Up Close and Personal with MeanMesa's "Doughnut Hole"

 The Sickly History of US Health Care

When Bush W.'s cronies were finally ordered to pass the Part D of Medicare at 3:00 o'clock in the morning, the thing had no room left for any additional "gifts" to its highly lobbied Big Pharma sponsors.  The Congressional "magic" had already been woven into its false pattern as an "entitlement benefit," designed to provide relief for seniors eating cat food so they could buy their medicine.

At first glance the thing might have looked like its authors had decided to expand Medicare coverage to include pharmaceuticals for seniors, but closer examination revealed that it was a thinly disguised, magnificently vague, wealth redirection scheme directly targeting the already bulging wallets of the pill makers.  The law made negotiating medicine prices illegal.

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That was the legislative gizmo which guaranteed that a massive new wave of "hard earned business profits" would flow from the Medicare Trust into the coffers of pharmaceutical corporations without any disturbing interruptions from administrative bargaining or troublesome calculations for "fair market" pricing.  The oligarchs had been salivating over the Trust for years, and while their Congressional servants were authoring Part D, their masters had insisted it would emerge in a scantily clad "constituent concern costume" designed to obscure its real purpose.

Well, those sky high prices weren't the only carefully engineered glitch in the works.  In an intellectually impressive moment during the demonic design of the bill's features, some right wing think tank denizen dreamed up the fabulously arcane concept of the doughnut hole.

Further this was not any sort of "common sense" style doughnut hole, either.  This one was a doozey.

Part D In a Happier World

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Part D's design would make it only partly driven by the cost of purchasing prescriptions under the plan. Had this been the case what we term the "doughnut hole" would have amounted to an annual "cap" on "covered expenses."

After suffering through years of abusive commercial health insurance policies, most Americans would have seen this and simply nodded.  "It's only to be expected that after Medicare Part D spends a certain amount on money on your prescriptions that you will hit the cost limit and further coverage will be dropped."

In fact, this is precisely what most Americans think this is how the "doughnut hole" provision works.  Part D will pay part of the cost for prescriptions until the "spending cap" is reached, and after that, you're on your own.

They would be wrong.

A Typical, Toxic, Republican "Poison Pill"

Let's see if we can trick the old people.

So, now we must pretend that we are the Republican Congressman writing the Part D legislation.  We certainly want it to LOOK like a pharmaceutical plan which would pay part of seniors' prescription costs -- but only up to a certain point, of course.  We have already "paid off" our Big Pharma sponsors with the part of the bill which makes it ILLEGAL to actually negotiate the price of pharmaceuticals, so the program will be paying the "full price" for this medicine.


Wait.  Where in the world will we be able to establish that "full price?"


Not a problem.  Just ask the pharmaceutical manufacturers what the "full price" will be, and that's it!


However, there is more to the scheme.

Everyone who has listened to the "news" in that last few years has heard about the "doughnut hole."  Just about all those folks would instantly tell you that the "doughnut hole" begins when a senior's annual prescription costs have hit $2,970.  This, not by accident, implies that a senior might have Part D coverage for the first $2,970 worth of prescriptions, that is, when Part D had paid $2,970, the senior would enter the "you're on your own" phase, that is,  the "doughnut hole."

Well, THAT is NOT the way it works.

Part D was designed to NEVER pay $2,970 for a senior's annual drug costs.  This includes ALL seniors with Part D coverage, and it includes ALL years for which they had Part D coverage.

Instead, Part D is carefully designed to pay part, usually around 60-70% of the annual prescription costs -- and this is the important part -- until the senior has "spent" $2,970 TOTAL.

That "TOTAL" is the "total" of the Part D coverage when ADDED to the co-payments, that is, when ADDED to the money the senior has paid "out of pocket."  To explain this a little more clearly, let's have a look at MeanMesa's "benefits letter" for October, 2013.

MeanMesa's October Medicare Part D Report

From this report we see the amount of prescription benefits paid by Medicare under Part D, and we see the amount paid by MeanMesa "out of pocket" in co-payments.

Medicare Part D paid:  $2,302.08

MeanMesa paid: $677.74

Year-to-date amount for "total drug costs:" $2,979.82

Because the Year-to-date total costs reached $2,979.82 which exceeded $2,970, MeanMesa's Part D Medicare benefits ended.  THIS is the way that Part D actually works in real life.  Medicare paid $2,302, but because MeanMesa paid another $677, the "cap" for Part D was exceeded.

This means that Medicare will offer no coverage for prescriptions for the rest of 2013 -- happily only a little more than a month.  MeanMesa has a "pill splitter." and the prescriptions already on hand can be "stretched" at half doses through most of the month of December.

Always remember, this is actually much better than it was before the Bush cronies paid off their health insurance bosses.  America has the "best health care" in the world -- for about the top 30% of income earners.  There will be a follow up post on this topic describing MeanMesa's twisted efforts to get a prescription from a Medicare doctor to a compounding laboratory pharmacy to keep $2,000 dollars worth of prescription expenses from driving this senior into the doughnut hole again in November of next year.