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Close the Doughnut Hole
July 23, 2009 • Volume 9, Issue 29
Medicare’s Part D drug benefit has a built-in gap in coverage known as the “doughnut hole,” when coverage stops and consumers must pay the full cost for their medicine. The doughnut hole exists because the high cost of drugs made it too expensive for Congress to provide continuous drug coverage—the kind of drug coverage most Americans have through their employer-sponsored health plans. People with limited incomes can get coverage during the gap through a federal program called Extra Help, but for people with incomes or assets too high to qualify for this program, the effects of the gap on their health can be devastating. Here is what the studies show:
- 3.4 million people with Medicare fall into the doughnut hole.
- Over one-third of people with diabetes and hypertension fall into the gap.
- Over 60 percent of people with diabetes, hypertension, congestive heart failure and high cholesterol fall into the gap.
- Many people who fall into the gap skip doses or stop filling all their prescriptions, reducing their drug use on average by 14 percent.
- Use of both generic and brand-name medicines to prevent blood clots drops sharply once people hit the gap, and continues dropping with each month they are in the doughnut hole.
- One in ten people taking medicine to control diabetes stop taking their drugs when they hit the gap.
The statistics are grim, but there is hope. Health reform legislation—HR 3200, America’s Affordable Health Choices Act of 2009—now making its way through the House of Representatives would phase out the Part D doughnut hole. The bill requires price concessions from drug manufacturers and uses the savings to help Medicare gradually narrow the coverage gap until, in 2023, it disappears completely. For the short term, the legislation also requires brand-name drug manufacturers to provide a 50 percent discount to people who fall into the doughnut hole, the result of a deal reached with drug makers, the White House and the Senate Finance Committee. Together, both provisions result in savings to Medicare of nearly $30 billion over ten years.
Health reform legislation that passes Congress must include a plan to fully close the doughnut hole. Please write your senators and representatives and remind them to Remember People with Medicare in health reform and close the doughnut hole when they pass health reform.
“Health reform legislation now before the House Energy and Commerce Committee would provide much-needed help to older adults and people with disabilities who face skyrocketing drug costs. The bill phases out the coverage gap, or “doughnut hole,” in the Medicare drug benefit over time and pays for it by securing lower prices for drugs covered under the benefit. The bill also provides short-term assistance by mandating 50 percent discounts from brand-name drug manufacturers during the coverage gap. The two provisions go hand in hand; both should be included in any final bill.” (Statement by Medicare Rights Center President Joseph Baker on New Proposals to Improve Medicare Drug Coverage in Health Reform Legislation, July 2009)
“For people with a chronic condition such as diabetes, stopping a medication even temporarily can have serious and immediate health consequences. The study found that 10 percent of Part D enrollees taking oral anti-diabetic drugs who reached the coverage gap stopped taking their medications.” (New Study Examines Impact of “Doughnut Hole” on People Enrolled in Medicare Drug Plans in 2007, Kaiser Family Foundation, August 2008)
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Medicare Part D Appeals Help for Advocates Is Here!
Medicare Rights Center’s new Medicare Part D Appeals: An advocate’s manual to navigating the Medicare private drug plan appeals process offers an easy-to-understand, comprehensive overview of the entire appeals process, including real-life case examples, a glossary of important appeals terms, a sample protocol for advocates, and links to important resources.
Register for a FREE copy of this great resource.
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Medicare Part D Monitoring Project
would like to hear about your experience, or that of someone you know, enrolled in a private drug plan. With information about what the issues are with Medicare Part D, we will be able to demand that those problems be fixed. Medicare Rights Center
Submit your story at http://www.medicarerights.org/issues-actions/tell-your-story.php.
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The Louder Our Voice, the Stronger Our Message
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Asclepios—named for the Greek and Roman god of medicine who, acclaimed for his healing abilities, was at one point the most worshipped god in Greece—is a weekly e-newsletter designed to keep you up-to-date with Medicare program and policy issues, and advance advocacy strategies to address them. Please help build awareness of key Medicare consumer issues by forwarding this action alert to your friends and encouraging them to subscribe today.
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The Medicare Rights Center is a national, nonprofit consumer service organization that works to ensure access to affordable health care for older adults and people with disabilities through counseling and advocacy, educational programs and public policy initiatives.
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