By Don Kuehn

The Medicare prescription drug program, known as Part D, has been in place since the beginning of the year. According to the Campaign for America’s Future, Sept. 22 was "D Day" for some 7 million older Americans who will have fallen into what is commonly called the "doughnut hole" of coverage.

The doughnut hole is a coverage gap that opens up after the insurance company and the insured together have paid $2,250 in drug costs. Then coverage stops, and all prescriptions must be paid solely by the patient until total outlays have reached $5,100.

For seniors with significant pharmacy bills, like my mother, for example, the coverage gap came quite early. She fell into the hole back in June. Since then we’ve paid enough out-of-pocket costs to exceed the $5,100 threshold, and she will emerge from the doughnut hole at the beginning of October. That means Medicare will pick up all but a 5 percent copay until Jan. 1. This is what the plan calls "catastrophic" coverage. But an estimated 55 percent of beneficiaries will have "fallen (into the hole) and can’t get up".

Defenders of the plan point out that poor people are eligible for subsidized help through Medicaid or SSI, and other beneficiaries will have saved almost $1,500 by the time they reach the dreaded doughnut hole.

True enough. But for a senior on a fixed income, the "sticker shock" of having to pay full cost for their medications on top of their monthly premiums can be traumatic. It turns the clock back to the days when many had to make choices about medications versus food, cutting pills in half to make them last twice as long and avoiding a healthcare system that increasingly favors pharmaceutical drugs over more-invasive therapies.

Some enrollees find out about the Medicare doughnut hole when they go to the pharmacy and are told that their copay has surged from what they paid the previous month. Medicare Part D providers are required to mail monthly statements to enrollees so they can follow along. But it may be difficult to grasp, even with a monthly statement, unless you completely understand how your plan works.

For example, take my mother’s case: An eye medication she uses to treat macular degeneration had a $28 copay before the coverage gap. After she fell into the doughnut hole, the cost soared to $109.63. The widely advertised Boniva was $28 before the gap and $79.91 after it. For these two prescriptions alone, her fixed income took a hit of $133 per month.

On top of that, five of the drugs my mother has taken since the Part D plan went into effect have gone up in price by almost 26 percent. Critics have long warned that "Big Pharma" would take advantage of seniors with unjustified price increases. In our case, at least, that’s exactly what is happening.

So, why bring this up now, near the end of the year? Because this is an annual ritual. Each year the enrollment "window" reopens, and seniors have to decide whether they want to stick with the plan they have, or bolt to another. The doughnut hole may be one factor that helps them decide.

If, like me, you are taking responsibility for an elderly parent, or if you are the beneficiary under the Medicare Part D plan, it will behoove you to assess the coverage you now have and make a decision. Formularies--the list of drugs covered by your plan--will change over time; some plans have deductibles, others don’t; some higher-cost plans even offer continuous coverage with no doughnut hole; your medication needs will change; and pharmacies may drop plans that have few enrollees. The best plan for you this year may not be the best in years to come.

Although social service agencies in most places are prepared to help seniors make a decision, the only way to really get through the morass of plans, costs and variables is by going online (www.medicare.gov).

Pharmacies and doctors are not supposed to give advice on the multitude of choices available or to steer patients into a particular plan (although there is plenty of anecdotal evidence that they have done so in the past and probably will in the future because many of their patients are unable to make these complicated decisions themselves).

A group in Congress is working to change the way Part D works. These legislators want a simple, affordable plan that allows Medicare to negotiate lower drug prices the way the Veterans Administration does. They call their plan the Prescription Drug Savings and Choice Act (H.R. 752).

The politicians who came up with the doughnut-hole idea had a choice, the sponsors say. They could have sided with older Americans and empowered Medicare to run an affordable program that would benefit seniors, or they could side with the private sector drug companies and shift costs onto seniors.

At a July news conference, U.S. Rep. Darlene Hooley (D-Ore) criticized pharmaceutical companies that "killed every attempt to allow Americans to benefit from the same low drug costs that other countries enjoy." Now, she said "an increasing number of seniors are finding themselves facing the ‘doughnut hole’ and once again being forced to choose between buying the drugs they need and putting food on the table."

Congress can make healthcare more affordable. A starting point would be to eliminate the doughnut hole. Next would be taking Medicare drug policy out of the hands of private insurers and requiring the government to negotiate lower drug prices.