread the false information that it would be too costly. This is not true. Then the right wing spread disinformation on people having to wait for surgery, etc. All have been proven false.

Until the politicians started cutting the VA appropriations they provided good insurance much cheaper than what we have now. My son is living proof of the quality care he got from the VA, with virtually no out of pocket expense. Without that care, he could never have afforded the thousands of dollars a severe accident required. The VA insurance is really socialism; the government pays the doctors, owns the hospitals, and negotiates drug prices. Some socialism is not bad.

It's true that the transition would make single payer insurance more costly initially, but once the insurance companies were out of the health care business, the savings would be enormous. There would be no more need for doctors to hire a slew of office personnel to handle the massive paper work the different insurance companies require. The government could reign in the Pharmaceutical industries obscene profits and negotiate lower prices on drugs.

The big losers would be the Insurance companies and big pharma. They will not let this happen with their hold on venal politicians who take money from them. The people better start actively letting their representatives know that they will vote out any politician who takes money from those two entities.

We, the people, had better start demanding affordable health care if we are ever to have it.

Vote, people, vote. Our complacency has given us what we have now. The internet makes it easy to find out where a candidate stands on issues. It is 83 days until the Midterms. Find out who backs Medicare for all and vote for them.

Ever notice those advertisements that come in your mailbox, and more importantly the ones on TV, meant to attract you to a particular Medical insurance company? Your premiums have to cover those and the marketing departments that think them up and produce them. Your premiums also cover a gazillion employees at insurance companies whose jobs mostly involve finding ways to say “not covered,” as well as highly paid CEOs and other top execs. Even not-for-profit insurance companies have highly paid top execs, marketing and advertising, and employees whose job it is to process bills your and tell you you’re not covered.

So don’t let people tell you that a national health insurance program would raise our rates. When you drop all that advertising, all those overpaid CEOs, and all those people whose job it is to process the paperwork and tell you they won’t pay for your care, there will be plenty of money to actually deliver healthcare services

Were it not for developments since 2016, I would say some form of single payer health insurance would be forthcoming including not only prescription drug coverage but also the vision, hearing and dental expenses that every senior no matter how healthy, spends a ridiculous amount on. (And btw, maybe they could cover what my Pt. D at least considers Tier 4, massive deductible, like T Dap update, shingles vaccine, and something else "highly recommended" my senile brain just lost!) But meanwhile a little regulation of the pharmaceutical industry which has famously boosted prices out of sight in order to increase profits for stockholders might be in order. Greed is rampant and the prime cause of our country's disintegration!

Medicare has certainly worked well for me. It's a good thing, too, because the cost of some of my cancer treatments was mind-boggling. Just an example: The Neulasta shot you get the day after a chemo treatment ... $10,000. For a single injection. And I had four of them.

It's criminal how much the drug and insurance companies are earning on the backs of sick people! How we ever got from Marcus Welby, MD, to todays' health care system is beyond me. The doctors should be calling the shots (no pun intended) but instead we have the tail wagging the dog. It's ridiculous, expensive, and dangerous. Doctors know what's best for their patients, not the insurance companies or Big Pharma.

My meds only cost $2-$4 dollars per month until last year when I was diagnosed with atrial fibrillation and was put on some expensive medications. I fell in the donut hole last month, and now fully understand the problem. One med went from $47 per month to S181 per month. Haven’t refilled the others yet so don’t know what they will be. Surprisingly, my doctor was not very knowledgeable about the donut hole, and when I explained it he gave me samples for 2 months. I am lucky since, as you stated Ronnie, the donut hole goes away in 2019. However, I have read that med or insurance prices may well go up. Also, my insurance may decide not to cover those meds. — Most definitely we all need better care than this.

May your kindness and generosity be returned to you ten-fold.
And let's make sure we all vote for what we want.

This article was so touching. Living in a country (Canada) with universal health care and some of the best facilities in the world I am grateful. Sometimes we gripe about our income taxes and other things, but the bottom line is I wouldn't trade it for anything. Thank you for sharing your story.

Thank you, Ronni, for your kind heart and generosity.

I worked at the welfare dept. when Medicare Part D came out. I was a supervisor and got the calls. I heard many sad stories.

Ronni, I know you don't advertise, but I recently ordered a drug, which my insurance no longer covers, from the UK through a web site recommended by my doctor. The cost for a 3 month supply is about the same as my one-month copay when it was covered. They even have medicines for pets. You have to submit a prescription and the medicine is mailed. I spoke to at least 6 people at this company to get this done, and they were very helpful.
I'm in a medicare HMO so the donut hole doesn't affect me, fortunately, but one is still at the whim of the insurance whether or not a drug is covered and how much one has to pay as a result.
And yes, blessings on you for your generosity.

You made me cry you did. The first reason is obvious, the second is my gratitude for universal health care that covers me with no limit. I know the real cost of my drugs monthly is around $5,000. They keep me alive. I could never afford them and would be dead by now without them.

I hope that the USA starts caring for its citizens, particularly it's most vulnerable.

And thank you Ronni.

XO
WWW

I’m not on Medicare because of a loophole won for me by the faculty union and long ago vanished except for those of us who were grandfathered in, so I may not have a horse in this race. But I want to comment on the absurdity of drug pricing. Because of macular degeneration and being fortunate enough to be treated by a cutting edge University Eye Center, I have injections in my retina every 4 to 6 weeks that have saved my vision. The injections supposedly cost about $18,000 each, which the Eye Center bills to my insurance. The insurance then pays about $8,000, still a hefty price, at which all concerned call it even for reasons nobody can explain to me. I only know because my insurance company sends me “informational” notices about the shocking charges and their payments.

Now you tell me, is this drug actually worth $18,000 a pop? If it is, why is $8,000 an acceptable payment? And what the eff is going on with the pharmaceutical industry? Or the insurance industry? And does anybody know?

Like Emma Jay, my spouse has a "platinum" retiree health plan from his former employer (a large HMO) that covers both of us for our lifetimes (unless they cancel it), so to date we haven't had to worry about the donut hole, deductibles or copays. We are SO LUCKY!!

As grateful as I am to have this plan, like Medicare, it doesn't cover eyeglasses, dental care, hearing aids or many "alternative" treatments such as chiropractic. Having not found effective treatment for my ongoing back problems through traditional medical channels, I recently decided to try chiropractic. In so doing, I've come face to face with out-of-pocket medical expenses --fortunately on a comparatively small scale.

I cannot imagine how average retirees--especially those who do not have a Medigap plan--manage to pay for healthcare. If I were in that situation, it's possible that I would have to let serious problems go undiagnosed and untreated due to lack of financial resources. No one in the U.S. should be in that position.

Medicare for all--VOTE for those who support it! (Thank you, Ronni, for helping that elder woman pay for her Rx. What a bad, sad situation or her to be facing late in life.)

Verify your Comment

Previewing your Comment

This is only a preview. Your comment has not yet been posted.

Working...
Your comment could not be posted. Error type:
Your comment has been posted. Post another comment

The letters and numbers you entered did not match the image. Please try again.

As a final step before posting your comment, enter the letters and numbers you see in the image below. This prevents automated programs from posting comments.

Having trouble reading this image? View an alternate.

Working...

Post a comment

Your Information

(Name and email address are required. Email address will not be displayed with the comment.)