The spectre of senior citizens choosing between food and prescription drugs has been used by politicians so many times, it's become a cliché. For one Cleveland couple, it could turn into a reality.
Wister Adrine, 85, takes a lot of medicines to treat his prostate cancer, congestive heart failure, hypertension and high cholesterol, said Brenda Adrine, his 61-year-old wife. Wister Adrine, a retired carpenter, has Medicare benefits that cover his health care expenses but last July, they came up short: He ran into the infamous "doughnut hole," a gap in Medicare's prescription drug coverage in which beneficiaries must pay the full cost for their medications.
"Once he hit that doughnut hole, I was shocked when we went to pick up his medications," said Brenda Adrine, a retired Department of Defense employee. Drugs that had been covered with no co-payments suddenly cost $140.
Things changed this year, when her husband's Medicare drug plan notified him that President Barack Obama's health care reform law offered bigger discounts for those in the doughnut hole. The law provided $250 rebate checks to Medicare beneficiaries who reached the doughnut hole in 2010, introduced discounts last year and phases out the coverage gap altogether by 2020. Enrollees get 50 percent discounts on brand-name drugs and 14 percent discounts on generic drugs during the doughnut hole in 2012. From March 2010 through April 2012, 5.1 million people on Medicare saved $3.2 billion on their prescription drugs due to these changes, according to the Obama administration.
These enhanced prescription drug coverage for Medicare enrollees would disappear if the Supreme Court overturns the health care reform law on constitutional grounds. A ruling is expected next week.
"There is no way I would allow him to cut back on his medication, so we would probably cut back on groceries and stuff like that," Brenda Adrine said. She and her husband live off their pensions and his Social Security benefits, which they also use to support his 48-year-old son, who has lupus. The bad economy wiped out their savings and their assets and forced them to file for bankruptcy two years ago, Brenda Adrine said.
President George W. Bush enacted the prescription drug benefit for Medicare in a 2003 law. Prior to that, seniors and people with disabilities on the program had to pay out of pocket, buy supplemental "Medigap" insurance, join a private plan that paid for medicines through a program now known as Medicare Advantage or go to Canada, where medicines are cheaper.
But the doughnut hole limits the benefit. Under that policy this year, beneficiaries must meet a $320 deductible. Then, Medicare covers 75 percent of expenses until the combined drug costs for a beneficiary and Medicare reach $2,930. From that point, until a person's out-of-pocket costs reach $4,700, the beneficiary pays full price. If costs rise even higher than that, Medicare covers 95 percent for the rest of the year.
"It was something that begged to be fixed from the very beginning," said Dan Adcock, the director of government relations and policy for the National Committee to Preserve Social Security and Medicare.
If the Supreme Court strikes down health care reform, re-filling the doughnut hole would be tough, said David Certner, the legislative policy director for the AARP.
"Hyper-partisan activity has really made it difficult to get anything done," he said. "When we're talking about something as big and controversial as health care, it's hard to have a great deal of confidence."
Then there's the price tag: Closing the doughnut hole is estimated to cost $24.4 billion from this year through 2019, according to a 2009 Congressional Budget Office analysis of the health care reform law -- and that doesn't account for the discounts drugmakers agreed to provide in the law. If the law gets struck down, pharmaceutical companies may not be able to copy the big health insurance companies that vowed to voluntarily retain elements of reform. The law establishes the "legal structure" that permits drug companies to sell drugs at a discount, Matthew Bennett, a senior vice president of the Pharmaceutical Research and Manufacturers of America, wrote in an email.
Older Americans are a highly motivated voting bloc that would normally be expected to pressure Congress to act, but the health care reform law has left most seniors cold. Fifty-one percent of people aged 65 and older had an unfavorable view of the law, compared to 33 percent who favored it, according to a survey conducted in April by the Henry J. Kaiser Family Foundation, a health care research institution. Among all adults, the split was 43 percent unfavorable and 42 percent favorable.
Patricia Morrison, 68, of Annapolis, Md., is one of the 33 percent. Morrison has reached the doughnut hole in each of the last two years and expects to hit it again this year. A 90-day supply of the drug she takes to treat autonomic neuropathy, a condition that causes rapid drops in blood pressure that can make her faint, costs her just $50 but the price, which gets counted against her drug coverage, is $535. "That's what's putting me in that doughnut hole," she said.
But Morrison got her $250 rebate check for 2010 and believes health care reform will cut her drug costs further as the doughnut hole gets smaller.
"If we get a decision that they're going to do away with the whole health care thing now, then I've got pretty big bills coming up for my medicine," Morrison said.
"If I have to pay 100 percent for my medicine for half of the year, then I'm either going to not take medicine or I'm not going to eat," she said. "That's the facts and that scares me."